Date: Wed, 5 Apr 2000 13:26:37 -0700 (PDT)

The New York Times

April 4, 2000

Removing Healthy Breasts Found Effective in High Cancer-Risk Group

A desperate measure for reducing the risk of breast cancer, removing both breasts while they are still healthy, has been proved effective even for women with genetic defects that put them at the very highest level of risk for the disease.

The new findings come from the first long-term study to include women with mutations in the genes BRCA1 and BRCA2, which cause 5 percent to 10 percent of all cases of breast cancer. Women with the mutations have a 56 percent to 85 percent chance of developing the disease. Removing the breasts reduces the risk by 90 percent for those women, according to a study presented yesterday in San Francisco at a meeting of the American Association for Cancer Research.

The study, conducted at the Mayo Clinic in Rochester, Minn., included 214 women considered to be at high risk because breast cancer ran in their families. All had their breasts removed as a preventive measure from 1960 to 1993. So far, of 148 who have been tested, 28 had BRCA defects, including 17 with defects specifically linked to cancer.

After a median of 15 years of follow-up, none of the 28 has developed cancer. Three breast cancer cases have occurred in the high-risk group despite the surgery, but none in women with BRCA defects.

Over all, in a group of 214 high-risk women, 38 breast cancer cases would have been expected.

The same researchers had already proved last year that breast removal could protect women who had a strong family history of breast cancer, and doctors had assumed that the findings would also apply to women with BRCA defects. But they could not be sure, because surgery had not been studied specifically in women known to carry the mutations. The operation can never remove all breast tissue, and there was always the possibility that enough mutant cells would evade the scalpel to give rise to tumors later on.

The new findings show that the surgery, prophylactic mastectomy, works. But not many women choose it, and it is controversial, especially when treatments for women who already have breast cancer are aimed at saving the breast when possible. In the study, the number of cancer cases averted was small compared with the number of women who had mutilating surgery and who might never have developed cancer.

A patients' advocacy group, the National Breast Cancer Coalition, said in a statement that very few women fell into the high-risk category, and that though the surgery appeared to help, it was drastic and "should not be recommended."

Still, the operation provides the largest risk reduction available. Another option is to take the drug tamoxifen, but it reduces risk by only 45 percent, and can be taken for only 5 years. It is not clear how long the protection lasts, and tamoxifen may cause blood clots or uterine cancer in some women.

Women at risk can also have frequent mammograms and breast examinations in hope of catching the disease early enough to cure it, but it is not clear how well that approach works.

The new information was presented by Dr. Lynn Hartmann, a medical oncologist at the Mayo Clinic and an author of the 1999 article showing that the operation worked. The 214 women she reported on yesterday were part of a group of 639 who had their breasts removed and had a risk reduction of 90 percent. In the original study, the researchers calculated the risk reduction by comparing women who had the surgery to their sisters who had not, and finding more breast cancer in the sisters who had not had the operation.

But at first, the researchers did not know whether any of the women had BRCA mutations. They have since gone back and begun performing genetic tests.

Dr. Hartmann said she did not think her findings would change doctors' or patients' minds about prophylactic mastectomy. "I have not seen waves of women coming forward to do this," she said, estimating that the operation was done only 10 to 15 times a year at the Mayo Clinic. "For women who are interested, the data just help them believe in the effectiveness of it. If a woman is not inclined in this direction, this is not going to change her preferences."

Dr. David Payne, a psychologist at the Memorial Sloan-Kettering Cancer Center in New York, said he counseled about one woman a month who was considering the preventive surgery. Most go ahead with it, and he said it was good news that the operation had proved effective. But he also said the data would not be used to push women into having their breasts removed.

"It's elective surgery, with incredible ramifications for body image," he said. "Our job to some degree is to slow down the process and make sure they're thinking through every part of it," he said.

Women's Health -- Breast Cancer

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