Mastectomy Vs. Lumpectomy: How Much Is Enough

March 31, 1985|By Betsy A. Lehman. Boston Globe.

LESS THAN a month ago, doctors told Lissa Kapust of Newton, Mass., that the lump in her right breast was cancerous. The tumor was small, though, and the cancer did not appear to have spread.

They also gave the 35-year-old clinical social worker a choice. She could have the breast removed, the traditional treatment called mastectomy, or just the section surrounding the lump, called lumpectomy, plus five or six weeks of daily radiation treatments.

They told her the best information now indicates that the two approaches give women with early breast cancer an equal chance of surviving at least five years--roughly 80 percent if cancer is not detected in lymph nodes under her arms and 65 percent if it is. Her surgeon reserved an operating room. She had until the day before to decide.

The first days were consumed with frightening diagnostic tests and seemingly interminable waits for results. Shocked and in disbelief, Kapust`s first thought was how much she wanted to live, no matter what the treatment, to raise her two young children, fulfill her marriage, pursue her career.

Like others faced with serious disease, Kapust said, she longed to believe she could strike a bargain: If she paid the price of a mastectomy, she could live. Gradually, as she gathered information and talked with doctors, she started having doubts. Perhaps she didn`t have to pay the highest price to get the best result. The doctors were telling her that paying probably wouldn`t even help. But they wouldn`t say what to do.

By coincidence, at the same time Kapust was mulling over her options, the New England Journal of Medicine was publishing interim results of the landmark National Surgical Adjuvant Breast Project involving more than 2,000 women throughout the United States and Canada. It offers the best evidence so far that the two treatments offered Kapust give equal results in many cases of small tumors. The study was big news for several days, with stories quoting some physicians as saying mastectomy soon would decline from favor on the strength of the new data, and others saying the data were good but too short- term to provide definitive proof.

As she struggled with her dilemma, Kapust recalls a ripple of anger on hearing Jane Pauley on the ``Today`` show say how nice it was that women today have a choice.

Not long ago, breast cancer patients didn`t have choices; their breast, and usually the muscles behind it were removed, often before they awoke from anesthesia at the time of the tissue-testing. Now, doctors give options, but some patients, unable to get unequivocal advice, feel torn by their freedom.

``My doctors were wonderful and caring,`` Kapust said. ``They gave me as much time as I wanted. What they said they couldn`t give me was direction. Their comment to me was, `You can`t make a bad decision.` . . . If you give the patient freedom you can be a good doctor, but even so it still leaves you, it left us, wishing for more direction.``

Doctors say it is difficult to give unequivocal advice for three reasons: First, they are not all persuaded that the two operations will prove equally good in the long run; second, not all women fall into the disease categories selected for the study; and third, it is relatively new for surgeons to share decision-making about breast surgery with patients, and it is a highly personal and time-consuming process.

The important thing is ``to express your reservations and to give an honest appraisal,`` said Dr. Alfred M. Cohen, codirector of surgical oncology (tumor treatment) at Massachusetts General Hospital. ``This is new, of course. Doctors didn`t do this even five years ago. That is the big difference --women know there are choices. Five years ago, women were embarrassed to ask and most surgeons were not interested in any other approaches.``

``What most middle-class women and their husbands want is a brief postgraduate course on breast cancer,`` said Dr. William C. Wood, director of the Massachusetts General Hospital Cancer Center. ``You spend an enormous amount of time explaining, which you don`t in other diseases.``

``I see a few patients a month who have been wiped out by the decision-making process psychologically,`` Cohen said. ``They are mostly professional women who have learned to make decisions in their lives. When they found out about this, they said, `I`m going to take control and make a rational decision.` They found out there was no way to do that. There`s not a scientific algorithm you put the various bits of data into and come up with a correct answer. It comes down to conflicting information from three or four doctors and being unable to make a nice rational calm decision.``