MEDICINE

A kind or gratuitous cut?

Debate over surgery touted as preventing breast cancer

Wendy Dennis September 7 1981
MEDICINE

A kind or gratuitous cut?

Debate over surgery touted as preventing breast cancer

Wendy Dennis September 7 1981

A kind or gratuitous cut?

MEDICINE

Debate over surgery touted as preventing breast cancer

Wendy Dennis

After breast cancer felled her mother, two aunts and a cousin in their 30s and 40s, Marlene Murray of Oakville, Ont., faced a tough choice. Plagued with breast lumps and repeated biopsies since age 16, she dreaded an unsure future until her doctor recommended prophylactic (preventive) subcutaneous mastectomy. Performed before any cancer cells are detected, the procedure removes nearly all the tissue below the breast skin, leaving the skin and nipple intact, and can be followed by breast reconstruction with p?astic or silicone implants.

Unlike more extensive mastectomies, this operation does not involve removal of the entire breast, chest wall muscles or lymph nodes. Still, recalls Murray, “I left his office and cried. But I watched four very young women deteriorate from breast cancer, so I didn’t debate for vanity’s sake.” Last January she underwent the surgery. She was 25 years old.

Murray is one of a small but growing group of women opting for a 25-year-old operation that has become increasingly popular in Canada over the past decade. In Toronto alone, more than 20 surgeons perform it, while in other centres doctors acknowledge they’re seeing more patients. Ironically, interest in the surgery is accelerating at a time when highly charged controversy surrounds mastectomy as a treatment for breast cancer. Heightened awareness of breast

cancer potential plus improved reconstructive techniques have recently spotlighted the procedure. Dismal breast cancer statistics have also helped. The disease strikes one woman in 11 in her lifetime, that risk spiralling again for

women whose close female relatives have suffered from the malady. For high-risk patients like Murray, proponents claim prophylactic subcutaneous mastectomy dramatically reduces the cancer hazard.

But camps divide over the precision of criteria used to pinpoint risks, including a hotly debated mammogram (breast x-ray) classification system widely used to determine who has cancer-prone breasts. Many doctors bitterly oppose the operation when there’s no positive evidence of cancer, and question how preventive it can be when some breast

tissue remains. To further complicate matters, a wide disparity exists among proponents and detractors as to what percentage of the breast tissue actually remains postoperatively.

Dr. Alan Bassett, director of the breast treatment unit at Toronto’s Mount Sinai Hospital, rejects the notion that subcutaneous mastectomy decreases the cancer risk and warns against telling a woman that the operation prevents cancer, when scrupulous medical monitoring may help her as much. He further theorizes that the operation might actually increase chances of getting the disease, now that the original cancer-producing influences are focused on a smaller amount of tissue. “We’re just starting to see women who’ve had subcutaneous mastectomies developing breast cancer,” he says. “The chickens are going to come home to roost over the next 15 years.” Defenders, while agreeing there’s no foolproof way to predict breast cancer victims, insist there’s certainly a highrisk population. According to Dr. Dale Birdsell, chief of plastic surgery at Foothills Hospital, Calgary, the operation should be performed only when several factors coalesce, conspiring to push the patient’s risks into the danger zone. Such situations occur rarely. When a woman shows a strong family history of breast cancer in close maternal relatives, severe breast pain, multiple breast lumps that must be tested on frequent anxiety-producing biopsies or has already lost one breast to cancer, she’s considered a possible candidate. Abnormal and possibly pre-malignant cell changes in the mammary glands are another indication. To those who claim only radical mastectomy removes all cancer threats, proponents of the newer operation counter that even then some susceptible tissue remains, while with subcutaneous mastectomy there are minimum risks and better reconstruction results. Comments Dr. Robert Newton, a plastic surgeon at Toronto General Hospital: “This operation substantially decreases the possibility of tumors. It’s not a clear-cut area; it’s still controversial. But patients aren’t being well-informed by medical practitioners. Women at least have the right to make up their own minds when presented fairly with the alternatives.” While women like Marlene Murray view subcutaneous mastectomy as a chance to live without fear, most doctors—proponents and detractors alike—are well aware of the operation’s limitations. Notes Dr. Reid Waters of Winnipeg, past president of the Canadian Society of Plastic Surgeons: “This is not the perfect operation to prevent breast cancer and we can’t sell it as that. It’s an operation where the jury is still out.”