By Deborah Kotz
Each year more than 200,000 women diagnosed with early-stage breast cancer, the most common kind, must make myriad treatment decisions. Among them: whether to have a mastectomy or breast-conserving surgery known as a lumpectomy.
If you’ve been diagnosed with a stage 1 or 2 breast tumor that’s not highly aggressive, you may have been offered both surgical options and left to decide which is best for you.
“Once we determine that we can remove the tumor with clear cancer-free margins, we generally leave the choice up to the woman whether to have a lumpectomy or mastectomy without recommending one over the other,” says Bonnie Sun, a breast surgeon at Sibley Memorial Hospital in the District of Columbia. “It becomes a personal decision, and the patient will have to decide, ‘what do I really want?’”
A large body of evidence indicates that breast cancer patients who have mastectomies face the same survival odds as those who have lumpectomies along with breast radiation, and for the past few decades oncologists have been encouraging women with early-stage breast cancer to opt for the less radical surgery.
In fact, an expert panel convened by the National Cancer Institute declared in 1990 that lumpectomy with radiation was “preferable” to mastectomy for women with stage 1 or 2 breast cancer – which helped drive down mastectomy rates for these patients from 100 percent in the 1980s to less than 40 percent today.
But the pendulum is starting to swing back a bit toward mastectomies. A 2014 study published in the journal JAMA Surgery – which examined anonymous records from 70 to 80 percent of American women who had breast cancer surgery – found that the percentage of those with early-stage breast cancer increased from 34 percent in 1998 to 38 percent in 2011.
While the study authors could not explain the reasons for the increase, several developments over the past decade may have contributed.
Improvements in breast reconstruction following mastectomy provide patients with more natural looking results than in decades past, says Mehra Golshan, director of breast surgical services at Dana-Farber Cancer Institute in Boston. More breast cancer patients are also getting insurance coverage for the procedure, thanks to a 1998 federal law mandating coverage.
In recent years, oncologists have moved away from strongly recommending lumpectomies toward involving women in a shared decision-making process, which entails a more in-depth discussion of the pros and cons of both surgeries.
Ask yourself the following questions to help determine which surgical option is best for you.
1. How much do you fear annual breast screenings and a potential new breast tumor? Many breast cancer patients opt to have a mastectomy – and even a prophylactic mastectomy on the other healthy breast – because they know they’ll feel extreme anxiety during future annual mammograms and over any abnormal finding, follow-up biopsy and possible diagnosis of another breast tumor down the road. About 5 percent of patients who opt for a lumpectomy will have a recurrence in the affected breast or opposite breast, Golshan says, but it’s rarely life threatening.
2. How much do you want to avoid a painful recuperation? Mastectomy with breast reconstruction typically involves multiple surgical procedures and a painful healing process that can last for weeks or even months. Lumpectomy, on the other hand, is usually a shorter procedure with a shorter recovery time but sometimes also requires a second surgery if a pathologist later finds cancer cells in the tissue surrounding the removed tumor.
“I give patients the option of speaking with women who have had lumpectomies and mastectomies, so they can get first-hand experiences of what others went through,” Golshan says.
3. Do you have concerns about radiation treatments? After lumpectomy surgery, patients typically need five to seven weeks of radiation therapy, five days per week, to destroy any stray cancer cells. Side effects from the treatments can include breast swelling, fatigue and skin redness and blistering (like a sunburn). Scatter from the radiation can, in rare cases, damage the heart, lungs or surrounding bones.
Some women are now being offered a new option called intraoperative radiation therapy, IORT for short, in which a single dose of radiation is delivered directly into the tumor site during lumpectomy surgery. Those who have IORT do not need subsequent radiation treatments, but only certain patients are candidates. “These are women over age 45 with early-stage invasive tumors less than 2.5 centimeters in size,” says Andrea McKee, chairman of the radiation oncology department at Lahey Hospital and Medical Center in Burlington, Massachusetts. Candidates also must have only ductal breast cancer, which occurs in the milk-producing ducts, with no signs of tumor cells in healthy tissue surrounding the excised lump and no spread to local lymph nodes.
Some caveats: Since the procedure is fairly new, many cancer treatment centers do not yet offer it, and some insurance companies do not cover it. What’s more, about 15 percent of patients who have IORT wind up needing traditional radiation treatments because their final pathology report shows that they weren’t appropriate candidates, McKee says.
4. How much importance do you place on breast appearance? On sexual pleasure? Reconstructed breasts may look great, but they don’t respond to cold, heat, touch or stimulation, which can reduce sexual pleasure, Golshan says. Lumpectomy will retain the sensation of the breast, but may result in a lopsided appearance if a large amount of tissue is removed or if a woman has a small breast. For this reason, breast reconstruction may be offered along with lumpectomy to even out breast size.
5. What’s your life expectancy? Women diagnosed with breast cancer at a younger age may be more likely to opt for mastectomy because their longer expected lifespan means they have a higher lifetime risk of recurrence. “We typically tell patients that their risk of developing another primary breast cancer is about ½ percent per year,” Sun says. A 30-year-old breast cancer patient who expects to live another 50 years will face a 25 percent risk of developing another breast cancer compared to a 5 percent risk for a woman diagnosed at age 70.
Young breast cancer patients are also more likely to carry gene mutations that put them at even greater risk of recurrence, Sun said, which could tip the balance toward having a single or double mastectomy.
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