Talking With Your Doctor About Breast Surgery Options

Deanna Attai, MD, FACS
September 11, 2014
· Amber Bauer, ASCO staff

Maintaining open and honest communication with your doctor is an important part of your care. In fact, research has shown that people who have a good relationship with their doctor tend to be more satisfied with the care they receive. However, starting some conversations can be difficult. So to get the ball rolling, the Cancer.Net Blog has created this new series that will ask doctors to share their tips and insights for discussing a number of potentially sensitive or difficult subjects that might come up during diagnosis, treatment, and follow-up care.

As you may have seen during our coverage of the 2014 Breast Cancer Symposium, researchers continue to learn more about the outcomes of various surgical options for early-stage breast cancer. To get a better understanding of these options and find out more about the decision-making process, I talked with ASCO member Deanna Attai, MD, FACS, a board-certified surgeon practicing in Southern California. Dr. Attai is also President-Elect of the American Society of Breast Surgeons.

Q: What surgical options do women diagnosed with early-stage breast cancer have?

Dr. Attai: Surgery is generally the first step in treating a woman with early-stage breast cancer. For many women with early-stage breast cancer, lumpectomy, sometimes called a partial mastectomy, is the preferred surgery. This involves the removal of the tumor and a border of normal tissue around it, called a margin. A lumpectomy is usually followed by some form of radiation therapy. The other option is a mastectomy, or removal of the entire breast. Radiation therapy is generally not used after mastectomy for early-stage breast cancer.

Q: What are the advantages and disadvantages for having a lumpectomy followed by radiation therapy?

Dr. Attai: There are a number of advantages, including that the recovery from a lumpectomy with sentinel lymph node biopsy is usually much faster than the recovery time associated with a mastectomy. The surgery is performed as an outpatient, so there is no overnight hospital stay. Drainage tubes are not usually placed. The postoperative pain is also usually less compared to the pain experienced after a mastectomy. Often with newer oncoplastic surgical techniques, the shape and contour of the breast can be maintained. It is generally not necessary to have additional reconstructive procedures. Probably the biggest advantage, though, is that the breast is not removed.

As for the disadvantages, although radiation therapy can be performed in several different ways, it may require a significant time commitment after surgery. Some women experience increased scarring, as well as alteration in the breast shape after surgery and radiation therapy. While the risk of local recurrence, or cancer coming back in the treated breast, is generally low, if the cancer does come back after lumpectomy and radiation therapy, a mastectomy is usually needed. The options for reconstructive surgery can be more limited if radiation therapy has been performed.

Q: What are the advantages and disadvantages of having a mastectomy?

Dr. Attai: The risk of cancer coming back in the skin or chest wall after a mastectomy is generally about 1% to 3%, although it is also very low after lumpectomy and radiation therapy. While some women make the decision to have a mastectomy because they feel it will provide peace of mind, we cannot guarantee that they will remain cancer-free. For early-stage breast cancer, there really is no medical advantage to mastectomy. Long-term studies have shown that there is no survival advantage for women who have a mastectomy. In other words, you will not live any longer if your breast is removed.

However, radiation therapy can generally be avoided in women with early-stage breast cancer who undergo a mastectomy. Patients with certain autoimmune and connective tissue diseases may be at higher risk for developing complications after lumpectomy and radiation therapy, so mastectomy may be recommended for these patients.

Some women think that if they have their breast removed, they will not need chemotherapy. The decision for chemotherapy is based on the stage of the cancer (tumor size and spread to lymph nodes) as well as the tumor biology (how aggressive the tumor cells are). Chemotherapy may be recommended regardless of the surgery. Surgery treats the cancer in the breast, while chemotherapy treats cells that might have spread elsewhere in the body. Your cancer can still spread even if you have had a mastectomy.

