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ASCO Expert Corner: Talking With the Doctor About Breast Surgery Options

Surgical options for the treatment of early-stage breast cancer include mastectomy and breast-conserving surgery (also called lumpectomy). Mastectomy is the removal of the entire breast, while breast-conserving surgery is removal of the tumor along with a margin (edge) of tissue around the tumor. Radiation therapy is usually given after breast-conserving surgery to reduce the risk of cancer recurrence (return of the cancer). Radiation therapy is sometimes recommended after mastectomy as well. Both types of surgery typically include an evaluation of the axillary lymph nodes, which are the lymph nodes located under the arm near the affected breast.

Women may choose between these two procedures; however, it is important to note that breast-conserving surgery may not be appropriate for all women. A multidisciplinary team of specialists (which may include surgeons, radiation oncologists, medical oncologists, radiologists, and pathologists) evaluate a number of factors to help a woman make this decision. Long-term survival and recurrence rates are identical for both options in appropriately selected women. To help women talk with their doctors about this decision, Cancer.Net spoke with Julie Gralow, MD, in 2008. This article was updated in 2012.

Q: What information should a woman share with her doctor when deciding between a lumpectomy and mastectomy?

A: If a woman has a clear preference for the type of breast surgery, she should clearly express that to her health care team. There are women who feel strongly (either negatively or positively) about both of the choices, and doctors shouldn't assume they know what the patient wants. There are some women who don't have a strong preference either way. Most women are aiming for the best chance at cure—never having to deal with this cancer again.

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

A: The advantage of lumpectomy is that the breast is preserved, which can have a favorable effect on body image for many women. The disadvantages include side effects from radiation therapy, the time needed to finish treatment (about six weeks, although we're studying shorter lengths of time), and a higher rate of in-breast recurrence. Some of that in-breast recurrence is due to the fact that normal breast tissue remains, and a second breast cancer can develop years later (it can do so in the other breast, too). Other recurrences are due to the same cancer coming back. After a surgery with clear margins (meaning no tumor at the edges) and radiation therapy, the risk of the same tumor returning is very low, but it is still higher than with mastectomy. It's very important to stress that survival and deaths due to breast cancer are not higher in women who choose lumpectomy, though. Another disadvantage of lumpectomy is that after review of the tissue removed during surgery by a pathologist, the doctor may recommend further surgery to clear any remaining tumor from the breast. This could be a re-excision, which isn't guaranteed to be successful (meaning even another surgery could be recommended), or even a mastectomy.

Q: What are the advantages and disadvantages for a woman choosing a mastectomy?

A: The disadvantage of mastectomy is that it removes the breast, which can have a real emotional, in addition to physical, impact. The good news is that there are increasingly good reconstruction and prosthesis (artificial breast) options. The advantage of mastectomy is that radiation therapy can be avoided for many (but not all) women, and the rate of recurrence in the chest wall (the area behind the breast), while not zero, is quite low. No surgery, including mastectomy, can guarantee with 100% certainty that the cancer won't return.

Q: What are some factors that play a role in a woman's choice between these procedures?

A: Body image often plays an important role for some women who feel very strongly that they want to make every attempt to retain their breast(s). Other women express wanting to avoid dealing with follow-up imaging of that breast and the chance that more biopsies (removal of tissue for examination under a microscope) will be needed or a recurrence will be found, so they prefer to undergo mastectomy, either with or without reconstruction.

Q: What are some questions for women to ask their doctors?

A: Women considering lumpectomy should ask their surgeon how likely it is that the first surgery will be able to clear all of the cancer (what's the chance that they may need another surgery?). Are there more tests that should be done to help in surgical planning to help evaluate for additional spread or sites of cancer? Also, they should ask for a good evaluation of what the in-breast recurrence will be predicted to be with a lumpectomy plus radiation therapy versus a mastectomy. The size of the cancer, the aggressiveness, whether it involves the lymph nodes, and other features all affect the rate of recurrence. Women thinking about mastectomy should consider speaking to a reconstructive (plastic) surgeon before making their choice to understand what their options are. Sometimes reconstruction can be performed at the same time as a mastectomy, while other times it's recommended that the reconstruction be delayed. Decisions about the optimal timing of reconstruction should involve the whole treatment team, because the surgery can influence the timing of future radiation therapy and chemotherapy.

Q: What other actions might be helpful for a woman to take during this time to help reach a decision?

A: Seeking a second opinion or an appointment with a reconstructive surgeon might be helpful. Sometimes women who have undergone reconstruction are willing to talk about the surgery and maybe even show their results (ask the reconstructive surgeon's office about that possibility). Members of support groups (or friends and family members) who have gone through the same choice themselves might be helpful in weighing the pros and cons.

Q: What are some important messages for women about this decision?

A: The decision about lumpectomy versus mastectomy is a very personal one. Friends and family may have helpful input and experiences to relate, but ultimately the choice has to be what feels right for the individual woman. Surgery after a diagnosis of breast cancer is usually never an emergency. If it takes a few weeks to get a second opinion or see a reconstructive surgeon in order to make the best decision, that's OK.

Dr. Gralow is Professor of Medicine/Oncology at the University of Washington School of Medicine and Fred Hutchinson Cancer Research Center in Seattle. She has served as the Cancer.Net Associate Editor for breast cancer and is a past chair of ASCO's Cancer Communications Committee.

More Information

Breast Cancer

Breast Reconstruction

Mastectomy: What to Know

Understanding Radiation Therapy

Frequently Asked Questions About Radiation Therapy

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