Consumer Reports Insights: Treatment options for women with breast cancer

Each year, about 207,000 women in the United States are told they have breast cancer. In most cases the condition is diagnosed early, when it's most treatable. And death rates are on the decline, probably because of better detection and treatment.

But the combination of early diagnosis and multiple treatments also forces patients and doctors to make a difficult decision: How aggressively should they treat breast cancer in its early stages?

The percentage of women who choose a mastectomy (which removes the entire breast) over a lumpectomy (which preserves most of the breast) is on the rise. One study found that from 2004 to 2007, 44 percent of women chose to have a mastectomy, compared with just 33 percent from 1994 to 1998. And the percentage of women who decide to have both breasts removed, not just the one with the tumor, has more than doubled since 1998.

It's important to take your time. Women who learn they have breast cancer often choose a treatment during their first visit to a cancer doctor. But it usually doesn't hurt to take a week or two to decide.

Surgery: Aggressive vs. minimal

Most women with breast cancer receive a diagnosis of either an early-stage tumor or ductal carcinoma in situ (DCIS), in which abnormal cells remain confined to the ducts in the breast and pose little threat of spreading.

Some experts question the need to treat DCIS at all, since the abnormal growths usually pose no long-term risks. But because doctors can't predict which growths might later prove invasive, most treat it like a more clearly dangerous tumor.

In those cases, as well as with early-stage tumors, the first tough decision is choosing between a lumpectomy and a mastectomy. While up to 80 percent of women are candidates for the less aggressive surgery, in this country only about 40 percent of them choose that option, compared with 55 percent in Japan, 63 percent in Germany and 81 percent in France.

Lumpectomy is not a good option if the tumor is too large or diffuse or if the patient can't tolerate radiation. But in other cases it's as effective as a mastectomy, so the choice depends on individual concerns. A lumpectomy spares most of the breast, leaves a smaller scar and eliminates the need to wear a false breast or have reconstructive surgery. But it usually entails two to six weeks of daily radiation treatments, which can cause significant fatigue, some permanent shrinking and hardening of breast tissue, and itchy and tender skin.

Mastectomy usually requires radiation only when the tumor is very large or cancer cells have spread to nearby lymph nodes. The surgery removes all the breast tissue from the side of the chest that has the tumor. That improves the likelihood of removing all the cancer and makes needing a repeat procedure less likely. Improved plastic surgery and advances in surgical techniques might be part of the reason more women are choosing to have a mastectomy.
Prophylactic mastectomy, or having a healthy breast removed along with a diseased one, does reduce the risk of developing a future breast cancer. But that's rarely necessary, since the chance of developing cancer in the unaffected breast is low. Women should consider nonsurgical options first.

Drugs: Get the right one

Several medications can reduce the risk of cancer's returning after surgery. But which one is best? That depends on your age and the kind of breast cancer you have.

Tamoxifen (Nolvadex and its generic equivalents) can cut the risk of recurrence when taken for up to five years after surgery, but only if the cancer is fueled by the female hormone estrogen. And because the drug blocks some of estrogen's effects on the body, it can bring on symptoms similar to those of menopause, including hot flashes, irregular periods and vaginal dryness.

Aromatase inhibitors, a newer class of drugs, cause fewer problems than tamoxifen. But they can cause bone loss, and only postmenopausal women should take them since they shut down estrogen production entirely. Three are now available: anastrozole (Arimidex), exemestane (Aromasin) and letrozole (Femara). Side effects such as aching joints and weak bones seem to be more common than with tamoxifen.

Targeted therapy with trastuzumab (Herceptin) can help the 20 percent of breast-cancer patients who have a protein called human epidermal growth factor receptor 2 (HER-2). People with that protein are more likely to experience fast-growing, treatment-resistant tumors.

Filtered and bottled water consumption could increase tooth decay risk

Little did I know that filtering my family's tap water might put our teeth at risk.

Two years ago, when I was pregnant and reporting on how the federal government was unwilling to regulate the rocket-fuel component perchlorate in drinking water, my husband and I decided to install a reverse osmosis filter in our kitchen tap. Since D.C. tap water has come under fire for its high levels of everything from lead to hexavalent chromium, it seemed like a sensible move.

But during a recent visit to the dentist, my hygenist remarked she had started noticing a rise in tooth decay among children who drank only filtered or bottled water, presumably because they were not drinking fluoridated water. And it suddenly occured to me: Neither was my 20-month-old son, with his 17 teeth.

As Americans' consumption of bottled water has risen - it has doubled over the past decade - it is reducing the daily exposure Americans get to the mineral that helps prevent tooth decay. And while researchers have yet to do a comprehensive study of what impact this is having, especially on children, many dentists and pediatricians believe the issue deserves serious examination.

