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by Kathy Steligo
For women diagnosed with breast cancer, surgery is performed to treat the disease. Many options are available and whenever possible, women are offered a chance to have a lumpectomy (or breast-conserving surgery.) Below are the different surgery types that pertain to a breast cancer treatment protocol.
When a woman finds a lump in her breast, or a mammogram reveals a suspicious area, a biopsy is performed to determine whether cancer is the cause. A surgeon performs a biopsy to remove a tissue sample or the entire lump, which is then reviewed under a microscope. Breast biopsies may also be done with a needle, depending on the type and location of the area in question.
Lumpectomy is surgery to remove a breast tumor and some of the surrounding tissue. This surgery is performed in a hospital under local anesthesia and a mild sedative, and does not require an overnight stay. Lumpectomy is appropriate for women who have single tumors under 4 cms, with surrounding margins of tissue that are free of cancerous cells. When followed by radiation, lumpectomy is as effective as mastectomy.
Mastectomy (Breast Removal)
Mastectomy removes the entire breast, either to treat breast cancer or to prevent it in high-risk individuals. Mastectomy is recommended for women whose cancers cannot be completely removed by lumpectomy, who cannot tolerate radiation, or who have two or more areas of cancer in different areas of the same breast. This surgery is performed under general anesthesia and patients usually spend one night in the hospital.
Total or simple mastectomy:
A total mastectomy removes the entire breast, including the nipple, areola, skin and the fatty tissue underneath the skin. Total mastectomy is appropriate for women with DCIS and those who choose prophylactic mastectomy.
Modified radical mastectomy:
A modified radical mastectomy removes the entire breast, including the nipple, areola, skin and the fatty tissue underneath the skin, and some underarm lymph nodes. Currently the most commonly performed mastectomy, modified radical mastectomy is recommended when invasive cancer is present.
A radical mastectomy removes the entire breast, all underarm lymph nodes and the chest muscle. Considered standard care for breast cancer years ago, this surgery is almost never used now.
Reconstruction (Breast Restoral)
After mastectomy, women may choose to wear prostheses or not, or have their breasts surgically reconstructed.
When reconstruction is performed immediately with mastectomy, the nipple and areola are typically removed along with the breast tissue, but most of the breast skin is kept to hold an implant or a flap of tissue from elsewhere on the body. Women who have immediate reconstruction need a longer hospital stay (usually a few days) than with mastectomy alone, and a longer recovery (between 3-6 weeks), depending on the type of reconstruction.
Women who are not at high risk for breast cancer or recurrent cancer in the nipple/areolar area may be candidates for one of the following skin-sparing mastectomy procedures:
Areolar-sparing mastectomy: preserves the areola and the remaining breast skin, but removes the nipple.
Nipple-sparing mastectomy: preserves the nipple and remaining breast skin, but removes the areola.
Areolar/nipple-sparing mastectomy: removes breast tissue through an incision in the fold under the breast, preserving the nipple and areola. This is also referred to as subcutaneous mastectomy.
This article was last reviewed August 2011.
Are Mastectomies Trending Higher in 2013?
Much Ado About Something
With Angelina Jolie’s announcement in May 2013 that she’d undergone a prophylactic double mastectomy in an attempt to lower her breast cancer risk, the media has been in feeding-frenzy mode when it comes to breast cancer. This is both good and bad. It’s never a bad thing to have breast cancer awareness a part of our national conversation – but unfortunately, when the media gets involved there is apt to be as much entertainment as science. And for most of us it is very difficult to tell the difference.
Following closely on the heels of Ms. Jolie’s revelation came yet another attention-grabbing headline, proclaiming that the majority of young women diagnosed with breast cancer are opting for mastectomies. This is an interesting development since, in many cases, current science indicates that the much less invasive and apparently equally effective lumpectomy would be a logical choice.
In a report given during the 49th Annual Meeting of the American Society of Clinical Oncology (May 31 – June 4 in Chicago), Shoshana Rosenberg, ScD, of Dana-Farber Cancer Institute and Harvard School of Public Health, and her colleagues shared their findings on this topic. Their study included 277 women who were diagnosed with breast cancer at age 40 or younger, who reported having a choice between a mastectomy and a breast-conserving lumpectomy. Their cancers ranged from stage 1 to stage 3.
