Lumpectomy or Mastectomy? How to Decide
09 Jul 2016
As part of early breast cancer treatment, you may be able to choose between a mastectomy or a lumpectomy with radiation. You may also wish that someone would just decide for you. Read on for the basics to help you decide whether to get a lumpectomy or mastectomy.
Are you worrying about making the wrong choice? Are you wondering if you’ll be second-guessing your decision should the cancer return in the future? Are your thoughts consumed with just getting the cancer out of your body by whatever means possible? These reactions and concerns are normal, but they still make the decision difficult.
Fortunately, there is no wrong decision.
What is a Mastectomy?
A mastectomy is a surgical procedure that removes the entire breast. Several types of mastectomies are available, depending on your situation:
- Simple (total): This type of mastectomy removes the whole breast, but does not remove any muscles from beneath the breast. Nor does it involve specific removal of underarm lymph nodes. It’s for women who are receiving a mastectomy to prevent breast cancer, also known as a prophylactic mastectomy, and women with large or multiple areas of DCIS (ductal carcinoma in situ).
- Radical: This is for women whose breast cancer spread to the muscles under the breast. Radical mastectomies remove the entire breast, the muscles along the chest wall under the breast, and levels I, II, and III underarm lymph nodes. The most extensive type, they are not commonly performed.
- Modified radical: Involving the removal of the breast and levels I and II underarm lymph nodes, physicians use modified radical mastectomies for most women with invasive breast cancer. During these type of procedure, no muscles from beneath the breast are removed.
- Partial: A partial mastectomy removes only the breast tissue that contains the cancer cells, along with some of the healthy tissue surrounding the area. Technically, a lumpectomy is a type of partial mastectomy, but partial mastectomies typically remove more tissue than most lumpectomies.
- Nipple-sparing: This type is similar to a total mastectomy in that the breast tissue is removed while the underlying muscle is left alone. However, in a nipple-sparing mastectomy, the nipple is also left alone, thus removing any need for nipple reconstruction.
When is a Mastectomy an Option?
In the past, mastectomies were the typical surgical treatment for all types of breast cancer. Since the early 1990s, physicians use lumpectomies more often for early stage breast cancer. Roughly 20 percent of women will have to have a mastectomy due to various factors relating to their cancer or the size of their tumor.
Among women whose breast cancer returned following a lumpectomy with radiation, a mastectomy is often used to treat the recurring cancer. Mastectomies are an option for women who have early stage breast cancer. They are also an option for ductal carcinoma in situ (DCIS), a form of non-invasive breast cancer.
Women with locally advanced breast cancer, which is cancer that has spread to the breast skin, chest wall, or lymph nodes, are candidates for mastectomies. Women with inflammatory breast cancer, an aggressive form of locally advanced breast cancer, are also good candidates. Those with Paget disease of the breast or nipple, a rare type of skin cancer, are as well.
Certain other factors such as your location, the training your surgeon has, and the hospital you go to affect the type of procedure available to you.
What are the Advantages and Disadvantages of Getting a Lumpectomy or Mastectomy?
Perhaps the biggest advantage of getting a mastectomy is simply peace of mind. The cancer is gone, and so is the tissue that the cancer affects. This is especially the case for women who have a bilateral mastectomy, a mastectomy that removes both breasts.
You also will not have to worry about cancer cells being left behind in the breast. While not common, occasionally a surgeon discovers that the cancer is more invasive than originally thought during a breast conserving surgery. In these cases, a mastectomy must be performed instead to ensure all the cancer cells are removed. This may require another procedure.
In terms of disadvantages, mastectomies are much more extensive procedures than lumpectomies. This means longer hospital stays and general anesthesia. A mastectomy also does not automatically mean you will not need chemotherapy. Recovery time after a mastectomy is longer and side effects may be more difficult to handle. Further, women receiving a mastectomy may be more at risk of suffering from various complications such as lymphedema.
Since a mastectomy removes the entire breast, you may also desire additional surgeries to reconstruct your breast. If immediate breast reconstruction is an option for you, then there is a higher risk of complications. These include poor healing and infection.
Lumpectomy with Radiation
What is a Lumpectomy?
A lumpectomy is a type of breast conserving surgery, or BCS. Rather than removing the entire breast, your surgeon removes only the tumor and a small amount of clean tissue from around the tumor (also called a clean margin). In some cases, surgeons may also remove some underarm lymph nodes. The breast is then closed with stitches.
Most lumpectomies take between 15 and 40 minutes to complete. Sometimes surgeons can feel where the tumor is located. If not, a mammography or other imaging technique determines the location. A pathologist tests the margin removed during the procedure. They check the tissue to see if any cancer cells spread away from the tumor. They then determine whether or not the physician removed the entire tumor.
