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Lumpectomy and Radiation vs. Mastectomy

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Published on January 16, 2020

Key Takeaways

  • Lumpectomy plus radiation is more aggressive treatment then mastectomy.
  • Some side effects, called collateral damage, do not go away. Studies show that chemo brain is one of those.
  • Surgery is a much less important part of treatment.

Surgery is the least important thing you do for treating breast cancer,” says expert Dr. Susan Love as she explains the latest research regarding lumpectomy vs. mastectomy and other treatment choices. She shares her views on the “Angelina Effect” and studies that show lumpectomy plus radiation is a more aggressive treatment than mastectomy. Dr. Love also gives her thoughts on side effects, the future of breast cancer treatment and how the Dr. Susan Love Foundation for Breast Cancer Research's Army of Women is helping move the field forward.

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Transcript | Lumpectomy and Radiation vs. Mastectomy

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrea Hutton:

I'm Andrea Hutton from Patient Power, and I am very excited to be here today with the venerable Dr. Susan Love, the Chief Visionary Officer of the Dr. Susan Love Foundation.  Thank you so much.  I'm very excited to be here to talk to you today.  

Dr. Love:

Well, thank you.  It's great to be here. 

Andrea Hutton:

So one of the things—since you are the visionary, I would love to hear about what your vision is for the future for breast cancer patients right now.  We've had the mastectomy of the past and what is surgery—the future of surgery for breast cancer patients?  

Dr. Love:

Well, I think one of the things that's become really clear at this meeting is surgery is probably the least important thing you do for breast cancer.  With the HER2 patients they have all these fantastic drugs, and you probably don't even need surgery at all in that, because you can watch the tumor shrink away with these drugs.  

Even with other kinds of, other types of breast cancer we know from long‑term randomized controlled trials that lumpectomy and radiation is as good if not slightly better than mastectomy in terms of survival and in terms of prevention because you can radiate a much bigger area than you can cut out.  So it's really—lumpectomy and radiation are more radical treatment than mastectomy.  And it sorts of kills me that we have two studies where women were willing to be randomized so we would have the answer, and we're very often ignoring it. 

Andrea Hutton:

So a randomized study, so some people got one thing and some people got… 

Dr. Love:

…and it was picked out of a hat, yeah. 

Andrea Hutton:

And you as a breast surgeon…

Dr. Love:

Yes. 

Andrea Hutton:

…are saying lumpectomy radiation.  

Dr. Love:

Why are we doing this?  Why are we doing mastectomies?  It makes absolutely no difference in terms of outcomes, in terms of living and dying.  It doesn't make any difference.  The drugs we have are really good.  The prevention drugs we have, you know, are preventing a second cancer.  And I think part of it, why people do it is because they get scared, and it's sort of if your breast betrays you cut it off, you know, punish it. 

But really you forget that you can't cut as much as you can radiate.  You can radiate.  Breast tissue goes from your collar bone to your ribs and from the middle of your chest all the way out here to your latissimus dorsi. 

Andrea Hutton:

Okay.  My bra is not that big, so…

Dr. Love:

…that's correct.  But there's breast tissue. 

Andrea Hutton:

Okay. 

Dr. Love:

And when you do a mastectomy you don't take all that out.  But you can radiate all of that.  So you can actually cover a bigger area with radiation, and just take the lump out and radiate the rest of it, and we know that you have good long‑term outcomes.  And so it is sort of surprising having been in this business so long to see this flip back to everybody having mastectomies.  

Andrea Hutton:

So last year, the year before, the Angelina Jolie effect, so you're actually—I mean it's worse than just mastectomy.  It's double mastectomy.  

Dr. Love:

Right.  But she has the gene.  She inherited the BRCA gene.  That's different.  Now we're talking about a prophylactic mastectomy so that you won't get breast cancer.  So she was a gene carrier.  That's why she did it. 

But most people who get breast cancer are not getting hereditary breast cancer.  They're not gene carriers.  The risk to the other breast is really not that high, and you can keep a sensate breast, which is kind of nice instead of having no sensation at all, which is what happens when you have lumpectomy—when you have mastectomy and reconstruction. 

Andrea Hutton:

So you're saying a lumpectomy radiation is actually the more aggressive treatment. 

Dr. Love:

Yes. 

Andrea Hutton:

Actually for the breast cancer itself. 

Dr. Love:

For the breast cancer itself, because you can radiate a bigger area than you can cut out. 

Andrea Hutton:

Wow.  Okay.  That is a big change.  So as a patient, we do definitely have that feeling of, okay, I want to start now.  I want to get rid of it and everything.  So how do you combat all of those years of people being indoctrinated into that kind of message? 

Dr. Love:

Well, it's only recently that they've been indoctrinated, because I've been in practice—I started a long time ago, and we were doing almost all lumpectomy radiation, so it's only in the last five years to 10 years really that we're seeing so many mastectomies and bilateral mastectomies.  Part of it I think is better cosmetic surgery, and so people will say, well, we can take them off.  We can give you new ones.  They'll be better than the old ones.  They will, but you can't—you have no sensation.  You don't know when you're hugging your kid.  I mean there's a lot of downside to it that I think people don't fully think about when they make that decision. 

