As Economy Turns, Cancer CentersEmploying Watchful WaitingBY ERIC T. ROSENTHAL

[ A L S O ]Ovarian Cancer: ‘Dark Side’ of IP Chemo in Advanced Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

DCIS: Big Increase in Use of Prophylactic Mastectomy . . 16

GIST Registry Shows Unexpected Practice Patterns . . . . . 26

ShopTalk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

POETRY by Caregivers: Connie Achord, RN, BC, OCN. . . 56

Misconceptions Keeping Latinas from Timely Breast-Cancer Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Conferences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

The leaders of a sampling of comprehensive cancer centers of varying

size, structures, and geographic locales tell how they are faring in

the new economic reality. The good news is that so far the recession

appears not to have been a detriment to providing continuing quality

cancer care. Still, none are taking anything for granted, and continue to

take a prudent, “hoping for the best, preparing for the worst” approach.

See Page 28

PERIODICALS

ONCOLOGYTIMES

Years

Publishing for

31

The Oncology & Hematology Source

[ News ✽ Analysis ✽ Commentary ✽ Controversy ]www.oncology-times.comMarch 25, 2009 ✽ Vol. 31 ✽ No. 6

IOM Says RethinkPhase III Trials &NCI CooperativeGroups

p. 35

Joe Simone: ‘EricHoffer’s Profound &Continuing Influenceon Me’

p. 4

Study: Cash-StrappedCancer SurvivorsSkimping on Health Care p. 5

ASCO KRAS-Test GuidelinesAre First of New Way to GiveClinical Advice

p. 41

More women with ductalcarcinoma in situ (DCIS)are choosing to add con-tralateral prophylactic ma-

stectomy to their treatment, despite thepaucity of evidence that it prolongs life,and even though there are potentialside effects and more inconveniencethan other prophylactic strategiessuch as mammography, magneticresonance imaging, and—for thosewith estrogen receptor positive disease—tamoxifen.

This is the finding of a 51,030-patient analysis of the Surveillance, Epi-demiology and End Results (SEER)database, available online ahead of print in the Journal of ClinicalOncology, by a team led by Todd M.Tuttle MD, MPH, Chief of SurgicalOncology at the University of Min-nesota. The study follows theirearlier investigation of contralateralmastectomy rates among patients withinvasive breast cancer ( JCO 2007;25:5203–5209).

The investigators used SEER data,which from 1998 included recordsof contralateral mastectomy plannedwithin six months of treatment forbreast cancer obtained from 16 geo-graphical areas including a quarter ofthe US population treated from 1998through 2005.

Rates More Than DoubledA total of 2,072 patients chose con-tralateral prophylactic mastectomyduring this period—the overall ratewas 4.1% for all surgically treated pa-tients and 13.5% for patients who hadmastectomy in the affected breast.During the eight-year study period, thecontralateral prophylactic mastectomyrate increased from 2.1% in 1998 to5.2% in 2005 for all surgically treatedpatients—a rise of 148%.

Taking only the patients whoseDCIS was treated with mastectomy(excluding those who had breast-conserving surgery) the rate increased188% in the eight-year period—from 6.4% in 1998 to 18.4% in2005.

Dr. Tuttle told OT that he and hiscolleagues could not explain the rea-sons for this surge in popularity forbilateral mastectomy, but that itseemed to be largely patient-driven,with women believing they are elimi-nating the risk of future cancer bychoosing to have double mastec-tomy—“Which is sadly, not the case,”he said.

Younger, White WomenThe study found that younger patients,white women, and those with lobularcarcinoma in situ were all more likelyto opt for bilateral mastectomy. Largetumor size and higher grade were bothsignificantly associated with higherrates of contralateral prophylactic mas-tectomy among all surgically treatedpatients, but among patients undergo-ing mastectomy those with smaller tu-mors and lower grade were more likelyto choose the procedure.

