Breast Cancer Patients Long-Term Quality of Life After Breast Conservation vs. Mastectomy and Reconstruction
Women facing surgery after a breast cancer diagnosis have the option of removing the entire breast (mastectomy) or only the affected breast tissue (lumpectomy). Regardless of which type of surgery a patient chooses, research shows both groups of women are equally satisfied with their breasts 10 years after surgery.
However, there were two areas where breast conservation patients and mastectomy patients differed: women who had a lumpectomy along with adjuvant radiation therapy (also known as “breast conservation”), reported better psychological and sexual well-being 10 years after surgery than those who underwent mastectomy and reconstruction.
“These findings may inform preference-sensitive decision-making for women with early-stage breast cancer,” explains Dr. Benjamin D. Smith, of The University of Texas MD Anderson Cancer Center.
According to a similar study, these findings “have substantial implications for patient decision-making, given that more women eligible for breast-conserving surgery are opting for a mastectomy,” shares Dr. Sudheer Vemuru, of the University of Colorado School of Medicine, Aurora.
“Overall, the preponderance of evidence suggests superior short-term and long-term patient-reported outcomes in patients with early-stage breast cancer undergoing breast-conserving surgery compared with mastectomy,” adds Dr. Vemuru.
Regardless of what type of surgery a patient ultimately chooses to have, if they are fully informed of ALL their options, they are far more likely to be satisfied with their overall outcome and feel they made the best choice for them. Patients and medical providers must work together to decide what surgical procedure(s) best meets the patient’s outcome goals and lifestyle.
Questions to Ask Your Doctor When Considering Breast Conservation vs Mastectomy and Reconstruction
If you don’t understand what your physicians or nurses are saying, don’t be scared to let them know your concerns. When you see your doctor, you may want to bring another person with you and have them take notes to help you remember what was said. Here are some questions to ask to better understand your options:
- Is breast-conserving surgery (lumpectomy) an option for me? Why or why not?
- What are the pros and cons of breast-conserving surgery versus mastectomy, with or without reconstruction?
- How many surgeries like mine have you done?
- Do I need lymph nodes removed? If so, how many and what are the risks?
- How long will I be in the hospital?
- How should I care for the surgery site? Will I need someone to help me?
- What will my breasts look and feel like after my surgery? How will the procedure impact my feeling?
- What will the scar(s) look like? Can they be hidden around the areola or in the breast crease?
More questions for your breast surgeon can be found here.
The Importance of Shared Decision Making
Shared decision-making occurs when the health care professional and patient work together to make a treatment decision that is best for the patient. The best decision takes into account evidence-based information about treatment options, the physician’s knowledge and experience, and the patient’s preferences and values. Multiple studies show this collaborative approach improves patient outcomes and satisfaction.
Shared decision-making is a method where both the patient and physician participate in the medical decision-making process together. To arrive at the best treatment plan for the patient, this approach considers all evidence-based treatment options and associated risks, the physician’s expertise, together with the patient’s preferences, values, and expectations.
Download the latest version of the Breast Advocate app here.
Low Vitamin D Levels Increase Breast Cancer Risk in Minority Women
Low vitamin D levels may play a role in developing breast cancer, particularly in minority women.
The immune-boosting benefits of vitamin D are well-known and several prior studies have looked at the impact of low vitamin D levels on various diseases.
According to a new study, Black and Hispanic American women with low vitamin D levels have a greater risk of breast cancer than those with adequate vitamin D levels. Having enough vitamin D may therefore help decrease the risk of breast cancer in minority women.
Study Results
Katie O’Brien, Ph.D., and colleagues looked at blood samples from 290 Black and 125 Hispanic women who later developed breast cancer. They also collected samples from 1,010 Black and 437 Hispanic women who did not develop breast cancer.
Over a nine-year period, women with sufficient vitamin D levels had a 21% lower breast cancer rate than women with vitamin D deficiency. The study found the link between vitamin D and breast cancer risk was highest in Hispanic women, who had a 48% decreased risk of breast cancer if they had sufficient vitamin D levels.
Enhanced Health Benefits
“Because women who identify as members of these groups have lower vitamin D levels, on average than non-Hispanic White women, they could potentially receive enhanced health benefits from interventions promoting vitamin D intake,” explains study co-author Katie O’Brien, of the U.S. National Institute of Environmental Health Sciences. “However, questions remain about whether these associations are truly causal and, if so, what levels of vitamin D are most beneficial.”
