BREAST cancer is the most common malignancy among women in the United States. While White women are diagnosed with the disease more often, more Black women die from it and more Black women are diagnosed at younger ages and at more advanced stages, according to a study reported by the American Cancer Society.

In 2003, Black women are expected to account for 20,000 new cases of breast cancer and 5,700 deaths from the disease. Breast cancer is the second most common cause of cancer death among Black women, second only to lung cancer.

The five-year survival rate for Black women with breast cancer is 70.6 percent compared to 86.7 percent among Whites. Approximately 212,000 American women will be diagnosed with breast cancer this year.

Some of the risk factors for contracting breast cancer are increasing age, obesity, regular consumption of alcohol, having had breast cancer, family history of breast cancer, beginning menstruation before age 12, having a later first pregnancy and starting menopause later.

The first symptom of breast cancer is usually a lump. But even with mammograms, ultrasounds and biopsies, breast cancer can be difficult to detect. Treatment usually involves a combination of surgery, radiation therapy, chemotherapy, or hormone-blocking drugs.

A new type of treatment uses radio waves to destroy a tumor, basically cooking the cancerous cells. A probe is inserted into the breast to reach the tumor without cutting the patient or causing bleeding. The physician sees where the probe is going by watching an ultrasound screen. Electrons are emitted for several minutes, dissolving the tumor until it cannot be seen on the screen.

New drugs are being used to fight breast cancer by starving the tumor of estrogen. These drugs inhibit the conversion of testosterone and other hormones into estrogen, which increases the risk of developing breast cancer. Oral chemotherapy is another new treatment, that is less toxic, creates fewer side effects and is less expensive than intravenous chemotherapy

ATLANTA -- Contrary to conventional belief, results of a new study suggest that surgical removal of the primary tumor can benefit women with stage IV breast cancer.

Although overall survival was unchanged at 5 years, there was a better progression-free survival for women who underwent local therapy of the primary tumor when initially presenting with metastatic disease, Roshni S. Rao, M.D., reported at a symposium sponsored by the Society of Surgical Oncology.

"This is important, because any time you can slow down the progression of the disease, it potentially gives other therapies a better chance at working." Dr. Rao told this newspaper. "It's entirely possible that as medical therapy improves, the metastatic progression-free survival seen in these patients will translate into a survival benefit."

The study joins a growing body of evidence that challenges traditional beliefs by suggesting that aggressive local therapy may prolong survival, said Dr. Rao, a breast-surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston.

Current treatment is generally directed at the sites of metastases, and the primary tumor is left intact. Surgery is undertaken only for palliation.

Only 3%-6% of American women diagnosed with breast cancer will be stage IV at presentation, but a staggering 50% of women internationally will present with metastatic disease, Dr. Rao said.

The retrospective, single-institution chart analysis included 224 women with stage IV breast cancer, including 142 patients who received systemic treatment without surgery and 82 who had surgery to remove the primary tumor and systemic therapy.

Of the surgical patients, 43 underwent mastectomies, and 39 had segmental resection.

All of the patients received hormonal therapy or chemotherapy within 3 months of diagnosis.

Both groups were similar in race, family and personal history of cancer, histology, tumor size, and estrogen- or progesterone-receptor status.

The surgical group was slightly younger than the nonsurgical group (49 years vs. 54 years); had one metastatic site (generally the liver); was more likely to receive chemotherapy than hormonal therapy as a first-line treatment; had a lower nodal stage (59 N0/N1 patients vs. 100); and was more likely to be Her2/neu positive (24 vs. 28 patients).

Initially, surgical patients demonstrated better survival than women who received systemic therapy alone. But this was not significant on final analysis, Dr. Rao said.

At 3 years, 119 of the 142 women (84%) in the nonsurgical group were alive, compared with 78 of the 82 women (95%) in the surgical group.

At final follow-up, there were 27 deaths in the nonsurgical group and 11 in the surgical group. Eleven patients who had surgical intervention at their primary site as well as their metastatic site had no evidence of disease during follow-up.

The only independent predictors of overall survival were having a single metastatic site and Her2/neu-negative status (hazard ratio 2.43 and 2.52, respectively).

