It might sound strange to think of a double mastectomy as comforting. But when faced with the daunting prospect of a cancer diagnosis, many women are drawn to its clear-cut promise – remove the breasts, and with them all traces of the life-threatening disease.
The simplicity of the approach can be deceiving, however, as mastectomies are often followed by multiple reconstructive surgeries, lingering pain or a loss of sensation.
Dr. Shelley Hwang has seen too many women suffer long-term emotional and physical damage after the procedure, so the breast cancer surgeon has staked out a fairly radical position: avoid the surgery or do smaller procedures whenever possible.
Now director of breast cancer surgery at Duke Health, Hwang has become a national proponent for a “wait and see” approach in cases of early stage breast cancer, particularly a non-invasive type known as DCIS, or ductal carcinoma in situ.
Her conservative approach is gaining traction, and Hwang has emerged as a national leader in the ongoing debate among doctors and researchers over whether some cancers are over-treated. This month, she was featured in Time magazine as one of the nation’s 100 most influential people.
Hwang says the choice of a cancer treatment is intensely personal, and her practice is to carefully explain the risks and advantages of possible treatments – not an easy task in the panicked moments after a cancer diagnosis.
Kimberly Evert-Kuhn of Charlotte says she’s grateful for Hwang’s personalized approach. She chose to have a lumpectomy, removing only part of one breast, Hwang counseled her that a mastectomy would likely yield a similar result with more complications.
Evert-Kuhn, 48, had the surgery in March and is finishing up a round of chemotherapy. She says talking through the options with Hwang was difficult, but worthwhile.
“The initial knee-jerk reaction for anyone one who faces this is to get a mastectomy,” says Evert-Kuhn. “You think, ‘I don’t want this inside me.’ But she was very patient with me, and in talking with her I realized that when it comes to surgery, less can be more.”
As she works with patents on an individual basis, Hwang is also leading research that she hopes will prove that alternative treatments such as hormone therapy can be effective in treating DCIS.
“Shelley is an exceptional surgeon-scientist, who is – through elegant and focused investigation – redefining our understanding of breast cancer,” Dr. Allan D. Kirk, surgeon-in-chief at Duke Health, says in a university statement. “However, her strongest trait is the genuine empathy, care and understanding she brings to each of her patients.”
Drawn to surgery
Hwang was born in South Korea and spent much of her youth in Utah and Seoul, a cultural mix she says may have helped her cultivate an open-minded attitude toward her career. She went to UCLA, where she originally planned to major in comparative literature.
But she also was working her way through college, and she found that some of the best jobs available were in research labs. Her work in the physiology lab drew her to apply to medical school, where she quickly fell in love with surgery.
“The first day of the surgery series, I knew I didn’t want to do anything else,” she says. “I’m attracted to the way that surgery can fix a problem in a very immediate way. It’s is a team sport, and you have this incredible team of people holding themselves to the highest standards.”
She planned to focus her career on underserved communities, and did a residency at Cornell University hospital in New York. But she soon found herself accepting a fellowship across the street from Cornell at Memorial Sloan-Kettering Cancer Center. There she focused on breast cancer, and even more specifically, early stage cancers.
Early in her career, she was struck by how eagerly women flocked to mastectomy, particularly young women whose first mammograms showed signs of cancer.
“This fear would drive them to have not only one but both breasts removed, but then it would change how they felt about themselves,” says Hwang, who spent most of her career at UCLA. “In some cases it would throw their lives off track. It made me so distressed.”
When it came to DCIS, in particular, she wondered if some patients might do just as well with hormone therapy. For some older patients, it seemed likely they would die of something else before the cancer ever progressed.
“Anytime you go into the operating room, there’s always a potential you’re actually hurting them,” she says. “It’s a serious charge that the patient gives you and I think it’s incumbent upon surgeons to be very thoughtful about what they do.”
While she seeks to minimize the complications of surgery in all of her patients, much of her work is focused on DCIS, a condition when abnormal cells are found in the milk ducts of a woman’s breast. In some cases, these cells will spread to other parts of the body, but in cases where they don’t, the condition is benign.
While DCIS is considered to be a form of cancer, there is some debate over whether it should be considered a precursor to cancer. And that debate has intensified as more sensitive mammogram technology leads to more diagnoses.
DCIS now accounts for 1 in every 5 new breast cancer diagnoses, according to the American Cancer Society. If caught at this early stage, it can almost always be cured. So for Hwang and others, the question becomes whether treatments go too far.
“With a survival rate of 98 percent, you’re not going to improve on that,” she says. “But you have to think there are patients for whom we’re doing too much.”
She and a similarly-minded colleague at UCLA began offering alternatives to surgery for patients with DCIS, and studying the results. They adopted a protocol called “active surveillance,” in which patients undergo regular mammograms and MRIs in an effort to catch abnormal growth.
Many also take medicine to block the hormone estrogen, which their research shows is nearly as effective in surgery at fighting these cancers. Patients began seeking Hwang out to explore options other than surgery, and she is typically monitoring 20 to 30 patients at a time.
Since coming to Duke in 2011, Hwang has continued to attack the overtreatment problem both with her own patients and her research. She’s heading a team that landed a $13 million grant earlier this year to compare the benefits of surgery versus hormone therapy and monitoring.
Other studies will try to tease out which early cancers are most likely to progress, and which can be monitored. Hwang’s hope is that these studies will back what she’s found in her own patients, and eventually lead to new guidelines for early stage cancer.
Over 15 years of studying these methods, she’s faced the criticism from many of her colleagues, and she knows it will likely continue even if her methods are proven effective.
“We need to dial back,” she says. “And that’s not something that feels very comfortable.”
Eun-Sil “Shelley” Hwang
Born: April 1964, Seoul, South Korea
Career: Chief of Breast Surgery, Duke Health
Education: B.S. and M.D., University of California at Los Angeles
Family: Husband John; children Spencer, Natalie and Katie
Fun Fact: Hwang says there were no doctors in her family, but her grandfather was well known for his knowledge of Chinese herbal medicine, particularly in matters related to fertility. She says the family joke is that he was “really good at getting women pregnant.”