How to Increase Your Vitamin D levels
Spending enough time outdoors in the sunshine is very important as your body naturally produces vitamin D when your skin is exposed to direct sunlight. Taking a regular supplement can also help increase your vitamin D levels, along with including certain foods in your diet, such as:
- Oily fish (eg salmon, sardines)
- Red meats
- Eggs (especially egg yolks)
- “Fortified” foods (eg some breakfast cereals)
More Information
To learn more about vitamin D and cancer prevention, visit the U.S. National Cancer Institute.
Lumpectomy is as Effective as Mastectomy for Younger Patients with Breast Cancer
According to a recent study, a lumpectomy is as effective as a mastectomy in women with non-metastatic breast cancer under the age of 40. Young women with early stage breast cancer who have breast-conserving surgery (lumpectomy and radiation) have the same survival rate as women who have a mastectomy. These findings show that advising patients on outcomes is critical in decreasing the unnecessary morbidity from surgical procedures that may not be indicated, given the increased use of mastectomy within this age group.
“[The study] results also emphasize the need for future attention on racial outcome disparities in young women,” Christine Pestana, MD, – said during the presentation, a researcher at the Oncology Department of Breast Surgery at the Levin Cancer Institute Atrium Health.
The Research Behind the Study
According to Dr. Pestana, 1 in 68 women will develop breast cancer by the age of 40, and these women are more likely to have advanced-stage disease at the time of diagnosis compared to older women.
“Outcome disparities persist between the two groups,” Dr. Pestana goes on to say that “mastectomy rates are increasing in younger patients despite lack of data supporting improved survival [compared to lumpectomy and radiation].”
The researchers evaluated the relationship between survival and surgical approach among approximately 591 women under the age of 40 (66% white, 25.9% black). These women are part of the Lewin Cancer Institute’s database of young women who have had surgery for nonmetastatic breast cancer. About a third (35.5%) of these women had a lumpectomy and the remaining (64.5%) had a mastectomy.
Researchers compared patient age, race, BMI, disease stage, grade, molecular subtype, lymphovascular invasion, extranodal extension, type of surgery, use and timing of chemotherapy, and hormone therapy use.
Study Results
After a median follow-up of 5.5 years, 72% of women (12%) were deceased. More than half of the women (53.3%) had hormone receptor-positive, HER2-negative cancer, 20.8% had hormone receptor-positive/HER2-positive cancer, 19.3% had triple-negative cancer, and 6.6% had HR-negative/HER2-positive cancer.
There was no difference in overall survival between women who underwent mastectomy and those who had breast-conserving surgery. Most (85.4%) women with HR-positive/HER2-negative disease received antiestrogen therapy. Researchers observed a 2.9-fold increased risk for death among women who had not been treated with hormone therapy compared to those who had hormone therapy.
Black patients had a higher risk of death in all molecular subtype groups. Even after researchers accounted for all other risk factors, multivariate analysis showed black women with triple-negative breast cancer had a 5.7-fold higher risk of dying.
“The results are particularly significant because younger women are increasingly being diagnosed with breast cancer, despite low rates overall, and a growing number are undergoing mastectomy and even prophylactic bilateral mastectomy rather than breast-conserving surgery,” Pestana said.
Clinical trials have also shown that women choosing to have lumpectomy and radiation have an overall rate of local recurrence at 5 years of less than 5%. This statistic compares similarly with mastectomy local recurrence rates.
While several studies show lumpectomy and radiation is associated with (at least) the same overall survival as removing the entire breast, there is no “one size fits all” approach to breast cancer surgery. There are many factors that patients will need to consider in deciding the best approach for their individual situation. Ultimately, the final decision should be reached using a shared decision-making approach between the patient and their healthcare team.
The Breast Advocate® App is the World’s first breast cancer surgery shared decision-making app. Download it free here.
New Protein Protects Against Breast Cancer Tumor Growth
New research performed in Sweden has found a key protein that protects against breast cancer tumor growth. The recent discovery at the Karolinska Institute in Sweden also showed that estrogen receptor (ER) negative breast cancer patients with higher levels of this protein, known as GIT1, have a better prognosis.
Breast cancer affects 1 in 8 American women at some point in their lives. Unfortunately, there are fewer treatment options for ER-negative breast cancers, which lack estrogen receptors (ER) and do not respond to anti-estrogen hormone therapy. Triple-negative breast cancers, which lack estrogen, progesterone, and HER2 receptors, are very difficult to treat since they lack the receptors that mainstay breast cancer treatments target.
