Early Lumpectomy Doesn't End Cancer Risk
Lumpectomy Safe, but Long-Term Vigilance a Must in Young Women
The Key: Long-Term Follow-Up continued...
"We really have to investigate why a women can be 35 and have breast cancer," Munster tells WebMD. "What is predisposing this young woman to breast cancer? Whatever made you susceptible to have breast cancer at a young age makes you more susceptible in the long run. That may be more important than whether the woman had a lumpectomy for her original tumor."
Munster strongly agrees with Arriagada that young women successfully treated for breast cancer should continue seeing a breast cancer expert. It's essential for their own health. And it's important for the next generation of women, too.
"It is really important that women under 40 with breast cancer be proactive in getting treatment at a major center where they have access to genetic counseling," Munster says. "They should think about becoming part of studies that look at this young group. We don't even know whether these young breast cancers respond to our treatments in the same way as breast cancers in older women. We need to study this, and young women can help by joining clinical trials."
Too Conservative Breast Conservation?
The lumpectomy procedure in the Arriagada study -- conducted in the 1970s -- used what surgeons call a 2-cm free margin. That is, the surgeons removed 2 cm of cancer-free tissue surrounding the tumor.
That's large by today's standards. But given the risk of recurrence in his study, Arriagada recommends a conservative approach to breast conservation.
"Breast-conserving surgery has become very popular. So the indication has been extended, and sometimes we have been less careful in the margin -- you can have a 3-mm, a 5-mm margin," he says. "For young people, we should insist on at least 1 cm of free margin."
That's controversial, Munster says. She says surgeons vary widely in their approach.
"These surgeons have strongly different opinions," Munster says. "They may consider an appropriate margin to be anywhere from 1 mm to 1 cm. Some people accept a millimeter, others only a centimeter. There is no real clear guideline."
One thing that is changing, Arriagada says, is that doctors now will consider a second lumpectomy for some patients.
"When the recurrence is a very small tumor, it is possible to perform a second breast conserving surgery," he says. "There is experience with this in Europe. The dogma was that after local recurrence, mastectomy should be performed. But for selected patients with very small, very well limited cancers, they can have a new lumpectomy with or without local radiation, and the prognosis is very similar to mastectomy. ... The second treatment of lumpectomy or local surgery does not change the prognosis for the patient with local recurrence."