A frequent component of treatment for breast cancer is surgery to remove the cancer.
While mastectomy was more common in decades past, experts at Dana-Farber want you to know that science and treatment have advanced. Improved screening, early diagnosis, and advances in medicine are enabling many more patients to have the option of breast-conserving surgery, also called a lumpectomy, than in the past.
If you are a candidate for lumpectomy but are considering a mastectomy instead, it’s important to know the facts. Here are five things to consider before you decide. Please be sure to work with your care team to understand your individual options, because every case is unique.
In some cases, lumpectomy is not an option and mastectomy is recommended, such as in cases of inflammatory breast cancer, in cases where the extent of tissue that needs to be removed would not result in a good cosmetic outcome, or in cases where the patient has a high risk of breast cancer recurrence due to a family history, inherited genetic mutation, or previous radiation to the chest. In these cases, the considerations below might not apply.
When lumpectomy is an option, survival benefits are equivalent to mastectomy.
Most patients with a newly diagnosed case of breast cancer and an average risk of the disease recurring can be treated with breast-conserving surgery. In these cases, more aggressive surgery to remove the entire breast or both breasts does not reduce the risk of recurrence of breast cancer. It also does not improve survival benefits over the long term.
In addition, improved imaging and assessments by pathologists of the edges of the tumor enable surgeons to remove the tumor precisely.
“We understand the gut feeling patients have that it must be better to get rid of all of the breast tissue,” says Tari A. King, MD, chief of Breast Surgery at Dana-Farber Brigham Cancer Center. “But we want to make sure our patients understand that breast cancer recurrence is not impacted by the type of surgery that we do. It’s the whole treatment package that matters.”
Surgery is one part of a bigger treatment plan.
In recent years, researchers have learned a lot about what drives the formation and growth of breast cancer for each of the many subtypes. As a result, there are many new medicines that are designed to block cancer growth.
These medicines work systemically, throughout the body, and reduce the risk of breast cancer recurring in the breast where the tumors were found (called local recurrence), in the opposite breast, and elsewhere in the body. These medicines are very effective.
“In the modern era with these medical treatments, the rates of local recurrence are exceedingly low, much lower than they were 10, 15, 20 years ago,” says King. “Even in our youngest patients with more aggressive disease subtypes, the risk is very low and is the same whether I remove the breast or conserve it.”
In cases where the cancer is deemed aggressive, meaning it is fast growing and likely to spread, the systemic treatment will likely be more potent. More intensive surgery does not change the need for more potent systemic treatment, nor does it improve outcomes.
Radiation therapy, which also aims to prevent recurrence in the breast where tumors were found, has also improved. Treatment times are shorter, and patients experience fewer side effects than in the past.
Mastectomy is major surgery.
Mastectomy with reconstruction is not the same as breast augmentation surgery, which involves placing breast implants under the existing breast, and does not have the same cosmetic or physical results.
For patients who need a mastectomy, surgical and reconstruction techniques are constantly advancing. Surgeons can offer immediate reconstruction in some cases, as well as different options for reconstruction. (Learn more here.)
Lumpectomy is much less involved than mastectomy and is less risky. It preserves the shape of the breast and the sensation in the skin and nipple and may preserve the ability to breastfeed if that is possible given other aspects of treatment. Breastfeeding may not be possible after radiation.
Quality of life matters now…and later.
Some patients know that the only way they will have peace of mind in the future is to have a mastectomy, despite their understanding that there are risks with no clinical reward. But not everyone is certain.
Recent studies have found that many women who have the option and choose breast-conserving surgery over mastectomy are more satisfied with their choice years later. The measures of quality of life include psychosocial functioning, body image, sexuality, intimacy, and more.
One decision-making challenge for patients is that the immediate fear of cancer diminishes their concerns about the future. For instance, in some cases, patients report feeling shame that they are thinking about body image or cosmetic outcomes when they should just be happy to have life-saving treatment.
But long-term satisfaction with body image, appearance, and sexuality matters and it is okay to think about how a decision today will affect quality of life in the future, says Elizabeth Farrell, MSW, LICSW, a lead clinical social worker in Dana-Farber’s Adult Social Work Program.
“It’s important for patients to understand that concerns about appearance are not all related to vanity,” Farrell says. “It’s more complex and related to the ability over the long term to see yourself as a person rather than as a cancer patient.”
Help is available.
The decision between lumpectomy and mastectomy is part clinical and part personal. At Dana-Farber, the shared decision should be in line with both patient preferences and the best possible clinical outcomes.
A key role of the care team is to lay out the most up-to-date treatment information so that patients can make informed decisions. However, absorbing and understanding information can be a challenge when emotions are high and there are many other things a patient is trying to absorb when they’ve received a cancer diagnosis.
Patients feeling overwhelmed or uncertain about their treatment can consider connecting with a clinical social worker. At Dana-Farber, clinical social workers provide emotionally supportive counseling and can help patients manage the emotional impact of a diagnosis and treatment.
They can also help patients have more productive and open conversations with their surgeons by helping them articulate priorities, concerns, and questions.
“People who have any sort of uncertainty or anxiety would benefit from a visit with a social worker,” says Farrell. “Sometimes one visit is enough to help someone work through their concerns.”
Dana-Farber patients can reach a clinical social worker by dialing 1-617-632-3301.
Younger patients with breast cancer (diagnosed at age 45 or younger) at Dana-Farber can also benefit from services and supportive resources provided by the Young and Strong Program.
Older patients (age 70 or over, regardless of age at initial diagnosis) at Dana-Farber might benefit from resources provided by the Program for Older Adults with Breast Cancer.
Peer support can also be valuable. Dana-Farber offers peer support for breast cancer patients through Soulmates. For patients receiving treatment elsewhere, Imerman Angels provides similar connections to peer support groups.