"I think it would be good to look at," said Howard Pollick, a clinical professor in the Department of Preventive and Restorative Dental Sciences at the University of California at San Francisco and a spokesman for the American Dental Association.

Prodded by studies showing that fluoride significantly reduced tooth decay, U.S. municipalities began adding it to public drinking water systems in the 1940s. Today, about 65 percent of Americans get fluoridated tap water, including 95 percent of people in Virginia, 99 percent in Maryland and 100 percent in the District.

While a vocal minority of Americans remain skeptical, the ADA and most other health authorities remain convinced that fluoridation benefits the general population.

District dentist Pierre Palian, who treats my family, told me that after utilities started fluoridating public water supplies, "the cavities rate was cut in half. The only thing they could attribute it to was fluoridating the water."

The Centers for Disease Control and Prevention identifies fluoridation of public drinking water as one of the top 10 public health achievements of the 20th century, noting that studies show it reduces cavitities in adolescents by between 8 and 37 percent, and among adults by 20 to 40 percent.

But when it comes to getting greater precision, researchers are faced with the problem that most people in the United States don't take their children to the dentist before age 3, and most drink water from a mix of sources. As a result, it's difficult to measure the impact of fluoride on children's teeth.

China tobacco profits undermine anti-smoking push

BEIJING -- China's addiction to huge revenues from its state-owned tobacco monopoly is hindering anti-smoking measures, potentially costing millions of lives in the country with the world's largest number of smokers, experts warned Thursday.

The health and other costs of smoking already exceed the tobacco industry's economic contributions by at least $9 billion, said a report prepared by a group of prominent Chinese public health experts and economists.

If trends continue, by 2030 an estimated 3.5 million Chinese will die from smoking each year - three times the current level, it said, citing China's failure to take basic measures such as passing a national law to ban smoking in indoor public places and raising the price of cigarettes.

The analysis underscores increasing concerns that the government is jeopardizing the country's economic potential by refusing to take serious action to combat a widespread problem that escalates medical costs and hurts productivity.

Political will is lacking because China's leaders often consider only the short-term benefits, according to Teh-wei Hu, a health economics professor at the University of California, Berkeley, who has advised the government to raise cigarette prices.

"When I talk to leaders in high-level positions, they say, 'Well, I know and people know that smoking is harmful, but I won't be popular if I raise the prices," Hu said.

The report, titled "Tobacco Control and China's Future," pointed to a conflict of interest in the system. China's State Tobacco Monopoly Administration, which sets tobacco policy and enforces rules, is the same federal agency that controls the China National Tobacco Corp. - the world's largest cigarette maker. The report criticized the administration for promoting tobacco production and sales and hampering efforts to strengthen tobacco control.
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"This is the first 'critical' report of China's efforts on tobacco control from within China itself," said Judith Mackay, a World Lung Foundation senior policy adviser who reviewed the report and wrote a preface. "This speaks volumes of the strengthening of the health groups in China in countering the powerful Chinese national tobacco monopoly."

Curbing tobacco use, which is linked to the deaths of at least 1 million people in China every year, is one of the greatest health challenges the country faces. Nearly 30 percent of adults in China smoke, making up about 300 million people - a number roughly equal to the entire U.S. population. The report said that while China's overall smoking rate has not seen any significant change over the last decade, tobacco-linked deaths have risen rapidly.

"While the (tobacco) industry remains a 'major taxpayer' today, it causes enormous social costs and overall poses a loss rather than a benefit to China," the report said.

The State Tobacco Monopoly Administration could not immediately be reached for comment. The tobacco industry's position has usually been that measures to curb smoking would reduce revenue to the government and put tobacco farmers out of work.

The report was timed for release days ahead of a Sunday deadline that China will fail to meet - to ban smoking at public indoor venues under a global anti-tobacco treaty backed by the World Health Organization.

Smoking is so entrenched in Chinese society that cigarette cartons are commonly exchanged as gifts. A study shows almost half of all male doctors smoke, and tobacco companies are even allowed to sponsor schools. In many parts of China, people will light up in hospitals, offices and even elevators.

However, last year, authorities did instruct kindergartens and elementary, secondary and vocational schools to ban smoking on school grounds and bar teachers from lighting up in front of students.

Nearly 60 experts were involved in writing or reviewing Thursday's report, including its chief authors, Dr. Yang Gonghuan, deputy director of the official Chinese Center for Disease Control and Prevention, and Professor Hu Angang of Tsinghua University, one of China's best-known economists and a key policy adviser.