“Identification of new molecular mechanisms that regulate the growth of ER-negative breast cancer is warranted, as these mechanisms may represent novel therapeutic targets,” explains Per Uhlén, professor at the Department of Medical Biochemistry, Karolinska Institutet.
Professor Uhlén and his team at the Department of Medical Biochemistry, Karolinska Institutet discovered a novel way by which the GIT1 protein regulates ap rocess known as Notch signaling. Overactive Notch signaling affects the development and progression of ER-negative breast cancer and has previously been linked to a worse prognosis.
“Our results provide important information about a mechanism that controls the initiation and growth of breast tumours,” continues Professor Uhlén. These study results could potentially lead to the development of new treatments for hard-to-treat types of breast cancer that do not respond to first-line therapies.
Collaboration to Develop New Treatment Options
Professor Uhlén’s research group is working closely with physicians who treat cancer patients to focus on research areas that are critical to patient care.
“We want to conduct research that can benefit patients with severe diseases,” says Professor Uhlén. “At Karolinska Institutet, we have state-of-the-art tools and equipment that can push the development of new therapies.”
Overdiagnosis of Breast Cancer May Not be as Common as Previously Thought
Screening mammograms save lives. However, studies also show they can lead to overdiagnosis of breast cancer. Overdiagnosis occurs when the tumors that are found would never have caused harm if they had not been detected. New research has found that this happens less often than experts previously thought.
Among women who have routine mammogram screening every 2 years between the ages of 50 and 74, about 1 in 7 breast cancers detected will be overdiagnosed. This is lower than previous reports that quoted estimates as high as 30%.
Dr. Katrina Armstrong of Massachusetts General Hospital in Boston states, “The good news is, it’s less common than we thought.”
According to Armstrong, the issue with overdiagnosed cancers is that they lead to unnecessary treatment and emotional baggage. Still, the chances of that happening are low for anyone undergoing breast cancer screening.
Approximately 7 in 1,000 women are diagnosed with breast cancer through mammography screening. According to the latest estimate, about 1 in 1,000 women who undergo screening will be diagnosed with a cancer that would not have caused any harm in the first place.
“Assuming that 60% of the 280,000 cases of breast cancer diagnosed in the United States each year are found through mammography screening, eliminating overdiagnosis could spare 25,000 women the cost and complications of unnecessary treatment,” shares Armstrong.
Why does overdiagnosis happen?
“No screening test is perfect, and there are always downsides,” said senior study author Ruth Etzioni.
Finding a tumor that would never have developed to the point of causing harm might lead to overdiagnosis. In other circumstances, the tumor is developing but would not have progressed to a “clinical disease” before the individual died of another cause.
According to Armstrong, the field has a “duty” to prevent overdiagnosis, and overtreatment, as much as possible. She believes it is possible, based on ongoing research. Studies are underway to increase the accuracy of screening technologies and to find better strategies to predict the progression of breast cancers.
More information on breast cancer early detection can be found at the American Cancer Society.
Are Lifestyle Factors the only Reason for Racial Differences in Breast Cancer Outcomes?
According to Dr. Svasti Haricharan, lead author of a recent study, “Society has internalized the narrative that lifestyle factors are to blame for racial differences in [breast cancer] outcomes, so most scientists don’t look at molecule-level differences between people.”
Researchers compared estrogen receptor-positive (ER-positive) cancerous tissue from black and white women with normal breast tissue. They discovered that eight DNA damage response and repair (DDR) genes in black women functioned differently in black women.
The repair response was inhibited by some of the dysregulated DDR genes.
Dr. Haricharan continues, “What we’re seeing here is a tangible molecular difference in how these cells repair damaged DNA – a critical factor in the development of cancer – which affects how cells grow and reproduce in tumors.”
Implications of the Study
This study proves that how patients do after a breast cancer diagnosis is certainly not just dependent on lifestyle factors. More importantly, doctors may need to adjust treatment plans for black women with breast cancer based on the findings of the study.
“This is something we can act upon immediately because helping these women is less about finding a new drug and more about changing the timing for treatments we already have available,” explains Dr. Haricharan.
Doctors use cyclin-dependent kinase inhibitors in the later stages of treatment for ER-positive breast cancer. They may be able to introduce this earlier in the treatment of black women with breast cancer, giving them a better prognosis.
Dr. Haricharan spoke with Medical News Today about the research and the team’s future plans.
