Under certain circumstances, people with breast cancer have the opportunity to choose between total removal of a breast (mastectomy) and breast-conserving surgery (lumpectomy) followed by radiation.
Lumpectomy followed by radiation is likely to be equally as effective as mastectomy for people with only one site of cancer in the breast and a tumor under 4 centimeters. Clear margins are also a requirement (no cancer cells in the tissue surrounding the tumor).
Although most women who have a choice prefer the less invasive lumpectomy, deciding between lumpectomy and mastectomy depends on a how you feel about the following:
- Do you want to keep your breast? If it’s important to you to keep your breast, you may decide to have lumpectomy with radiation instead of mastectomy.
- Do you want your breasts to match as much as possible in size? For most women, lumpectomy has a good cosmetic result. In rare cases when a larger area of tissue needs to be removed, lumpectomy can cause the breast to look smaller or distorted. There are types of reconstruction available for both lumpectomy (if there is significant distortion) and mastectomy. If you need to have a large area of tissue removed and two breasts of matching size are very important to you, you and your doctor will need to decide which surgery is best for your situation.
- How anxious will you be about breast cancer coming back? If removing the entire breast would help you worry less about the possibility of the breast cancer coming back (recurrence), you might consider mastectomy.
There are also other, less personal factors that can affect which type of surgery you have:
- Where you live: Research has shown that women who live in the United States are more likely to have mastectomies than women in other countries. In the Midwestern and southern parts of the U.S., mastectomies are very common. We don't know why this is, but it probably has something to do with the attitudes of women and their doctors.
- Where you go for treatment: Lumpectomies are more commonly performed in university-based hospitals than in community hospitals.
- When the surgeon was trained: Older surgeons in some parts of the United States may be more old-fashioned and less likely to offer lumpectomy with radiation as an option for their patients, particularly their older patients. Until the mid-1980s, mastectomy was the standard of care for any stage of breast cancer, and research has shown that surgeons trained before 1981 recommend mastectomy more often than lumpectomy. If you feel strongly about one option over the other, ask your surgeon how many mastectomies and lumpectomies he or she performs and why. Seek a second opinion to get a more complete and balanced understanding of your options. Don't let hidden biases or unchanging attitudes keep you from getting the best care.
Lumpectomy: Advantages and disadvantages
The main advantage of lumpectomy is that it can preserve much of the appearance and sensation of your breast. It is a less invasive surgery, so your recovery time is shorter and easier than with mastectomy.
Lumpectomy has a few potential disadvantages:
- You are likely to have 5 to 7 weeks of radiation therapy, 5 days per week, after lumpectomy surgery to make sure the cancer is gone.
- Radiation therapy may affect the timing of reconstruction and possibly your reconstruction options after surgery. Radiation therapy also may affect your options for later surgery to lift or balance your breasts.
- There is a somewhat higher risk of developing a local recurrence of the cancer after lumpectomy than after mastectomy. However, local recurrence can be treated successfully with mastectomy.
- The breast cannot safely tolerate additional radiation if there is a recurrence in the same breast after lumpectomy. This is true for either a recurrence of the same cancer, or for a new cancer. If you have a second cancer in the same breast, your doctor will usually recommend that you have a mastectomy.
- You may need to have one or more additional surgeries after your initial lumpectomy. During lumpectomy, the surgeon removes the cancer tumor and some of the normal tissue around it (called the margins). A pathologist looks to see if cancer cells are in the margins. If there are cancer cells, more tissue needs to be removed until the margins are free of cancer. Ideally, this is all done during the lumpectomy, but analyzing the margins can take about a week. So sometimes after the pathology report is done, the margins are found to contain cancer cells and more surgery (called a re-excision) is needed.
Mastectomy: Advantages and disadvantages
For some women, removing the entire breast provides greater peace of mind ("just get the whole thing out of there!"). Radiation therapy may still be needed, depending on the results of the pathology.
Mastectomy has some possible disadvantages:
- Mastectomy takes longer and is more extensive than lumpectomy, with more post-surgery side effects and a longer recuperation time.
- Mastectomy means a permanent loss of your breast.
- You are likely to have additional surgeries to reconstruct your breast after mastectomy.
Making your own decision
Your breasts may be such an important part of your identity — your sense of who you are — that you'll go to great lengths to preserve them. That's a completely acceptable approach to take, no matter what your age or figure — AS LONG AS it doesn't endanger your overall health and chances for a full recovery.
Expert QuoteWhen I explain to a patient that they have more than one option, many ask, 'What would you do if it was your wife?’ and I say that I'd explain the options to my wife in the same way and let her make the decision. But for myself, in this group of patients who have the choice, I'd feel comfortable going either way based on the scientific information. It's basically a matter of where your comfort level is.
Thomas G. Frazier, M.D.