Radical choices in mastectomy
CMAJ 1997;156:1121
In response to: D.E. Leask
Re: "A surgical subculture: the use of mastectomy to treat breast cancer" (CMAJ 1997;156:43-5 [abstract / résumé])
Dr. Leask's letter illustrates part of the problem described in the article "Patterns of initial management of node-negative breast cancer in two Canadian provinces" (CMAJ 1997;156:25-35 [abstract / résumé]), by Dr. Vivek Goel and associates. Mastectomy rates vary among Canadian provinces, and travel time to a radiation-therapy facility is inversely associated with the use of breast-conserving surgery in both provinces (although it is not statistically significant in Ontario). However, travel time and other variables were insufficient to explain the large difference in mastectomy rates between British Columbia and Ontario.
Everyone who sees many women with breast cancer knows that some women prefer definitive treatment by surgery if it will shorten the time they have to spend away from home. As well, we all know surgeons (and not exclusively surgeons in rural communities) who tend to perform mastectomies in older women as well as those who tend to perform mastectomies because they privately still hold the opinion that mastectomy is the better treatment. More than once a patient has told me that her surgeon gave her both options but concluded, "If you were my wife . . ."
There also is the distressing fact that some women still need radiation therapy after a mastectomy, when the risk of local or regional recurrence is high. The combination of these treatments exposes these women to
a considerable risk of lymphedema.
I did not wish to patronize, and Leask's statement that all surgeons are aware that partial mastectomy and irradiation are the treatment of choice in most cases of breast cancer brings me some reassurance.
Adalei Starreveld, MD
Radiation Oncologist
Cross Cancer Institute
Professor
Department of Oncology
University of Alberta
Edmonton, Alta.
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