“Black women are severely underrepresented in virtually all datasets of patient tumors, so a lot of previous results about breast cancer only accurately reflect what’s happening to white women,” said Dr. Haricharan. “We hope our research will highlight the need to study cancer in different racial and ethnic groups more closely and improve outcomes for historically marginalized patients.”
New Study Advances Personalization of Metastatic Breast Cancer Treatment using Immunotherapy
According to a recent study led by researchers at the National Cancer Institute’s (NCI) Center for Cancer Research, an experimental form of immunotherapy that uses an individual’s own tumor-fighting immune cells could potentially be used to treat people with metastatic breast cancer. The study found that most women with metastatic breast cancer can build an immune response against their tumors, which is required for this type of immunotherapy and relies on TILs (Tumour-Infiltrating Lymphocytes).
In a clinical trial of 42 women with metastatic breast cancer, 67% established an immune response against their cancer. Six women were treated with this method, with half of them experiencing a significant tumor decrease in tumor size.
Mutations in tumor DBU create abnormal cells called neoantigens. TILs can target neoantigens that the immune cells cannot recognize. When mutations in tumor DNA occur, neoantigens are created. Other types of immunotherapy have been proven to be beneficial in treating cancers, such as melanoma, that have many mutations and neoantigens. Its effectiveness in cancers that have fewer neoantigens, such as breast cancer, however, has been less clear.
The goal of this study was to see if using immunotherapy to treat metastatic epithelial-type cancers, such as breast cancer, could result in tumor regression.
In the trial, researchers used whole-genome sequencing to find mutations in tumor samples from 42 women with metastatic breast cancer whose cancers had progressed despite conventional treatments. TILs were extracted from the tumor samples, and their reactivity against neoantigens produced by the various tumor mutations in the tumor was examined in lab testing. TILs recognized at least one neoantigen in twenty-eight women. Almost all of the neoantigens discovered were specific to each patient.
The researchers developed the reactive TILs to large numbers in the lab for each of the six women who were treated. Next, they gave each patient intravenous infusions of the immune cells. All of the patients received four doses of pembrolizumab (Keytruda), a checkpoint inhibitor, before the infusion to prevent the newly introduced T cells from becoming inactivated.
The study reported that “objective tumor regression was noted in three patients, including one complete response (now ongoing over 5.5 years) and two partial responses (6 and 10 months).
The researchers recognized that the use of pembrolizumab could raise questions about its impact on the outcome of the TIL therapy. However, they determined that treatment with such checkpoint inhibitors alone has not previously resulted in long-term shrinkage in people with hormone receptor-positive metastatic breast cancer.
This study shows that most patients with breast cancer are able to generate a natural immune response to their tumors. Most patients with breast cancer generated a natural immune response which could potentially be harnessed to improve breast cancer treatment with immunotherapy in the future, particularly for those who don’t respond to standard therapies.
Having Dense Breasts and a High BMI May Increase Breast Cancer Risk
According to research published in the JAMA Network Open, the combination of having dense breast tissue and a high body mass index (BMI) increases the risk of developing breast cancer, with a stronger association identified among postmenopausal women.
Both factors should be included in risk classification in population-based screening, explained Thi Xuan Mai Tran, Ph.D., from Hanyang University in South Korea.
“Women with obesity and dense breast tissue might benefit from tailored early screening strategies to detect breast cancer,” states Tran.
Dense breast tissue and obesity are both known to be significant risk factors for breast cancer. However, how these two factors combine is not clear, particularly when it comes to menopausal status.
Tran’s team sought to look at the relationship between breast density, BMI, and menopausal status. The team looked at data from the Korean National Cancer Screening Program, which included 3.2 million premenopausal women with an average age of 45 years and 4.4 million postmenopausal women with an average age of 60 years. Premenopausal women were found to have 34,466 cases of breast cancer, while postmenopausal women had 30,816 cases.
The researchers found that increased breast density was linked to a higher risk of breast cancer in both premenopausal women across all BMI groups.
Without taking BMI into account, premenopausal women in the BI-RADS 4 category had twice the risk of breast cancer compared to those in the BI-RADS 1 category who were underweight.
When breast density and BMI were paired with breast cancer risk, Tran’s team discovered that high breast density and high BMI had a “significant” positive interaction for both premenopausal and postmenopausal women, with the latter having the strongest effect.
“Our findings suggest that breast density notification should be provided not as a stand-alone risk factor but as an adjunct factor with BMI for risk stratification in population-based mammographic screening settings for public health significance,” the researchers concluded.
