Americans have a unique aversion to risk -- particularly when it comes to pharmaceuticals and medical treatment. We want all the benefits of modern medical technology, but many of us won't tolerate any of the risks associated with them. We've come to expect absolute safety as well as assurances of efficacy: that is, we want an ironclad guarantee that the drug or procedure works as expected, with no serious downsides.
The weighing of benefits versus risks has long been part of the decision-making process by physicians and their patients when it comes to the use of radiation, or radiotherapy, following breast-conserving surgery, more commonly known as lumpectomy.
Breast irradiation can cause scarring, fatigue, limitation of limb movement, even a slight increased risk of heart disease and other cancers. In about 1 in 4 cases, women who have undergone surgery for breast cancer do not undergo subsequent six- or seven-week radiation treatment, and fear of the side effects is no doubt the deciding factor for many women.
While irradiation is standard treatment at many large medical institutions in the U.S., many women and their physicians opt for a process known as "watchful waiting" -- essentially, careful monitoring to see if a recurrence of breast cancer develops after surgery, in the belief that mastectomy is always an option in that event.
"Watchful waiting" assumes that the risks of radiation outweigh the benefits, but an important new study in the British medical journal, the Lancet (December 17, 2005) concludes just the opposite.
Sir Richard Peto and his colleagues at Oxford University statistically re-examined 78 high-quality studies, reports involving some 42,000 women, concluding that the benefits of radiotherapy after lumpectomy definitely outweigh the risks. The authors conclude that "watchful waiting" is simply not a safe option, since the cancer may have spread beyond the breast by the time the recurrence is detected.
Normally, breast-conserving surgery is aimed in part at removing only cancerous tissue, leaving as much of the breast as possible in the surrounding area intact. Like recently-developed techniques for removing the cancerous portion of the prostate without simply eliminating all sexual functionality in the male patient, breast-conserving surgery can be a great boon to patients in allowing them to proceed with their lives in as normal a fashion as possible and maintain their confidence and self-image. Breast-conserving surgery may, however, leave a few cancer cells behind. Radiotherapy, as the Lancet study notes, is thus the recommended follow-up to surgery, but that recommendation is not always followed.
This latest study establishes that radiation treatment is the most effective post-operative treatment to reduce the risks of recurrence and death after breast-conserving surgery -- despite the inherent risks of the radiation process. For the 1 in 4 lumpectomy patients who currently do not get radiotherapy, the Lancet study is a wake-up call.
The study authors note that in addition to radiotherapy reducing the odds of cancer recurrence, we now know that it also reduces the long-term odds of mortality. The odds of mortality 15 years after surgery are approximately 35.9 percent without radiotherapy and only 30.5 percent with radiotherapy. It may sound like a small mathematical difference but translates into lives saved.
With radiation therapy, as with prescription drugs, the demand for absolute safety, zero risk, is impossible to satisfy. The key is to weigh the benefits against the downsides. For breast cancer patients who have undergone lumpectomy -- or are about to -- the new Lancet study should end that debate, once and for all.