Issue link: https://viewer.e-digitaledition.com/i/1483585
Conversation I ncrea si n g ly, de - e s c a l at ion w it h respect to the management of the a xil- lary nodes has been embraced, reducing the incidence of ly mphedema a mong patients with early-stage disease. But other changes in protocols have lagged at a nationa l level. " T he movement of brea s t c a nc er t her apy for w a rd i s of t en a s t or y of doi n g le s s i n s t e a d of doi n g mor e ," Dr. Shubeck says. MULTIFACETED DISCUSSIONS AROUND BREAST SURGERY Jacqui Shine, PhD, a writer and historian, was diagnosed with Stage 0 ducta l car- cinoma in situ (DCIS) in January at age 38. Shine was aware of her family history of breast cancer — both her mother and ha lf-sister had developed the disease — so her physicians were surprised when she opted to delay surger y for ca ncer treatment after unexpectedly breaking her ankle around the same time. W hile Shine did ultimately receive a double mastectomy in June — after weighing genetic testing and other health factors — she agrees that more physicians need to have longer conversations with patients about breast cancer surgery. "Patients are giving up their part of their sexual life that involves their breast … a nd reconstr uction is not going to be the same," Shine says. "And I think [t h i n k i n g a bout t hat] i s i mpor t a nt , especia lly for younger people who have been diagnosed with the least-invasive kinds of cancer." Shubeck says this should be an import- a nt pa r t of treatment discussions but often isn't. " M a s t e c t omy le a d s t o s en s a t ion changes, at the very minimum," Shubeck says. "I think de-esca lation in terms of the surgica l ma nagement of breast c a nc er i s i mpor t a nt t o c ombat t he traditiona l histor y of the breast being trivia lized. … Some women don't see t hem selves a s a sex ua l bei n g when they 're diagnosed with breast cancer, so they don't really think about how much their breasts mean to them — and then six months a f ter diag nosis, that pa r t might become important again." PHYSICIANS, PATIENTS AND RISK TOLERANCE Patient anxiety about poor outcomes is not the only reason for high rates of breast cancer surgery. "The data indicate that if given the option, patients would decline certain treatments, but they proceed with the treatments because they were not offered a choice for omission," says Lesly A . Dossett, MD, MPH, Assistant Professor of Surgery and Chief of the Division of Surgical Oncology at the University of Michigan, who co-authored the study with Dr. Shubeck. However, physicians have a range of professiona l opinions about optima l treatments for breast disease, and some may proceed more cautiously than others or be willing to tolerate less residual risk for their patients. Physicians should stay up to date on the data supporting omission of certain treatments and engage in discussions with patients when omission of treat- ments is a n option, Dosset t notes. It m ay a l so be wor t hwh i le t o prov ide recommendations for menta l hea lth care in addition to oncologica l care to help patients manage anxiety. " T he excit i n g t h i n g a bout brea s t cancer therapy is it 's changing so fast. Dr. Shubeck says. "It's important to help patients know how we can better tailor their medica l therapy." n Is Breast Cancer Over‑Diagnosed? ACCORDING TO RE SE A RCH published in February in Annals of Internal Medicine by Duke Cancer Institute, around 1 in 7 breast cancers in women age 50 to 74 are likely over-diagnosed by mammogram. Using a combination of real data for nearly 40,000 women and computer simulation, researchers found an estimated 15.4% of women, diagnosed either with indolent preclinical cancer or with progressive preclinical cancer that would not have advanced before they died from a different cause, may have been unnecessarily treated. While not definitive, the study suggests that older women at average risk may want to further discuss the risks of screening mammograms, especially if they have other health concerns. De‑escalation Cancer Surgery 1 5 M D N E W S . C O M /// M D N E W S C E N T R A l P E N N S y lVA N i A ■ 2 0 2 2