Why Are We Treating Anxiety with Surgery?

Less than a month until the release of Less Radical!

He was an unlikely hero-- a Jewish kid from Pittsburgh who had to make it past antisemitic quotas to get into med school. And the thanks he received for his discoveries? A performative misguided Congressional hearing that destroyed his reputation and haunted him until his death.

Less Radical is the story of Dr. Bernie Fisher, the surgeon-scientist who not only revolutionized breast cancer treatment, but also fundamentally changed the way we understand all cancers.

If you or someone you know has had cancer, Bernie is a part of your story-- and you’re part of his. I can’t wait for you to hear it. For those of you who have already subscribed, THANK YOU! And if you are new here, welcome! You can subscribe by clicking the button below to get the first episode delivered directly to your inbox on September 25.

---

The most recent NCI data indicate that 75% of American women over 50 have had a screening mammogram in the past two years. Current national recommendations set the minimum screening age at 50. Using this age cutoff, 2700 mammograms must be performed to prevent one woman from dying of breast cancer.

Some suggest that screening should start at 40. At this lowered age, between 12,000 and 25,000 screening mammograms must be performed to prevent one death.

Despite being the gold standard for breast cancer screening, mammograms (like all screening tests) are not perfect. Mammograms miss certain cancers. More aggressive tumors can develop between annual mammograms and dense breast tissue found in many pre-menopausal breasts obscures many masses.

New legislation, introduced and championed by women, requires physicians inform women of their breast density. Here is the wording that must be included in reports with women who have dense breasts:

“Breast tissue can be either dense or not dense. Dense tissue makes it harder to find breast cancer on a mammogram and also raises the risk of developing breast cancer. Your breast tissue is dense. In some people with dense tissue, other imaging tests in addition to a mammogram may help find cancers. Talk to your healthcare provider about breast density, risks for breast cancer, and your individual situation.”

Although well-intentioned, this mandate is flawed.

There are no evidence-based guidelines to direct further screening tests for women with dense breasts. Your healthcare provider does not know what to say in this conversation. There’s no guidance.

Breast magnetic resonance imaging (MRI) is suggested by some as a good follow up test.

I have some thoughts. I was part of the wave of doctors in the 2010’s who ordered a breast MRI on everyone. Breast MRI found some mammographically occult cancers, but it also led to many more biopsies as we tried to figure out what exactly we were looking at.

I remember one patient who had five biopsies in her C cup breast.

After three hours on the biopsy table, the patient got up and declared she would just have a mastectomy instead. After her surgery, the pathologist found one tiny cancer in an otherwise normal breast. The lesions seen on MRI were just normal breast tissue.

Our desire to know more led many women like this patient to choose unnecessary mastectomies. The correlation between receiving an MRI and having a mastectomy was borne out in several analyses at the time and we soon abandoned routine MRI.

MRI’s were not the only factor contributing to the resurgence of patients demanding more radical surgery for breast cancer. Physicians have also played a role.

In their book No Longer Radical, breast cancer physicians Dr. Rachel Brem and Dr. Christy Teal argue that surgery should be as radical as the patient desires. Like generations of Halstedian surgeons before them, Brem and Teal suggest that mastectomies offer peace of mind: “You have the opportunity to potentially change your future with mastectomies.” 

Brem and Teal argue for mastectomies on breasts with cancer and those without: “Preventative mastectomies can be one of the most positive, empowering ways for a woman to take control of her life by boldly and actively reducing her odds of getting breast cancer.”

After a consultation, Brem and Teal report that forty percent of women who see them elect to have “preventative” mastectomies. To remove breasts without cancer.

This is the RIGHT choice, Brem and Teal emphasize, because it’s what they chose for themselves: “[W]omen deserve to know that they may have access to a procedure that has brough relief, freedom and even joy to both of us personally.”

No longer radical?

Perhaps.

A recent study of over 660,000 breast cancer survivors found that only 69 out of 1000 women will develop a cancer in their other breast. In this study, women who chose to remove both breasts eliminated this risk.

When the researchers looked at death due to breast cancer, however, choice of surgery didn’t matter. Women who chose to keep their healthy breast had the same death rate (around 16%) as women who chose to remove them. Choosing the more radical route did not impact how long they lived.

Don’t get me wrong. Prophylactic mastectomies have a role in breast cancer care. Women with genetic mutations and strong family histories should absolutely consider this option. But for the vast majority of us, I wonder if the late 19th century belief that surgery could remove every last cancer cell has just found another host. Surgeons still hold the scalpel, but now they want women to demand that they use it. 

This controversy is not new. Shortly after his landmark study NSABPB-06 was published in 1985, Dr. Bernard Fisher sought to quell women’s concerns that by choosing to save their breasts instead of removing them that they would be sacrificing a chance to be cured. Fisher wrote, “Of course there are a lot of women who say ‘I don’t want to do this [lumpectomy]. I don’t want to take the chance.’ But this is the message that must be gotten out: they’re not really taking a chance; The survival rates are the same.”

Then as now, anxiety cannot be cured with surgery.

Exaggerated perception of risk leads women at normal risk of breast cancer to choose drastic measures. They unwittingly respond to fear of cancer with giant surgical procedures and still the worry is there. An analysis of nineteen studies including over six thousand women showed that fear of cancer remained consistently high in women who chose to prophylactically remove a breast without cancer.¹

Fisher explained these results forty years ago: “Cancer is not a surgical disease any more than atherosclerosis is a surgical disease,” he wrote, “you are nowhere near preventing or eradicating either process with just surgery.” 

A “one size fits all” approach of mastectomizing every woman is exactly the opposite of where we should be. We need individual approaches not sharper scalpels. If the medical community is doing its job as Fisher intended, the role of the surgeon should be shrinking not resurging.

Surgeons like Shelley Hwang at Duke University School of Medicine are doing just that.

Dr. Hwang is trying to find which breast cancers do not need surgery at all. She is the primary investigator of a national study, called COMET, which is assessing whether women with the lowest risk pre-cancerous breast lesions can avoid surgery.

Women with pre-invasive cancerous cells, or DCIS, who enroll in the trial are randomly assigned to either surgery or observation. Using the data obtained from this trial, Hwang envisions a future where women with breast cancer might not need surgery at all.

“For women who have the kind of DCIS that may never become invasive cancer, much of the treatments that are recommended may be overtreatment and not offer the patient any benefit.”

What a radical idea.

On My Mind…

I had a GREAT time in New England this summer. Hello to all my New Hampshire people! Todd and the animals did great without me but there is no place like home.

1. Srethbhakdi A, Brennan ME, Hamid G, Flitcroft K. Contralateral prophylactic mastectomy for unilateral breast cancer in women at average risk: Systematic review of patient reported outcomes. Psychooncology. 2020 Jun;29(6):960-973. doi: 10.1002/pon.5379. Epub 2020 Mar 31. PMID: 32201988.