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Katharine Yao, MD, discusses the changes she has seen in her years of experience with breast surgery in the past decade. According to analysis of the National Cancer Data Base, double mastectomies have almost tripled over the past decade. This trend is particularly marked in younger patients. Approximately 40% women under 45 years old are choosing to have both breasts removed for their newly diagnosed breast cancer. She shares what led her to medicine, her passion for care for her patients, as well as her insight on the analysis she has done.
What influenced you to go into medicine? Why did you choose oncology, and specifically breast surgery? I chose breast surgery because there is such a close relationship between what happens in the research realm and what happens in the clinic. In other words, findings in the research world are easily translated into our clinical practices and it is very gratifying to know you are making a difference for patients by being involved in important research studies. Breast cancer treatment has made such large strides through the years and I feel privileged to be a part of this progress.
What have been the biggest changes, trends and discoveries in the field of breast cancer since you have been practicing medicine? I think one of the biggest changes in breast cancer over the past decade is that we have learned there are different types of breast cancer that can be treated in different ways. We used to treat all breast cancers the same but now we have targeted therapies for certain types of breast cancer and these targeted therapies have revolutionized the way we treat breast cancer.
Another area that has exploded in the field is genetic testing for breast cancer (and other cancers as well). We have much more knowledge about genetic mutations that predispose to breast and ovarian cancer, and we now can test for many more genes. Genetic testing for BRCA has become commonplace with much faster turnaround thereby allowing patients to use the information for surgical decision making.
I am a surgeon so I have to discuss discoveries in breast surgery! Breast surgery continues to evolve and has changed dramatically over the past 20 years. We have gone from radical mastectomies and lymph node dissections to now small lumpectomies and removing just a few nodes from the axilla. We are continuing to explore ways to spare patients more surgery and better ways to conserve the breast. For those patients who have a mastectomy, we have many more reconstructive options available to patients as well.
According to your analysis of the National Cancer Data Base, more and more women are electing to have double mastectomies for Stages 0 to 3 breast cancer. What factors do you think contribute to this rise? There are many reasons that patients choose a double mastectomy but our research has shown that how much patients value keeping their breast or removing the breast for peace of mind are highly associated with getting a double mastectomy. In my conversations with patients, peace of mind is a big driving factor for the double mastectomy choice and this “peace of mind” can mean different things to different patients. For some, “peace of mind” means avoiding future mammograms, reducing the risk of getting cancer in the other breast or getting a better cosmetic result. We have also shown from our research that patients have misperceptions of the impact of double mastectomy on their survival. Patients feel that a double mastectomy will give them a better survival then a lesser surgery and we have a decision aid that explains to patients that cancer can come back whether a double mastectomy is done or not.
What led you to do this analysis? In my clinic I was seeing that more and more women, particularly younger women, were requesting bilateral mastectomy. At the time we were a beta test site for the National Cancer Data Base participant user file and we started to look at the rates of bilateral mastectomy and saw a dramatic increase. At first I thought this was a troubling trend but now after researching and surveying many women who have had this surgery, we realize that it may be the best option for some women as long as they are properly informed of its impact on their outcome.
What were the key findings of your research? Did anything stand out to you specifically? Or surprise you? I was initially surprised to see such a dramatic increase over the past decade particularly amongst younger women despite the fact that no clinical trials or large studies were published that showed that bilateral mastectomy was superior to unilateral mastectomy (surgery that removes one breast) or lumpectomy. I think we have learned that the reasons why women choose a double mastectomy are different then a decade ago and we have to become comfortable discussing these reasons with our patients.
Did you find that the national trends reflected what you were seeing in your practice at NorthShore? Yes, our trends here at NorthShore mirror what we have seen nationally.
What is your advice to patients recently diagnosed with breast cancer who may be considering a double mastectomy?
We always inform patients that a double mastectomy does not give a patient any advantage with respect to survival or recurrence. We also explain the surgical risks of double mastectomy. Lastly, we always try to elicit patient’s values and preferences for certain types of surgery so we can make sure patients are making surgical decisions that correlate with their values. If a patient is very worried about cosmesis, future mammograms or biopsies, the risk of cancer in the other breast or just really needs “peace of mind” then we discuss double mastectomy. It is important for patients to understand that all surgeries have upsides and downsides and it is just a matter of finding the right procedure for each patient. We currently developing a decision aid to help patients make these decisions.
What does the future hold for breast cancer prevention, diagnosis and treatment? What are you personally most excited about? I am excited about how much we have personalized breast cancer treatment. We have discovered that one size does not fit all. We need to move in this direction with breast cancer screening and develop individualized screening regimens based on each patient’s risk profile. Fortunately, we are currently working on incorporating risk models and genomic risk scores into risk assessment for our patients so that we can tailor our screening regimens.