Cause célèbre: Rush to judgment for mastectomy?

Celebrity can bring attention to a cause — and it can bring unnecessary angst. Many women rushed to get genetic testing for the cancer-causing BRCA mutations after actress Angelina Jolie said in May 2013 that she underwent a double mastectomy based on a positive BRCA test. … It was an unnecessary rush to judgment, concluded a study published in The BMJ. [1]

Sunita Desai and Anupam B. Jena, authors of the research study, noted:

• Daily BRCA test rates increased immediately after the 2013 editorial, from 0.71 tests/100,000 women in the 15 business days before to 1.13 tests/100,000 women in the 15 business days after publication.
• In comparison, daily test rates were similar in the same period in 2012 (0.58/100,000 women in the 15 business days before 14 May versus 0.55/100,000 women in the 15 business days after), implying a difference-in-difference absolute daily increase of 0.45 tests/100,000 women or a 64 percent relative increase (P<0.001).
• The editorial was associated with an estimated increase of 4,500 BRCA tests and $13.5 million expenditure nationally among commercially insured adult women in those 15 days.
• Increased BRCA testing rates were sustained throughout 2013.
• Overall mastectomy rates remained unchanged in the months after publication, but 60 day mastectomy rates among women who had a BRCA test fell from 10 percent in the months before publication to 7 percent in the months after publication, suggesting that women who underwent tests as a result of to the editorial had a lower pre-test probability of having the BRCA mutation than women tested before the editorial.

Now a Danish study concludes one in three women with breast cancer detected by a mammogram is treated unnecessarily: [2]

• Screening was not associated with lower incidence of advanced tumors.
• The incidence of nonadvanced tumors increased in the screening versus prescreening periods (incidence rate ratio, 1.49 [95 percent CI, 1.43 to 1.54]).
• The first estimation approach found that 271 invasive breast cancer tumors and 179 ductal carcinoma in situ (DCIS) lesions were overdiagnosed in 2010 (overdiagnosis rate of 24.4 percent [including DCIS] and 14.7 percent [excluding DCIS]).
• The second approach, which accounted for regional differences in women younger than the screening age, found that 711 invasive tumors and 180 cases of DCIS were overdiagnosed in 2010 (overdiagnosis rate of 48.3 percent [including DCIS] and 38.6 percent [excluding DCIS]).

Dr. Leigh Erin Connealy notes if your diagnosis is early stage breast cancer, make sure your doctor isn’t using the C-word for DCIS or LCIS. If that’s not an issue, get a second opinion anyway.

Remember that even if DCIS and lobular carcinoma in situ (LCIS) have been ruled out, your diagnosis is still not bulletproof. No single test is enough to launch an intervention as drastic as a biopsy, surgery, radiation, or chemo. Mammograms, for example, miss up to 20 percent of pathology warnings. So insist on having every additional test and consultation available:

• Thermography
• Ultrasound
• Full blood sugar panel
• Thyroid function
• Vitamin D sufficiency
• Vitamin A sufficiency
• Digestive system (biome) health and diet — consult with a qualified nutritionist

If all evidence indicates early stage breast cancer, talk seriously with your doctor about the possible interventions, possible or likely side effects, and the best treatment options, including possibly a lumpectomy — targeted surgical removal of affected or vulnerable cells. This procedure, Dr. Connealy points out, has been proven as effective as mastectomy in preventing the spread of early-stage cancer.