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.