Andrea Hutton:

Yeah.  I mean one of the things that you talk about a lot is collateral damage. 

Dr. Love:

Exactly. 

Andrea Hutton:

Those are the things that people don't talk about when they talk about mastectomy is the lack of sensation. 

Dr. Love:

Exactly.  

Andrea Hutton:

And that's just I mean it may be very far down the list of…

Dr. Love:

Yeah. 

Andrea Hutton:

…things that affect you, and that's—you don't even hear it. 

Dr. Love:

Well, if you think you're going to save your life and you say, oh, well, I'll do it, you know, I'll do it, but it makes a big difference not to have any sensation.  And there's other collateral damage as well.  We did a study on women with metastatic breast cancer and we asked them, tell us your collateral damage in your own words because I didn't want to put any ideas in.  And there were lots of things that came up.  There were real problems for people that the drug companies and the studies don't show. 

For example, trastuzumab (Herceptin), the biggest complaint was rhinorrhea, a continuously runny nose.  Now, you wouldn't think, well, that's not life-threatening, but it's a real bother to have your nose running all the time.  So there are things like that that are collateral damage that going to be—it's sort of like having your car in a car accident.  You can have it fixed, but it never drives the same way again.  Once you've been through cancer and the cancer treatments your body never works the same way again, and there are lots of things that you start noticing that, gee, why is that?  And that's collateral damage.  And it's not going to get better. 

Andrea Hutton:

And a lot of those things are—I'm still in treatment but I had my chemotherapy 10 years ago, and there are long tails for lots of things. 

Dr. Love:

Oh, they don't go away.  The chemo brain doesn't go away.  They actually did a study—I had leukemia six years ago and I had a bone marrow transplant, so I've had chemo and I've had chemo brain.  And they did a study in people who had had bone marrow transplants and they said that you either—they found definitely there's chemo brain and a fog sort of that comes with having had chemo, and they can't decide whether you fast forward aging—so we're all deteriorating in our brains with aging.  Do you just fast forward a few years or do you drop to a lower curve and then go down at the same rate?  But they definitely documented that you're… 

Andrea Hutton:

…that there's a drop. 

Dr. Love:

It's true.  And it doesn't get better. 

Andrea Hutton:

I didn't need a study to tell me that. 

Dr. Love:

I know.  None of us did, but it's nice to have somebody say, yes, it was the poison you took. 

Andrea Hutton:

Yeah. 

Dr. Love:

Now, you'd still take the poison again because we're happy to be here, but it is nice to acknowledge that.  And then maybe that's the first step to trying to figure out is there a way we could do the treatment and not get the same collateral damage.  Because now that we're doing so much better keeping people alive for a long time, even with metastatic disease, we really want the quality of life to be as good as we can get it.  

Andrea Hutton:

Absolutely.  And then we're learning other things too, just about the breast itself.  And so can you talk to me, you know, I'm hearing words like microbiome and micro—what are the things?  

Dr. Love:

Well, the breast is this amazing organ, right?  It's the only one we're not born with.  So you're born with stem cells behind your nipple and it's not till puberty that, whoosh, you develop breasts.  It's sort of like those sponge animals in a capsule and you put them in water and they turn into—well, that's what it is. 

So then puberty.  Now you have breasts, every month at the ready, is this the month I'm going to have to go into action and become a milk factory?  No.  Maybe it's this month.  No.  And then finally you get pregnant, and then it does turn into a milk factor, and then makes this—sends immune cells to the baby, sends milk, nourishes them.  And it changes.  As the baby ages the milk changes to adapt.  And then at the end massive cleanup and then new ducts for the next kid. 

Are they in the same pattern as the old ducts or are there extra stem cells behind the nipple that grow back?  We have no idea because nobody's ever looked at the anatomy of the breast ducts.  So we've been working—I've been working on this forever because it drives me crazy, and we now have the first 3‑D printing of human breast ducts, and it's beautiful.  It looks like coral.  It's not like a pizza like you see in the textbooks, and it's not in quadrants, but there's an inner group and an outer group—an outer group and an inner group of ducts, and it's really very—it's really great.  And it's done on ultrasound.  So that's a first step. 

That means now we can start to then sample the fluid from that duct.  You could do a liquid biopsy on it and see whether it's cancer or not even without surgery, and maybe you squirt the treatment down the duct and fix it.  I mean that—then we're really getting somewhere.  So that's where we're heading at the Dr. Susan Love Research Foundation.  We're—I'm not the chief visionary officer for nothing.  I'm always trying to figure out what the next thing is going to be that will make it better for all of us.  

Andrea Hutton:

Okay, I need to go back to that.  So targeted therapy literally meaning like into that little duct… 

Dr. Love:

Yeah.

