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Lumpectomy vs. mastectomy: How to choose

October 24, 2017 | UCI Health
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Most women diagnosed with breast cancer have some type of surgery, and it’s remarkably successful in saving their lives.

“We’re fortunate to be in a time when women do have choices for surgical options,” says Dr. Karen Lane, surgical oncologist and breast surgeon at the UCI Health Pacific Breast Center. “There are different types of mastectomy, and they can be done with or without reconstruction.”

Today, there’s so much information — from news reports of research, to advice from friends in similar situations, to Internet searches — it can be hard for women to sort it all out.

Breast cancer surgery options

Here’s a look at the most commonly performed mastectomies:

  • Partial mastectomy: Also known as lumpectomy and breast-conserving surgery, partial mastectomy removes cancer from the breast. The surgeon removes only the tumor and a small margin of normal tissue around it, leaving most of the breast skin and tissue in place. The breast looks as close as possible to how it did before surgery. Most often, the general shape of the breast and the nipple area are kept.
  • Total mastectomy: Also known as a simple mastectomy, this surgery removes the breast, nipple, areola and sentinel lymph node or nodes. It leaves the chest wall and more distant lymph nodes intact. Surgeons can often save the breast skin for women who plan to have reconstructive surgery.
  • Preventive mastectomy: Also known as bilateral prophylactic mastectomy, this surgery removes both breasts before cancer has a chance to develop or spread. Some surgeons remove the entire breast, while others leave the skin and nipples intact to aid in breast reconstruction surgery.

So which is most effective? A recent article in the medical journal Oncology concluded that survival is about the same for partial and total mastectomy and that removing both breasts to prevent future cancers doesn’t improve survival. Doesn’t it make sense then to choose the less aggressive approach?

Not necessarily, says Dr. Lane. It’s a lot more complicated and more personal.

“The most important thing is that everyone’s cancer is different. The type of surgery to choose depends on many factors, including age, genetic predisposition, gene mutation, extent and location of tumor in the breast, density of breast tissue or difficulty of reading image, and lymph node involvement,” says Lane.

Factors that affect your choice

Here are a few considerations that can factor into choice of surgical procedure:

  • Radiation tolerance: Partial mastectomy is typically followed by daily radiation therapy over three to six weeks, and one of the factors affecting choosing this surgery is a patient’s tolerance for radiation. Some medical conditions, prior exposure or a patient’s negative feelings about radiation will eliminate this as an option. While a surgeon at UCSF Medical Center, Lane had some patients who had experienced the nuclear power plant disaster at Chernobyl reject this option because of their fear of radiation, despite reassurances that breast radiation was very well tolerated. The rigorous schedule for radiation treatment or lack of easy access may also make it an impossible choice. Intraoperative radiation therapy — one shot of radiation in the operating room after the cancer is removed — can be an alternative for some patients. It’s something UC Irvine Medical Center provides that that few centers offer.
  • Large, invasive tumors: In cases of multiple tumors or more extensive, invasive types of cancers, it may not be possible to save the breast. Mastectomy with or without reconstruction is recommended. In other cases, chemotherapy before surgery can shrink tumors to enable partial mastectomy where mastectomy would otherwise have been required.
  • Genetic predisposition: Some women with a genetic predisposition to develop breast cancer opt for bilateral mastectomy—removal of both breasts—as a preventive measure after developing cancer in one breast. In women with the BRCA1 or BRCA2 gene mutation, chances of breast cancer can be as high as 80 percent, and chances of getting another tumor are also high. Some, like Angelina Jolie, choose double mastectomy.  Lane has had patients in their 20s and 30s choose to remove both breasts after developing breast cancer without a demonstrated genetic predisposition. Cancer in such young women makes her wonder if there is some genetic explanation that has not yet been discovered.

To gain clarity — and comfort — Lane encourages patients to talk to each other, do research and consult their doctors, including a plastic surgeon, if they’re having trouble deciding.

“I give my opinion to my patients as if they were my family members,” she says. “But the choice has to be their personal preference, and they should be happy with their choice.”

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