There is likely to be a short-term shortage of trained surgeons and radiation therapists to meet the growing demand for less-disfiguring surgery for breast cancer, experts in the field predicted today.
"We might be inundated," said Dr. Samuel Hellman, a radiotherapist at the Memorial Sloan-Kettering Cancer Center here. "We don't have enough radiologists, enough equipment to take care of the most common cancer fatal to women . That worries me."
Hellman was attending a two-day meeting organized by Sloan-Kettering and Harvard Medical School to help doctors develop guidelines for breast-preservation operations.
The meeting sought to put into practical terms the findings of a major national breast cancer study, which found that surgical removal of a malignant lump followed by radiation, called lumpectomy or segmental mastectomy, appears as effective a treatment as removal of the entire breast.
Effectiveness was measured in terms of projected five-year survival after treatment. The rate was about 75 percent for both groups. The average follow-up was 39 months.
Lumpectomies, a less disfiguring surgery, are controversial among those who believe that longer follow-up is needed before shifting away from breast removal.
But more than 200 physicians attending the meeting here supported making lumpectomy an option for patients with early breast cancer whose tumors are less than 1 1/2 inches in diameter.
"The most interesting and significant thing is, here we have a bunch of physicians who are now arguing about the nuts and bolts . . . rather than the right and wrong of doing the thing," said Dr. Bernard Fisher of the University of Pittsburgh, who led the National Cancer Institute lumpectomy study. "We've come a hell of a long way," he told the gathering.
But the consensus at the meeting was that patients should not opt for a lumpectomy unless they also get reliable radiation therapy, with adequate medical follow-up. The Fisher study found that lump removal with radiation helped protect against local tumor recurrences. Nearly a third of the five-year survivors who had only a lumpectomy had recurrences, compared with 8 percent of those who also received radiation.
"We all agree local excision alone is not a good treatment and should not be recommended," said Hellman, who did pioneering work in this area. He and others here emphasized that for the next several years, women needing treatment should seek centers with expertise in lumpectomy and radiation therapy to assure the best results.
Poorly done surgery or radiation therapy may lead to "bad results that may discredit this product entirely," Fisher said.
Sloan-Kettering's Dr. David W. Kinne agreed that patients who do not receive adequate care might "look worse after breast preservation" -- with the possibility of a disfigured breast, unsightly scars or radiation damage -- than after breast removal. He noted that although the new techniques can preserve the breast with excellent results, women should be prepared for "more treatment than with a mastectomy." Post-operative radiation therapy can last eight or nine weeks.
"It shouldn't be done at every little hospital," Hellman said. Because there are fewer than 2,000 cancer radiation therapists in the country, "there are places in the country where this is not available."
Most large cities do have major cancer treatment centers, he noted, but if the demand for segmental mastectomy grows quickly, there could be a shortage of treatment facilities and trained personnel.
About half the 119,000 women in the United States who get breast cancer each year could be candidates for lumpectomy and follow-up radiation, estimates suggest. Those whose lymph nodes are involved might also need chemotherapy.
Kinne said about 14 percent of breast-cancer patients at Sloan-Kettering have lumpectomies. Harvard radiologist Dr. Jay Harris said the figure is 50 percent to 75 percent for patients hospitalized in the Harvard-affiliated hospitals.