Andrea Hutton:

…and…

Dr. Love:

…and just squirt a little bit in, yeah.  It's—actually it's not—it doesn't hurt.  We've done it in the past and—but the rats—we put some chemotherapy down the ducts.  It worked very well, but the problem is that in the rats we gave it to if you waited two years, they got second cancers, so we had to stop.  But now we have a way to image and figure out the right way, and we have better drugs, so it will be better. 

But the nipple is not very sensitive.  It's really actually meant to be chewed on by babies and lovers and people like that.  So you can put a little bit of procaine (Novocaine) in there and it's completely numb, and you can put the fine catheter down through a milk duct, just a little ways past the sphincter and squirt the saline in.  And it's really painless.  I've done it to myself many times, because I wouldn't do it to other people unless I tried it. 

Andrea Hutton:

You're a chief visionary officer and guinea pig. 

Dr. Love:

That's correct.  The patient number one.  

Andrea Hutton:

You're really giving back. 

Dr. Love:

But I think—I think we'll be able to take it to the next step because really what we do now where we blindly pay no attention to anatomy, if we don't do the whole breast and we take a chunk out, we pay no attention to where the ducts are, we may be—we're probably leaving a lot of duct stuff behind.  Then we radiate it or then we—you know, we don't—to do it without any anatomy is crazy, and yet that's what we've been doing all these years. 

Andrea Hutton:

And the breast changes.  I mean I'm thinking about it now…

Dr. Love:

Yeah. 

Andrea Hutton:

…listening to what you said about it, it really is the organ that changes the most…

Dr. Love:

Right. 

Andrea Hutton:

…with the exception of your skin as an organ. 

Dr. Love:

And then menopause, then it's a whole retirement, literally. 

Andrea Hutton:

And in terms of exciting things that you maybe heard at this medical conference. 

Dr. Love:

Well, the interesting thing, and I've been going to this medical conference for a long time, since it started actually, is how surgery has become much less important, that you hardly hear anything about surgery, whereas it used to be all about surgery, it started about surgery.  But now with all the great drugs we have you don't even need surgery.  For the HER2-positive cancers they have such great drugs now that they're not even doing surgery.  You know, you give the drugs first, you watch the tumor shrink away and then you don't have to do surgery. 

Andrea Hutton:

So that's neoadjuvant. 

Dr. Love:

That's neoadjuvant. 

Andrea Hutton:

People hear neoadjuvant, it means before surgery. 

Dr. Love:

Give the chemo before surgery, yeah.  Yeah.  As opposed to adjuvant which means after surgery. 

And some of the other kinds of subtypes.  The only one that's not working great with the neoadjuvant right now is the hormonal tumors, but I think that may be in part because we don't have the right drugs.  But I think that also will—you can shrink hormonally positive tumors.  It just takes a lot longer than it does with drugs. 

Andrea Hutton:

Now, I know you also have a—the Army of Women. 

Dr. Love:

Yes. 

Andrea Hutton:

This long‑term huge study of…

Dr. Love:

…well, it's not a study.  So what the—where the Army of Women started was I was getting mad that all this research was on rats and mice and nobody was doing anything on people.  And when I went to the scientists and complained they said, well, that's because we don't know how to find women.  And I said, well, I do. 

So we started the Army of Women and it's a big—it sounds really fancy, but it's a big email list.  And researchers come to us that need people for their studies, we vet them, and then if they're good studies we e‑blast them out to everybody.  We don't select because if we select, we'd have to keep your data up to date, right?  And this way you may not fit the study but your sister who lives in Idaho might be perfect. 

Andrea Hutton:

So it's an email that says we're looking for people who have this. 

Dr. Love:

Right.  And you may know them.  And it works.  My best example was we had a study that needed Vietnamese women, and we have probably two or three in the whole army, and yet we had the right ones.  We had that study filled in one day, because she knew everybody.  And that's so it virally goes out, and then it accelerates research.  You don't want the researchers to have to spend years recruiting people.  You want them to get the research done so we can go forward with the next idea. 

And so that's really—and now we're—we met today with the male breast cancer groups who want to be part of the Army of Women, so we're trying to figure out how we're going to—but we definitely are going to add them, because they're also needed for studies.  And there are a lot of studies where you can include them, where they're just automatically not included. 

Andrea Hutton:

And you don't have to have cancer. 

Dr. Love:

Anybody on the planet can sign up. 

Dr. Love:

Exactly.  Because you need people who don't have cancer to compare to the people who have cancer.  

Andrea Hutton:

And you don't ask for any information either. 

Dr. Love:

No, we don't, because the information changes, you see.  I might ask you have you ever been pregnant today and you say no, and then nine months from now you have a kid and then you have been pregnant.  I don't want to have to keep my database up to date.  I just want to keep your email up to date, and then you can self‑select.  So we'll tell you the criteria.  You decide which studies you want to follow up on. 

Andrea Hutton:

Well, the only way we get new treatment is by being in research. 

Dr. Love:

It's research.  You're right.  That's exactly right.  That's exactly right. 

Andrea Hutton:

Well, thank you so much for being with us and willing to talk with us today and to provide some knowledge and, of course, always hope.  Thank you so much, Dr. Love.  

Dr. Love:

Well, thank you.  This is great. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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