According to Rosenberg, “Women diagnosed with breast cancer at an early age typically have a different set of medical and psychosocial issues and concerns than do older women. We are interested in learning from women who had a choice about surgery, what factors were associated with their decisions.”
Overall, the researchers discovered that 172 of the women (62 percent) opted to have either a single or double mastectomy. Factors associated with choosing a mastectomy included having a genetic mutation (like Ms. Jolie), an overabundance of the HER2 protein in tumor cells, signs of spread to the lymph nodes, higher tumor grade, lower body mass index, having two or more children, increased anxiety and greater patient involvement in the decision.
Other factors of interest that were not significantly associated with the decision included age, race, marital status, tumor size, having an estrogen-sensitive tumor, having a first-degree relative with breast or ovarian cancer (like Ms. Jolie), fear of recurrence and depression.
The new research also documents a growing trend toward prophylactic mastectomy — removal of a noncancerous breast after discovering breast cancer in the other one.
In 1998, fewer than 2 percent of women with breast cancer chose this option. In the new study, 37 percent chose prophylactic mastectomy in the non-cancerous breast. And, considering just women who chose mastectomy at all, more than 60 percent had prophylactic removal of the noncancerous breast.
The study did not look at women with a so-called stage-zero (ductal carcinoma in situ — DCIS). The study also didn’t include women where breast cancer affected both breasts or had metastasized to other organs.
While the research involved just 227 Massachusetts women and may not be nationally representative, the study authors say it’s in line with other studies suggesting that many of today’s breast cancer patients are choosing mastectomy.
“Rates of mastectomy, particularly in young women with breast cancer, are on the rise, and it is not entirely clear why,” said Rosenberg. “Our data suggest that disease and genetic factors may be related to choice, as well as anxiety and how the decision was made. Further research is clearly warranted in an effort to help ensure women can make informed, quality decisions about their breast cancer therapy.”
But lumpectomy outcomes are good
Two studies from 2011 showed that women younger than 40 with breast cancer who had a lumpectomy had a similar risk of recurrence and lived as long as those who had mastectomies.
In the first study on breast cancer recurrence, researchers analyzed medical records from 628 women age 40 and younger with breast cancer, who had either a lumpectomy or a mastectomy; they found almost no difference in the number of recurrences. For the women who had a lumpectomy, researchers found that five percent had a recurrence within five years and 13 percent had a recurrence within 10 years. For the women who had a mastectomy, 9 percent had a recurrence within five years and 11percent had a recurrence within 10 years.
In the study that evaluated treatment and survival information from 14,760 women, ages 20 to 39 (one in seven breast cancer patients falls in this age group), with early-stage breast cancer, researchers found that the women had similar survival rates about six years after treatment whether they received lumpectomy or mastectomy.
Of these women, information from a smaller group of 4,644 women whose treatment was matched based on the size of the tumor, the grade of the tumor (how much the cancer cells look like normal cells), and the number of lymph nodes that had cancer also showed no difference in survival between the women who had lumpectomy or mastectomy.
Specifically, after five years, 93 percent of the women who received a lumpectomy were alive, compared with almost 92 percent of the women who had a mastectomy. After 10 years, about 84 percent of women who received a lumpectomy and the women who received a mastectomy were alive. After 15 years, 77 percent of women who received a lumpectomy were alive, compared with 79 percent of women who received a mastectomy.
According to Julliette Buckely, MD (lead author of the study on breast cancer recurrence and a fellow in breast surgery at Massachusetts General Hospital in Boston), “Previous research has suggested that breast-conserving therapy leaves women at greater risk for local recurrence. However, we found no significant difference in the rates of local recurrence between women who received breast-conserving surgery or mastectomy. The results suggest that advances in chemotherapy, imaging and radiation have reduced local and distant recurrence risks and have made breast-conserving therapy a safe option for young women.”
Usama Mahmood, MD (fellow in radiation oncology at the University of Texas M.D. Anderson Cancer Center in Houston) and lead author of the study on breast cancer survival says, “Our findings show that breast-conserving therapy leads to similar survival rates as mastectomy. These findings can provide reassurance to younger women with early-stage breast cancer who are considering less aggressive surgery.”
Is 50 the new 40?
