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Comparing Breast Conservation versus Mastectomy

Women with a diagnosis of early breast cancer or ductal carcinoma in situ (DCIS) are frequently faced with the dilemma of deciding between conserving their breast (lumpectomy) versus undergoing a mastectomy (removal of the entire breast). The anxiety of this decision is compounded by the number of choices, conflicting information from different physicians, and the relatively rapid time frame in which decisions must be made. Breast conservation treatment including radiation therapy is well established as an alternative to a mastectomy. Numerous studies have shown equivalent survival and local control.

There are situations when a mastectomy is the only option. This is necessary for some larger tumors or multicentric cancers(multiple independent deposits of cancer cells spread throughout the breast). In these instances, the breasts cancer medical team will inform the patient that a mastectomy is the only option. We as breast surgeons have the role of educating the breast cancer patient and try to offer different surgical options. The information will not only help the patient to make an intelligent decision, but choose what might be best for their particular situation. In the scenario when you have the option of choosing between a mastectomy and a lumpectomy the final decision is very personal. What might be the best option for one patient might not be the first choice for another. There are women who feel strongly about one option over another. Physicians respect the patient’s decision as long as the patient is well informed about the medical facts and options. Some women may choose a mastectomy, despite the likely success of breast conservation. This does not reflect their emotional stress, but rather is simply a preference or the right option for “peace of mind”.

 

Mastectomy versus Lumpectomy

 

Pros and Cons of Breast Conservation (Lumpectomy) versus Mastectomy

Lumpectomy:
A lumpectomy implies the complete removal of the breast malignant tumor with a concentric margin of surrounding healthy tissue in a cosmetically acceptable fashion.

Advantage:

  The main advantage of a lumpectomy is simply preservation of the breast. This decision could have a positive psychological and body image effect for some women


Disadvantages:

  The need of radiation therapy to complete local treatment. It could take up to 6 weeks to finish treatment. Radiation therapy can have side effects, although modern radiation therapy has shown to be extremely safe
  Even with the addition of radiation treatment, retention of the breast will always leave the patient with some risk of local failure through the development of a new primary tumor in the breast or a possible recurrence (the original cancer coming back)
  The possibility of having a positive lumpectomy margin (cancer cells extend to the edges of the tissue removed), which will cause another visit to the operating room. Even a second operation does not guarantee the clearing of surgical margins. This means a third surgery and the potential for a future mastectomy
  Once local treatment is completed (surgery and radiation therapy) the affected breast will need to be monitored very closely, due to the risk of the cancer coming back. This means that periodic mammograms, ultrasounds, and in some instances breast MRI’s will be required

We would like to stress however, that the results are as good as the mastectomy option in terms of survival.

Mastectomy:
A mastectomy implies the complete removal of the breast and nipple-areolar complex.

Advantages:

  Radiation therapy is not needed in most of the cases
  The patients do not need to worry about in-breast recurrence or the possibility of another new tumor developing in the breast
  The chances of having to return back to the operating room to clear margins are very low
  The rate of local chest wall recurrence is very small when compared to a recurrence after a lumpectomy. It is important to acknowledge that breast cancer may return in the chest wall even after removing the entire breast
  In the absence of the breast, there is no need to follow up periodically with breast imaging studies and no need for further breast biopsies


Disadvantage:

  The disadvantage of a mastectomy is the loss of the breast. This can have a negative emotional and physical impact on the patient. On a positive note, breast reconstruction techniques continue to improve, thus giving the patient a reconstructed breast with excellent cosmetic appearances in most cases