Surgery

Choosing Between Breast-Conserving Surgery and Mastectomy

Breast-Conserving Surgery

The advantage of breast-conserving surgery (lumpectomy) is that it preserves the appearance of the breast. A disadvantage is the need for several weeks of radiation therapy after surgery. Some women who have a mastectomy will still need radiation therapy. Women who choose lumpectomy and radiation can expect the same chance of survival as those who choose mastectomy.

Although most women prefer lumpectomy and radiation therapy, your choice will depend on a number of factors, such as:

  • How you feel about losing your breast
  • Whether or not you want to devote the additional time and travel for radiation therapy
  • Whether or not you would want to have more surgery to reconstruct your breast after having a mastectomy
  • Your preference for a mastectomy as a way to “take it all out as quickly as possible”

In determining the preference for lumpectomy or mastectomy, be sure to get all the facts. Though you may have a gut feeling for mastectomy to “take it all out as quickly as possible”, the fact is that in most cases doing so does not provide any better chance of long term control or a better outcome of treatment. Large research studies with thousands of women participating, and over 20 years of information show that when lumpectomy can be done, mastectomy does not provide any better chance of survival from breast cancer than lumpectomy plus radiation. It is because of these facts that most women do not have their breast removed.

For most women, breast conservation will be the treatment of choice since it is less traumatic, and the survival results are identical to survival rates with mastectomy. However, not all women are candidates for breast conservation, and some women prefer mastectomy. We believe women should be given the facts and encouraged to make their own choices.

Breast conservation therapy is not an option for all women with breast cancer.

Those who may not have breast-conserving therapy include:

  • Prior radiation therapy of the affected breast or chest
  • Suspicious or malignant appearing abnormalities that are widespread throughout the breast
  • Women whose lumpectomy, including any possible repeat lumpectomy when needed, cannot completely remove their cancer with a satisfactory cosmetic result
  • Women with active connective tissue disease involving the skin (especially scleroderma or lupus) that makes body tissues especially sensitive to the side effects of radiation
  • Pregnant women who would require radiation while still pregnant
  • Women whose tumors are larger than 5 centimeters (2 inches) and can not be shrunk by treatment before surgery

If cancer cells are present at the outside edge of the removed breast tissue (the margin), more surgery is usually needed to remove any remaining cancer. Most often this additional surgery is a repeat lumpectomy, but sometimes it requires removal of the entire breast (mastectomy).

Women considering breast conservation must have a clear understanding of the issue of “margins”. The goal in breast conservation is to remove the tumor with a surrounding rim of normal tissue. Obtaining a clear margin can be a challenge. Although the surgeon attempts to take out the entire tumor at the time of the initial surgery, in some cases the tumor cells, which are not visible during the surgery, are found to extend to the edge (margin) of the lumpectomy specimen, and a second operation is required. Fortunately, the vast majority of women who initially choose breast conservation will ultimately achieve a good to excellent cosmetic result. Long-term survival is equal to that with mastectomy.

Mastectomy

Mastectomy is the removal of the entire breast, including the nipple, Mastectomy is needed for some cases, and some women choose mastectomy rather than lumpectomy. Different words are used to describe mastectomy depending on the extent of the surgery in the armpit and the muscles under the breast. In a simple or total mastectomy, the entire breast is removed, but no lymph nodes from under the arm or muscle tissue beneath the breast is removed unless a sentinel node excision is performed (see Sentinel Node Excision). In a modified radical mastectomy, all the muscle under the breast is also removed.

If a woman has a mastectomy, she may want to consider having the breast rebuilt; this is called breast reconstruction. This requires additional surgery to create the appearance of a breast after mastectomy. The breast can be reconstructed at the same time the mastectomy is done (immediate reconstruction) or at a later date (delayed reconstruction).

How does a woman decide with her doctor on the type of reconstruction, and when should she have the procedure? The answer depends on the woman’s personal preferences, the size and shape of her breasts, the size and shape of her body, her level of physical exercise, details of her medical situation (such as how much skin is removed), and if she needs chemotherapy and/or radiation.

Women considering mastectomy should be given the option of immediate reconstruction. Some women, however, are not good candidates for immediate reconstruction. For these women there is still the option of delayed reconstruction, and this option should be taken into consideration at the time the initial mastectomy is performed.

If you are thinking about breast reconstruction, please discuss this with your doctor when you are planning your treatment so that a referral can be made to a plastic surgeon.