Instead of a lumpectomy, some going even further

More patients are choosing to have both breasts removed

By Erin Middlewood, Columbian special projects reporter

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Toni Storm-Dickerson carefully scraped breast tissue away from the underside of the 43-year-old patient’s skin.

A routine mammogram had spotted irregularities in one of the patient’s breasts. Given that the woman’s breasts weren’t large, removing the lump and preserving the breast wasn’t the best option because it would significantly disfigure the breast, Storm-Dickerson said. But the patient chose to go even further. She elected to have both breasts removed during her September surgery at PeaceHealth Southwest Medical Center in Vancouver.

It’s a decision more women diagnosed with breast cancer are making.

Studies show a sharp increase in the number of women with breast cancer undergoing mastectomy instead of a surgery to remove tumors while preserving the breast. Also rising is the number of breast cancer patients opting to remove the opposite, healthy breast as well.

The rate of women with early-stage cancer in one breast who choose to remove both breasts more than doubled, from 1.8 to 4.5 percent between 1998 and 2003, according to a key study published in 2007 by the American Society of Clinical Oncology.

“A lot more patients are choosing mastectomy than they used to. The change is patient-driven, and that has a lot to do with reconstruction options,” said Storm-Dickerson, a surgeon at Compass Oncology in Vancouver.

Patients who have their healthy breast removed with the cancerous one do so to reduce the risk of the disease recurring, but also for symmetry. Both breasts can be reconstructed to look the same.

The federal Women’s Health and Cancer Rights Act of 1998 requires group health insurance plans that cover mastectomies to also cover breast reconstruction surgeries.

In the operation on the 43-year-old woman, Storm-Dickerson was able to preserve the entire envelope of the breasts, including the nipples. That’s possible in about 3 to 5 percent of mastectomies she performs, Storm-Dickerson said. Women with smaller breasts are better candidates for that type of surgery. Although they are able to keep their nipples and better recapture the original appearance of their breasts, they lose sensation.

Storm-Dickerson worked alongside plastic surgeon Dr. Allen Gabriel, who removed the healthy breast as she removed the cancerous one. Then he inserted chest expanders.

After healing, the expanders will be injected with a little saline each week to create a pocket underneath her chest muscle, where implants will go in a later reconstructive surgery.

Patients whose nipples are removed can have artificial nipples constructed later from folds of skin with tattooed “areolas.”

Given that mastectomy and reconstruction are major surgeries, doctors counsel patients on the risks. Doctors consider the size, number and placement of tumors in making a surgical recommendation.

When Cindy Horenstein was diagnosed with ductal carcinoma in situ in 2002, she didn’t want to take any risks.

Even though it’s the earliest stage of breast cancer, “I wanted to cut to the chase and contemplated a prophylactic double mastectomy,” Horenstein said. “I had a 4-year-old, I was very freaked out that I wasn’t going to be around to raise him.”

But she talked with her oncologist and decided on a lumpectomy, along with 6 weeks of radiation and five years on the drug Tamoxifen. She lived cancer-free until a tumor was discovered in an annual follow-up magnetic resonance imaging test this year. The cancer reached her lymph nodes. This spring, Storm-Dickerson performed a bilateral mastectomy. Horenstein wrapped up chemotherapy in September, and has reconstructive surgery scheduled for later this month.

“We didn’t spend time going back to 2002, saying we should have done it differently,” said Horenstein, 52, a Vancouver attorney. She’s confident she, her husband and her doctor made the best decision they could the first time around, just as they did this time in deciding on a surgery to remove both breasts followed by chemotherapy and ongoing hormone therapy.

“A big part of supporting patients is letting them know about their options,” Storm-Dickerson said. “As providers, our responsibility is to get people cancer-free, but also to support them, and education is an important part of patient support.”