Be sure to discuss your breast density and weight management with your healthcare team. It is very important to know if you have dense breasts as you may benefit from a tailored breast cancer screening strategy to increase the chances of early detection.
Depression in Breast Cancer Patients: Prevalence and Relationship to Quality of Life
According to a recent study, at least 1 in every 10 patients diagnosed with breast cancer require treatment for depression. Unfortunately, patients generally don’t get the care they need unless doctors screen them for the mental health disorder. About 1% of breast cancer patients who were not screened were ultimately diagnosed with depression, data showed.
The findings are based on an analysis of a program introduced by the Kaiser Permanente health system in 2017 to identify cancer patients who need behavioral healthcare. This program successfully guided 7% of breast cancer patients with depression into the treatment they needed.
“Early identification and treatment for mental health issues is critical, yet depression and other mental health issues are often under-identified and under-treated in breast cancer patients,” study co-author Erin E. Hahn said.
“Our study showed that the use of implementation strategies to facilitate depression screening is highly effective … [at helping] our cancer patients achieve the best possible health,” states Hahn, a research scientist with Kaiser Permanente Southern California in Los Angeles.
According to the National Institute of Mental Health, over 20 million people in the United States are diagnosed with depression each year.
Research suggests that roughly 25% of patients diagnosed with breast cancer develop this mental illness, which produces chronic feelings of sadness, loss of interest in daily activities, loss of energy, difficulty sleeping, and even thoughts of suicide. Some types of breast cancer treatment, such as chemotherapy, hormone therapy, and surgical removal of the ovaries can increase the risk of depression.
Hahn and her colleagues enrolled 1,436 breast cancer patients treated by Kaiser Permanente doctors for this study. Patients were divided into 2 equal-sized groups and either received specific screening for depression followed by tailored interventions, or education only.
Among those who completed the screening, 10% had scores that indicated a need for mental health care. Furthermore, patients who were screened were more likely to be referred to behavioral care and required fewer oncology visits.
“The trial of this program was so successful that we have rolled out depression screening initiatives across all our Kaiser Permanente medical oncology departments in Southern California,” study co-author Hahn said.
“We are incorporating the lessons learned from the trial, particularly the importance of ongoing audit and feedback of performance and are encouraging our clinical teams to adapt the workflow to meet their needs,” she said.
Depression is a mental illness and is a lot more than just not feeling yourself for a few days. If you can’t shake the feeling of sadness, are disinterested in life activities, or are having problems coping in any way, please reach out to your healthcare team for help.
Cardiovascular Imaging Can Be Inaccurate After Breast Reconstruction With Implants
Over half of women who are treated for invasive breast cancer decide to have breast reconstruction with implants after a mastectomy. The demand for breast reconstruction procedures is expected to increase a lot over the next decade.
According to a recent study, however, breast implants may alter the interpretation of some types of imaging studies.
“There have been several reports in the medical literature of women with breast cancer and implants in whom the results of cardiac studies, such as echocardiography and nuclear tests, were inaccurate,” says Ohad Oren, MD, Cardiovascular Medicine at Massachusetts General Hospital.
Dr. Oren does also highlight that cardiac imaging mistakes are actually uncommon in women who have breast reconstruction with implants. However, at the same time, he emphasizes the importance of determining the appropriate imaging technology to use in these women in order to maximize accuracy.
Women diagnosed with breast cancer can be at increased risk of developing cardiovascular disease after treatment with certain chemotherapy drugs and radiation, especially when the cancer involves the left breast.
“Radiation, in particular, increases the risk of coronary artery disease and heart attacks, and also predisposes women to diseases of the pericardium and heart valves, and to heart-rhythm abnormalities” explains Dr. Oren. “Currently, there is no uniform recommendation for screening women with breast cancer for the presence of heart disease, despite the fact that the most common cause of death among women diagnosed with early-stage breast cancer is heart disease.”
The authors of the study suggest that research needs to be a combined effort between cardiologists, oncologists, radiologists, plastic and reconstructive surgeons, and breast implant manufacturers.
“We need to identify the optimal imaging tests that would detect heart problems in women with implants and minimize the potential for missed or incorrect cardiovascular diagnoses,” says co-author Ron Blankstein, MD,
The authors conclude that understanding how breast implants may impact the quality and accuracy of imaging results when choosing between different tests is critical in creating strategies for the precision and treatment of cardiovascular disease in this high-risk population.