The researchers pointed out thatthe absolute risk of breast cancer inthe contralateral breast among pa-tients with DCIS is quite low—ataround 0.5% to 0.6% per year, with a 20-year risk typically of no morethan 10% to 12%. And survival ratesamong women with DCIS are veryhigh (approximately 98% to 99%). Sothe recent increase of contralateralprophylactic mastectomy in patientswith DCIS (similar to that already re-ported among patients with invasivebreast cancer) is not being driven byevidence of clear efficacy for avoidingdeath.

“It’s possible that the improvementin mastectomy techniques and aware-ness of genetic testing have played a

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Big Increase In Use of ProphylacticMastectomy for DCIS BY PETER GOODWIN

TODD M. TUTTLE, MD, said he andhis colleagues could not explain thereasons for the surge in popularityfor bilateral mastectomy, but that itseemed to be largely patient-driven,with women believing they areeliminating the risk of future cancerby choosing to have doublemastectomy—“which is sadly, notthe case.”

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role. Also the attitudes of younger womenhave changed, with many of them lessconcerned about mastectomy,” Dr. Tuttlenoted.

When questioned about the reasonsmore women are choosing double mastec-tomy he mentioned the feedback hisgroup has received from patients: “Sincewe published our studies, we have receivedmore than 100 e-mails from patientstelling us why they chose to undergo bi-lateral mastectomies when they only haddisease in one breast. A lot of them fearcancer. And, as noted, a lot of them thinkthat if they have bilateral mastectomies,that they’re going to eliminate the chanceof ever getting cancer again, which, unfor-tunately, is not necessarily true.”

Symmetry, ObesityOne advantage though, Dr. Tuttle ex-plained, is that contralateral prophylacticmastectomy makes it easier to achieve sym-metry, giving a cosmetic result less likely tochange as patients grow older. And, henoted, the increasing prevalence of obesityin the community is a possible contributingfactor favoring the choice of bilateral mas-tectomy because symmetry is even harder toachieve in obese patients who have a singlemastectomy.

Clinical Experience ConfirmedIn an accompanying editorial, AbramRecht, MD, Professor of Radiation Oncol-ogy at Harvard Medical School and De-puty Chief of the Department of RadiationOncology at Beth Israel Deaconess Medi-cal Center, reflected on the surprising dataemerging from this SEER database analy-sis. The article “confirms something thatwe’ve seen clinically for a while,” he notedin an interview.

Dr. Recht said he was struck to see it putas dramatically as Dr. Tuttle’s article onDCIS, just as the data published in 2007had shown for patients with invasive cancer.

When he was asked if the large increasein the popularity of contralateral prophy-lactic mastectomy is justified by evidencethat it saves lives he said: “No!”

He noted that at the same time as breast-conserving therapy has been more widelyadopted, the study has now shown that

there has—paradoxically—been a move in amore aggressive surgical direction.

Little DataIn his JCO editorial Dr. Recht said hewanted to express how little data there areshowing that contralateral mastectomy hasany benefits beyond clearly reducing therisk of developing contralateral breast can-cer, and he observed that patients oftenhave a different perspective:

“It’s quite clear that the great majorityof patients I see who have opted for con-tralateral prophylactic mastectomy believethat there is a survival advantage. But it’sbeen astonishingly difficult to actually finddata supporting that belief.”

The reasons for the choice of prophy-lactic mastectomy—made because of aperception of risk—cannot easily be as-sessed from the SEER data. Among theyounger, mainly white patients who optedfor it, there wasn’t any indication whetherthese individuals were truly at high risk ofdeveloping new contralateral breast can-cers—because of factors such as having astrong family history, or even having

BRCA-1, or BRCA-2 mutations confer-ring susceptibility to breast cancer on ge-netic testing.

“But even in these limited populationsof high-risk patients, one really can’t, at thispoint, find data showing that contralateralprophylactic mastectomy will benefit theirlong-term breast cancer-specific survival,”Dr. Recht said.

