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Can prevention be part of cure?
By Afifa Jabeen Quraishi
Published in The Saudi Gazette on 14 - 02 - 2009

Is removing the unaffected breast by preventative mastectomy the key to curb or decrease future risks of breast cancer in women with the disease in one breast? According to a new study conducted by researchers at The University of Texas M. D. Anderson Cancer Center and to be published in the March 2009 issue of CANCER journal, it is.
The study found certain patient and tumor characteristics that predict whether a breast cancer patient with disease in one breast will benefit from a contra lateral prophylactic mastectomy (CPM) – a preventative procedure to remove the unaffected breast.
Because patients with a history of carcinoma of one breast have a significant increased risk of developing contra lateral breast cancer, many women are prompted to consider CPM as a preventive measure.
“Removing the contra lateral breast does decrease the risk of developing a cancer in that breast,” Dr. Kelly Hunt, M.D., professor in the Department of Surgical Oncology at The University of Texas M. D. Anderson Cancer Center and head researcher of the study, said to Saudi Gazette.
Contra lateral is the opposite or unaffected breast. Unilateral refers to the breast affected with cancer.
“Gender, age, BRCA 1 or BRCA2 ( Breast Cancer Antigen 1 & 2 are the markers of predicting breast carcinoma in females)mutations, family history of breast cancer, personal history of breast cancer, race, density of breast tissue, use of hormone replacement therapy (HRT) have all been described to affect breast cancer risk.
However, we found that they did not predict those patients that had an unsuspected cancer in the opposite breast at the time of their mastectomy,” said Dr. Hunt.
In Saudi Arabia, breast cancer constitutes 18 percent or one-fifth of all cancers in Saudi women. Whilst locally advanced breast cancer disease is unusual in Western countries, it constitutes more than 40 percent of all non-metastatic breast cancer here.
Hunt's Study on
Methods: Hunt studied 542 patients treated at the M. D. Anderson Cancer Center between 2000 and 2007 who had breast cancer in one breast and who chose to have both breasts removed. The collection of patient data and analysis of the data took about 12 months.
Results: Examination of the prophylactic mastectomy specimen (opposite breast) by pathologists revealed that twenty-five patients (5%) had cancer in the contra lateral breast. There were 82 patients (15%) who had cells in the other breast that were abnormal and could signify higher risk for breast cancer development. “When we looked for clinical features that were associated with finding cancer in the contra lateral breast, we found three important factors: when the ipsilateral cancer was of invasive lobular subtype; when there was more than one cancer in the breast; and when the patient had a 5-year Gail risk of 1.67 percent or greater,” Hunt said.
The Gail model is a breast cancer risk assessment tool used for women without a cancer diagnosis that takes into consideration a woman's menstrual history, age, family history and history of prior breast biopsies, and the number of biopsies with atypical hyperplasia to estimate a 5-year and a lifetime risk of developing breast cancer.
Conclusion: The findings of the study indicated that CPM may be a rational choice for breast cancer patients who have a 5-year Gail risk 1.67%, more than one tumor in the breast, or a breast cancer of invasive lobular histology. Dr. Hunt said those who do not have these factors are at lower risk and CPM may be an unnecessary surgery for patients who are not likely to develop contra lateral breast cancer.
An aggressive treatment
Hunt said CPM is an aggressive treatment because it removes all of the breast tissue and is not reversible.
“The procedure has not been shown to improve survival in patients with a diagnosis of breast cancer. Since most breast cancer patients (80%) do not develop another cancer in the opposite breast, there is no need to remove the healthy unaffected breast tissue,” she said.
Hunt said the cost of CPM varies depending on the medical facility. “CPM is technically similar to a standard mastectomy for breast cancer treatment and can be performed by most surgeons trained in this procedure,” she said.
Hunt hoped the information in the study can reduce the fear that women have about developing another breast cancer. “Women should more carefully understand their risks before making decisions about their health care. The study has been received favorably,” she added.
Breast Cancer expert
weighs in
Dr. Iqbal Musani, pathologist at the Jedani Group of Hospitals in Jeddah, said, “The study discusses all the pros and cons of the removal of the other (contra lateral) breast even if it has no cancer at the time of removal of the affected breast. It found evidence of very early cancer in 30 percent of patients and if it is genetic in origin, patients who have a 5-year Gail risk 1.67%, more than one tumor in the breast, or a breast cancer of invasive lobular histology. Then the other breast will be affected later.” However, he said: “The study does not deal with the main breast cancer- as it is a well known entity as far as its diagnosis and management is concerned.”
Commenting on the criteria considered in the study, Dr. Musani said: “Firstly, if blood relatives like the mother, sister or any other close relative is suffering from breast cancer, and the patient had cancer in one breast then it suggests genetic predisposition in that, the other is better taken off. Secondly, if cancer markers like BRCA1 and BRCA2 are positive in patients along with the above mentioned criteria, then the potential risk looms in the other breast so again, it is better removed.”
“Thirdly,” he said, “in the case of an advanced breast cancer over a long period, there are chances that the other breast may already have it. Fourthly, in health conscious societies, where modern replacement models such as, breast prosthesis, etc. are available, people can have both the breasts similar, in their choicest sizes and contours, which unlike normal breasts, do not become flabby and pendulous due to its anchorage and definite beauty enhancing properties. So, more women go for contra lateral mastectomy along with operation in the original breast,” Dr. Musani added.
He said cancer, in general, is not very common in Saudi Arabia as compared to third world countries, and that factors of affluence and genetics are accounted for their low incidence.
However, according to a CNN report, nearly 70 percent of breast cancer cases in the Kingdom will not be reported until they are at a very late stage, compared with 30 percent or less in the US. Thirty percent of Saudi patients are under 40 years.
“Here, majority of the breast cancers are detected late because most do not have a prophylactic approach to the disease, such as, regular mammography, self-examination of the breast, etc.,” said Dr. Musani.
Dr. Hunt said breast examination can be performed by trained health professionals and it should be done on an annual basis as part of regular medical check-ups.
“However, women should be encouraged to take their time in deciding whether or not to get CPM. Depending on the risks involved, not everyone needs that dramatic measure. I always try to get patients to give more time and consideration to it,” she added.
In late 2007, the former US first lady Laura Bush's visit to the Kingdom gave a boost to the awareness of breast cancer in the kingdom, with the signing of the US-Saudi Arabia Partnership for Breast Cancer Awareness and Research program, which the MD Anderson Cancer Center in Texas is a part of.
The World Health Organization estimates that 84 million people will die of cancer between 2005 and 2015, and in the year 2010, cancer will become the leading cause of death internationally.

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