In this month's Health Services Research Lantz Janz, and Fagerlin et al. explore patient satisfaction with decisions about surgical treatments for early stage breast cancer among a population-based sample of women. Deciding whether to undergo breast conserving therapy (BCT) or mastectomy remains difficult for women diagnosed with early stage breast cancer. Despite the substantial differences in the side effects of these treatments, no survival differences have been shown up to 20 years later among women with stage I and II cancer (Veronesi et al. 1981; Fisher et al. 1985; Sarrazin et al. 1989; Blichert-Toft et al. 1992; Lichter et al. 1992; Early Breast Cancer Trialists' Collaborative Group 1995; Morris et al. 1997; van Dongen et al. 2000; Fisher et al. 2002). Although randomized trials suggested higher quality of life (QoL) and satisfaction among women receiving BCT as compared with mastectomy (Moyer 1997; Curran et al. 1998), a substantial percentage (36 percent) undergo mastectomy. Despite the psychosocial benefits associated with reconstruction after mastectomy, most women (60 percent) do not choose reconstruction (Cancer Statistics Review 1973-1989; Mueller et al. 1988; Sorrentino et al. 1988; Handel et al. 1990; Brown 1991; McKenna et al. 1991; Schain 1991; Dowden and Yetman 1992; Nognchi et al. 1993; Corral and Mustoe 1996; Street and Voigt 1997).

How do we explain such decisions? Decisions about surgery are made at a time of heightened anxiety when it may be difficult for patients to understand complex information regarding treatments (Jefford and Tattersall 2002). Women may not be aware of the evidence favoring BCT, or the quality of the evidence may be lacking. The beliefs and practices of the patient's oncologist or surgeon may influence the decision, as evidenced by geographic variations in surgical practices (Foster, Farwell, and Costanza 1995; Steele et al. 1995; Goel, Iscoe, and Sawka 1996; Kotwall et al. 1996). Factors such as the cost and availability of the procedures and insurance coverage may also influence these decisions (Roetzheim et al. 2002). The federal Women's Health Rights and Cancer Act of 1998 mandated that insurance companies cover breast reconstruction surgery but there have been some difficulties in implementation.

Although decisions about surgical treatments for breast cancer are characterized as preference-based, up to 29 percent of women in parts of the U.S. do not receive adequate discussion of the different surgical treatments for breast cancer, and fewer than half achieved their preferred level of participation (Degner et al. 1997; Keating et al. 2002).

In the present study, the authors use three measures of satisfaction among women who underwent either BCT, mastectomy, or mastectomy with reconstruction: satisfaction with the type of surgery received, satisfaction with the process by which the surgery decision was made, and feelings of regret concerning the type of surgery received. Although overall levels of satisfaction were high among women in all surgical treatment groups, approximately one in four women scored low on at least one measure of satisfaction. Ethnic minority groups and women of lower socioeconomic status (SES) were more likely to report decision regret, while woman who reported at least some involvement in the decision-making process were less likely to report regret. While other studies have suggested that women of lower SES and some ethnic/minority groups are more likely to prefer a more passive role in clinical decision making (Benbassat, Pilpel, and Tidhar 1998), the finding that women of lower SES and racial/ethnic minorities were at increased risk of dissatisfaction with their breast cancer treatment decision has not been reported in a large population-based study.

Surprisingly, this study found that patients who were more involved in decision making were more likely to undergo mastectomy. This finding appears inconsistent with previous research suggesting that patients who are more informed in treatment decisions are less likely to choose more intensive surgical treatments (O'Connor et al. 1999); one study reported a statistically significant reduction in major elective surgery when using a decision aid compared with usual care (RR 0.76, 95 percent CI: 0.6-0.9) (Murray et al. 2001). It also runs counter to the prevailing view that BCT is what women would choose if given the opportunity by their physicians (Masood 2003). Although women more involved in the decision making were more likely to undergo mastectomy, the present study also shows that women who chose BCT were less likely to report low satisfaction or decision regret than women who received mastectomy (with or without reconstruction). However, these differences were small and of uncertain clinical significance. Clearly, being involved in decision making is not sufficient to ensure that women are satisfied with their decisions, nor does being involved entail being informed.