BRCA 1 and BRCA 2 mutations, hethought, have not played a big part in thedecision-making process—except for the factthat discussion of these factors has raisedpublic awareness of genetic issues. He ob-served that prophylactic mastectomy is oftencarried out even in the absence of thesemarkers of risk.

Earlier evidence suggesting that con-tralateral prophylactic mastectomy confersa survival advantage may have been flawedby the fact that patients of higher socioeco-nomic status tended to be the ones whoopted for it, he said.

He pointed out that although it isknown that contralateral prophylacticmastectomy (CPM) nearly eliminates thechance that a patient will get cancer inthat breast, some patients may die of theiripsilateral breast cancer before they havethe chance to develop contralateral breastcancer.

“Also, cure rates for such contralateralcancers are likely to be high, and it’s impor-tant to point out to our patients that wedon’t have evidence yet to show to showthat individuals having CPM are improv-ing their long- term chances of cure—or ifthey are, by how much—and that they haveto consider the potential downsides of thetreatment against potential but nebulousbenefits.

“I tell patients that at present there’s re-ally no evidence that having contralateralprophylactic mastectomy will increase theirchance of surviving breast cancer. There’s ahope that it might—based on suppositionsand assumptions in some modeling stud-ies. But the reality is we don’t yet have suf-ficient information to tell them that thereis such an improvement, or precisely whatdegree of improvement there might be,” hesaid.

But he added: “I do tell them that itclearly does reduce—dramatically—therisk of developing new breast cancer. Andfor some individuals that peace-of-mindfactor is sufficient for them to go aheadwith surgery.” O

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When ABRAM RECHT, MD, was asked if the large increase in the use ofcontralateral prophylactic mastectomy isjustified by evidence that it saves lives, hesaid, "No, but I do tell my patients that itclearly does reduce—dramatically—therisk of developing new breast cancer. Andfor some individuals that peace-of-mindfactor is sufficient for them to go aheadwith surgery.”

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At the same time asbreast-conservingtherapy has been

more widely adopted,this new study shows

that there has—paradoxically—been

a move in a moreaggressive surgicaldirection for DCIS.

✽ In Brief | Study Links Second-Hand Smoke to Cognitive Impairment

Exposure to high levels of second-

hand smoke resulted in a 44% in-

creased risk of cognitive impairment in

non-smoking adults over the age of 50

in a study published online in BMJ

(2009;338:b462).

Using saliva samples and a detailed

smoking history from the 4,809 study

participants, a team led by David J.

Llewellyn, PhD, Research Associate

in the Department of Public Health

and Primary Care at the University of

Cambridge, measured levels of coti-

nine, a byproduct of nicotine, in the

patients’ saliva and assessed the

levels of exposure to second-hand

smoke.

A series of neuropsychological tests

were then used to assess aspects of

brain function such as verbal memory,

numerical calculations, time orienta-

tion, and verbal fluency, and these re-

sults were then added together to

provide a global score for cognitive

function. Those patients whose scores

were in the lowest 10% were subse-

quently identified as suffering from

cognitive impairment.

“We have conducted the first study

to examine the association between

second-hand smoke exposure and

cognitive impairment in elderly non-

smokers,” Dr. Llewellyn said in a news

release.

“Our results suggest that inhaling

other people’s smoke may damage

the brain, impair cognitive functions

such as memory, and make demen-

tia more likely. Given that passive

smoking is also linked to other seri-

ous health problems such as heart

disease and stroke, smokers should

avoid lighting up near non-smokers.

Our findings also support calls to

ban smoking in public places.”

Patients with high levels of sali-

vary cotinine were more likely to be

cognitively impaired. Possible ex-

planations for why exposure to sec-

ond-hand smoke may increase the

odds of developing cognitive im-

pairment, including dementia, are

an increased risk of heart disease

and stroke which are known to in-

crease the risk of such ailments, the

authors noted.