More women are choosing to have bilateral mastectomies when they are diagnosed with early-stage breast cancer, even though there's little evidence that removing both breasts improves their survival compared with more conservative treatments.
The biggest study yet on the question has found no survival benefit with bilateral mastectomy compared to breast-conserving surgery with radiation.
The study, published Tuesday in JAMA, the Journal of the American Medical Association, looked at the records of all women in California who were diagnosed with early-stage breast cancer from 1998 to 2011 — 189,734 women, all told.
Women who had breast-conserving surgery had a 83.2 percent survival rate at 10 years, compared with 81.2 percent for those who had a double mastectomy. But women who had a single mastectomy fared worse, with a 79.9 percent survival rate, enough to be statistically significant.
"We think that poorer survival in this group may be due to other factors that we weren't able to account for," says Scarlett Gomez, a research scientist at the Cancer Prevention Institute of California and the senior author of the study.
The women who had single mastectomies tended to be minority, especially Filipina or Hispanic, to be lower income and to be uninsured.
One factor affecting these women could be lack of access to medical care, Gomez says. For instance, a woman who has breast-conserving surgery typically has to go for radiation every day for six weeks to kill remaining cancer cells. Lower-income women may have a hard time doing that, Gomez says. "The only option available to them may be unilateral mastectomy."
And if women having single mastectomies tended to be poorer and minority, women who chose bilateral mastectomies tended to be younger, white and better off.
By 2011, the last year of the study, 33 percent of the women under 40 were choosing bilateral mastectomy, even though most of them had stage zero or one cancer, a very early, very treatable form.
Those women also were more likely to be treated at an academic medical center, which, along with their youth and low-risk cancer, should make it more likely that they would survive. So why are they not doing any better than women who have lumpectomies and radiation?
"I don't think we know," Gomez told Shots. "This is complete conjecture at this point. A bilateral mastectomy is major surgery, and just like any major surgery there are complications, side effects. So any advantage that comes from lowering your risk of cancer in the [healthy] breast could be offset by the fact that you're having major surgery."
Doing a randomized trial that directly compares the various treatments could help figure that out, but Gomez and others say it would be pretty much impossible to recruit lots of women in a trial that wouldn't give them a choice of treatments.
"Given the vast size of our data set, I think these findings may be as good as it's going to get in terms of giving us clues," Gomez says.
Doctors have been increasingly concerned that women are choosing bilateral mastectomy in the mistaken belief that it eliminates their future risk of cancer.
Double mastectomies made headlines in 2013, when actress Angelina Jolie had a prophylactic double mastectomy after being diagnosed with a BRCA gene mutation that vastly increases cancer risk.
But 95 percent of breast cancers aren't caused by BRCA mutations. And most of the women who are choosing double mastectomies haven't been diagnosed with a BRCA mutation.
"Bilateral mastectomy surgery maximally reduces the risk of a breast cancer patient developing a completely new breast cancer, but it does not affect the potentially life-threatening risk of the known first cancer damaging other organs in the body through metatastic spread," Dr. Lisa Newman, director of the University of Michigan Breast Care Center, told Shots via email. She wrote an editorial in Tuesday's JAMA on the issue.
And since tiny bits of breast tissue can remain in the chest after surgery, a woman who has had a double mastectomy can still get breast cancer again.
Gomez hopes that these new numbers will shift the focus to better understanding women's decision-making process, and to educating physicians on better communications.
Doctors can't presume to dictate which choice will give a woman the best quality of life, Newman says. But doctors do have to counsel patients to have realistic expectations about their treatment choices.
"We are trying to understand he factors that might be motivating this trend, since there is no definitive survival advantage that has been demonstrated," Newman adds.
Two U.S. news organizations, CNN and the Associated Press, were granted interviews with three men detained by North Korean authorities. To learn more about why, and what North Korea hopes to gain from the publicity, Melissa Block talks with Georgetown professor Victor Cha, the former director for Asian Affairs at the National Security Council.
Tom Hanks' love affair with typewriters began in the 1970s, with his first proper typewriter — a Hermes 2000. Typewriters are "beautiful works of art," he tells NPR's Audie Cornish. "And I've ended up collecting them from every ridiculous source possible."
Hanks admits he started his collection when he had a "little excess cash" but, he points out, it's "better to spend it on $50 typewriters than some of the other things you can blow show-business money on."
The obsession has now resulted in an app called Hanx Writer: For iPad users who are nostalgic for the clickety-clack of keystrokes and "ding!" of the carriage return, Hanx Writer will type and print documents just like an old manual typewriter. The design of the app, which Hanks created with the developer Hitcents, was based on typewriters from Hanks' own collection.
As for whether version 2.0 will have a white-out option? "That would be funny," Hanks says.
On differences from modern word processing — such as the function of backspace and delete
On the app, you can't just hold down the button and it deletes line after line. You literally have to do it one at a time: tuk, tuk, tuk, tuk. ... Or you can just not care and just go on with whatever horrible syntax you happen to personally use.
When I use my manual typewriter, I'm merciless with the X-ing out key. And sometimes it's nice ... when you're typing a letter on the app just to maintain that false Luddite sensibility. It's kind of like when you take a video and you add onto it the scratchy 8 mm filter that you can download. ... It's not authentic in any way other than the way it appears.
On how using the app changes the writing process
It makes me work a little slower, and when you work a little slower, you work a little bit more accurately. ... I like operating a little bit slower. Now, the only thing I get from this app is the sound and the speed. What I really, truly miss is the physical trail that typing usually gives you. Typing on an actual typewriter on paper is only a softer version of chiseling words into stone.
On whether this is a gateway typewriter experience for a new generation
I think in a lot of ways much of what ... the app-makers out there are discovering [are] these kind of like backdoor Luddite habits. The amount of cool things you can do with a photographic app now to make it look like anything from a daguerreotype from the 1860s to a Polaroid from 1972 — that gives it a patina. And because you've paid attention to it a little bit more, you haven't just taken a picture and sent it off, that means it becomes some sort of artistic expression.
On the trade-offs
If you do want to adhere to a couple of arcane rules in which speed and volume might be sacrificed a little bit — but the advantages that you get of more of a relaxed pace and a specific look to it — to me that's a wonderful trade-off.
Just in time for back-to-school season, funny newsman John Oliver and incorrigible consumer Cookie Monster are co-anchoring a news special on words, in a video that includes appearances by Saturday Night Live's Kate McKinnon and weatherman Al Roker.
Sharing the anchor desk of W-ORD News, Oliver and Cookie Monster banter about the silent "b" in crumb and puzzle over the length of the word "abbreviation." In another highlight, Roker adapts his forecast to warn of the arrival of the word "hangry" across most of the Midwest this week.
The segment is part of a series of collaborations between the makers of Sesame Street and the website Mashable.
"This project is in support of Sesame Street's Words Are Here, There and Everywhere, a fantastic digital resource that encourages families to explore the world of words all around them," Mashable's Matt Silverman writes.
As you might expect, things can go off the rails when Cookie Monster is on the set - a point driven home by a clip of outtakes.
"Thank you, Cookie," Oliver tells his partner. "You're a great hype man."
On a final note, we'll mention that the credits show the segment's two stars received equal treatment on the set:
"Production Assistance & Stand-In for Mr. Oliver: Eric Larson
"Production Assistance & Stand-In for Mr. Monster: Noah Sterling"