A major disadvantage is that a mastectomy is permanent—you cannot replace the natural breast. Even with modern plastic surgical techniques, the breast and nipple lose sensation (become numb) after mastectomy. So when a woman is really struggling with the decision between lumpectomy and mastectomy, I will often recommend lumpectomy. I never want to perform more than one operation, but after a lumpectomy, we can always do additional surgery if a woman changes her mind. If we start with a mastectomy, we don’t have that option.

Another big disadvantage is that we know the more surgery that is performed, the higher the complication rate. Mastectomy with reconstruction has been associated with a 30% to 50% complication rate, including infection, poor healing, unplanned return to the operating room, implant problems, and more. When you consider that many women undergoing a mastectomy for early-stage breast cancer receive no additional medical advantage with the procedure, the potential benefits generally do not outweigh the risks. 

Q: What other factors play a role in this decision?

Dr. Attai: The decision-making process is very complex, and there are multiple factors involved. One factor is fear—a woman may want to have both breasts removed due to fears of the cancer returning or spreading. This is where physicians have an obligation to spend time with their patients to first hear her fears and concerns, and then discuss the medical facts. Many women have inaccurate perceptions of their risk of developing another cancer. With the exception of patients who test positive for BRCA 1/2 or other genetic mutation, that risk is often fairly low, and it is not outweighed by the potential complication rate of more aggressive surgery.

As a patient, you should obtain facts about your tumor type, as well as the recommendations of your doctor. However, it is equally important to discuss your concerns and preferences. Regardless of the type of surgery to be performed, many (but not all) women express concerns regarding body image, sexuality, and attractiveness to their partner. This is very personal to each woman, and her feelings regarding breast cancer, the surgery, and the impact she thinks it will have on her life need to be discussed.

Q: How can communicating with the health care team affect the decision-making process?

Dr. Attai: First of all I would stress that open and honest communication is essential. It is important that your doctor understands your point of view. If you do not feel that the lines of communication are open, this needs to be addressed. If you are not comfortable talking to your doctor about your concerns, it is reasonable to obtain a second opinion. Just as in all aspects of life, personalities do not always “click”. Your doctor does not have to be your best friend, but you should feel comfortable bringing your questions and concerns to his or her attention.

Q: What questions should women ask their doctors?

Dr. Attai: Women should write down their questions and bring them to the attention of their doctor. No question is too trivial. Some common questions include:

  • How much recovery time will I need after surgery?
  • Will drainage tubes need to be placed?
  • Will I need physical therapy after surgery?
  • What is the likelihood of prolonged pain, infection, bleeding, and other complications?
  • What is a reasonable estimate of what my breast might look like after surgery?
  • How likely is lymphedema?
  • What other treatments will I need after surgery?
  • What is the likelihood of my cancer coming back?

If a mastectomy and reconstruction is to be performed, women will often receive a recommendation from the plastic surgeon regarding the type of reconstruction that might be best. It is very reasonable to ask why the plastic surgeon is making that specific recommendation and whether there are any other options.

Q: Is there anything else you would suggest that women do to help them make an informed decision?

Dr. Attai: Ask your doctor for a copy of your pathology report, and ask him or her to explain the commonly used terms, such as cancer type, ER/PR, HER2/neu, and Ki67. Also ask what the cancer’s stage is. Then do some directed research on reputable sites, such as Cancer.Net, cancer.gov, and cancer.org, to see if they provide additional information not covered during your consultation. By obtaining information from your doctor first, you will be able to research the options most pertinent to you and your tumor. Then return to your doctor with additional questions or concerns. Also don’t hesitate to get a second opinion either if you are not comfortable with your initial consultation or if you want reassurance about the recommendations.

In most cases of early-stage breast cancer, you have time. Gone are the days when a woman was taken to the operating room having her breast removed within days of feeling a lump. Take some time to gather your information, talk to family and friends, and get your questions answered.  Then take some time to process that information and come up with a decision that you feel is right for you. There may not be one “right” way to treat your breast cancer; it is important that all factors are discussed and considered.