Radiation therapy usually follows lumpectomy. This not only reduces the chances of cancer recurrence, it also kills any remaining cancer cells. In contrast, radiation therapy is not frequently required following a mastectomy. However, this is not the case for everyone.
Surgeons attempt to maintain the original appearance of the breast during a lumpectomy. They often used curved incisions when cutting into the breast to match the natural shape.
When is a Lumpectomy an Option?
Lumpectomy with radiation treats fairly small tumors or those in the early stages of breast cancer. Ideally, tumors should be smaller than about four centimeters in diameter. Women with inflammatory breast cancer or multiple tumors are often not good candidates for this type of procedure. Tumors that are large relative to a woman’s breast size are also a common disqualifying factor, as are tumors that have spread throughout the breast.
Sometimes a woman is eligible for a lumpectomy, but not for radiation. Pregnant women cannot receive radiation therapy. Nor can women who have already have radiation therapy completed on the same breast. In addition, women with systemic lupus or scleroderma are not good candidates for radiation treatment.
What are the Advantages and Disadvantages?
Since lumpectomies with radiation are less invasive, women have shorter, and often easier, recovery times than women who have had a mastectomy.
However, the primary advantage of a lumpectomy is preserving the sensation and appearance of your breast. While breast reconstruction can recreate the appearance of the lost breast, it may lose sensation and the process is more intensive. A lumpectomy with radiation preserves your original breast and the results after surgery are often more cosmetically appealing and natural-looking.
Unfortunately, despite the cosmetic advantages, lumpectomies have plenty of disadvantages.
Radiation therapy may take up to seven weeks following the initial surgery, meaning treatment continues longer than desired. If you still want to have breast reconstruction after a lumpectomy, radiation therapy may affect the timing and type of reconstruction options available to you.
Ultimately, you may need additional surgeries after your lumpectomy. If the margin that was removed is discovered to have cancer cells, more tissue must be taken out. Surgeons try to have pathologists examine the tissue during the procedure, but this is not always possible. In such cases, the margin may not be fully analyzed for around a week after surgery. Similarly, once you receive radiation therapy in one breast, it cannot receive it again. If your cancer returns in that same breast, a mastectomy may be the only option left.
Overall Survival and Recurrence Rates
Numerous studies compare survival and recurrence rates between women who have had a mastectomy versus lumpectomy with radiation. Local recurrence, which is cancer returning in the breast, occurs at only a slightly higher rate among women who had a lumpectomy with radiation. Meanwhile, the risk of metastasis or distant recurrence, which occurs when cancer spreads to other organs, is the same for both procedures.
Survival rates are also largely the same among women with early breast cancer who received either treatment. This suggests that lumpectomy with radiation is at least as good as a mastectomy. However, a few studies that suggest that lumpectomies with radiation have a slightly higher survival rate.
Questions to Ask Yourself When Deciding Between a Lumpectomy or Mastectomy
If both a lumpectomy or mastectomy are an option for you, the decision relies solely on what you feel is the best course of action for you. We’ve included just a few questions you can ask yourself to help you decide.
- How worried you are about recurrence? For some women, the fear of breast cancer recurrence is a strong deciding factor. If you know that having a mastectomy would help you worry less, then it may be the better option for you.
- Do you want to avoid painful recoveries? A lumpectomy does not guarantee your recovery will be less painful, but it’s associated with shorter and easier recovery times. Many women find that recovery following a mastectomy is longer and involves more pain due to the more extensive nature.
- Do you want to preserve your natural breast? Your breasts are a part of you and it is completely normal to want to preserve them as much as possible. Lumpectomies with radiation allow you to preserve your natural breast as much as possible.
- Are you concerned about radiation? The length and nature of radiation therapy may worry you. Radiation therapy can cause a wide range of side effects, including skin redness, breast swelling and fatigue. Additionally, in rare cases radiation can scatter to other areas of the body and damage the heart, bones or lungs.
- How old are you? The younger you are when you are diagnosed with breast cancer, the greater risk you have of developing cancer again later in life. Younger women may prefer mastectomy because it limits the risk of recurrence.
It’s Your Decision
The chances of survival and recurrence are the same for both lumpectomy or mastectomy. It’s important that you evaluate the pros and cons carefully before making your final decision. Each woman has her own reasons for choosing between a lumpectomy or mastectomy.
Even though their personal reasons may not always relate to you, it is helpful to discuss the decision with other women who have been through the same situation. As always, you should also thoroughly discuss your options with your physicians.