In January of 2013 it was announced that women with stage l or ll breast cancer who underwent breast-conserving therapy plus radiation exhibited higher rates of overall survival and disease-free survival than women having mastectomies.
In the study by E. Shelley Hwang, MD, MPH (chief of breast surgery at Duke Cancer Institute in Durham, North Carolina) and colleagues, published in the journal Cancer, the investigators reviewed data from 112,154 women who had been diagnosed with stage l or ll breast cancer in California between 1990 and 2004. Within the group, 50,383 patients had mastectomy without radiation and 61,771 had lumpectomy plus radiation. The women were followed through December 2009.
Less invasive treatment was associated with improved survival in all age groups, for both hormone-sensitive and hormone-resistant cancers. The greatest benefit was seen among women with HR-positive tumors who were aged 50 years or older at diagnosis and had undergone lumpectomy with radiation. These patients had a 13 percent lower risk of death from breast cancer, and a 19 percent lower risk of death from any cause, than did women undergoing mastectomy.
In the first three years after surgery, women who underwent mastectomy were more likely to die of heart disease and other diseases than were women in the lumpectomy group, the possible significance being that the lumpectomy patients were generally healthier.
All things considered
Not only is a healthy debate warranted, it’s important for young women to advocate for themselves and make the decision that is best for them. As we know all too well, breast cancer is not a one-size-fits-all disease.
Jolie’s disclosure has been widely praised for highlighting the complicated choices faced by women at risk for the disease. Unfortunately, it has also renewed fears that women might choose a more radical approach to dealing with that risk when less invasive methods are available and provide similar results.
According to Dr. Rosenberg, “We’re not saying this is a good or bad decision. We want to make sure that women are making informed decisions and that they themselves weigh the risks and benefits. For some women, mastectomy may be the right decision.”
What are some of the underlying factors that may determine a woman’s decision to have a mastectomy when a lumpectomy would work just as well? Some women may be concerned that they’ll get a poorer cosmetic result from lumpectomy and radiation than from mastectomy followed by reconstruction. The study didn’t address this possibility, or the concerns a woman might have about the side effects or burden of weeks-long radiation treatments that usually follow lumpectomy.
Another key factor that wasn’t addressed is economic issues, such as the cost of one procedure versus another, or whether it makes a difference if women have insurance coverage.
Rosenberg says the point isn’t to question whether many younger women who choose mastectomy are misguided or making a bad decision. She feels that it’s most important to remember, “We just want to make sure it’s an informed decision. You want to make sure the patient understands the benefits and harms of each option.”
Decisions, decisions: Informed decisions
When you realize that 280,000 women were diagnosed with breast cancer last year, and that 108 women die of breast cancer every day, it becomes even more important to share information that is accurate and not fueled by hype and/or hysteria. Probably one of the very most important decisions any woman facing breast cancer can make is to fully investigate her options, so that regardless of which surgeries or treatments she chooses, she knows she has done everything possible to tailor them specifically to her diagnosis.
Where you live can affect the quality of your healthcare, so if you live in a small, rural community, don’t be afraid to ask for a second opinion (or third, or fourth) from the nearest large teaching hospital or medical center. And even if you live in a large, metropolitan area, you are still entitled to feel comfortable with your treatment options.
It has also been found that the age (and even gender) of your doctor can play a role in his or her recommendations regarding treatment. What does this mean to you? It means you want to be absolutely sure you feel you are in good hands. Your relationship with your medical team is going to play a huge role in your recovery. You will want to make sure you feel not only a bond of trust, but also the ability to speak your mind, ask questions, and search for the latest science-based data available for your particular situation.
Dr. Freya R. Schnabel, director of the breast surgery department at NYU Breast Surgery Associates, notes that some women with early breast cancer may choose a mastectomy for various reasons, such as strong family history or not wanting to undergo frequent breast surveillance, but she stresses that women should understand that in most cases a mastectomy is not giving them a better chance for a cure.
“I feel that sometimes patients think that because a mastectomy is a bigger operation, it means that it’s a better treatment,” Schnabel says. “And even though they would prefer, perhaps, a lumpectomy, their sense is that it’s a better treatment and they opt in that direction.”
These new developments are definitely going to be a topic of discussion for quite some time, which will hopefully translate into continued research and better surgical and treatment options in the future. For the time being, however, women need to continue to learn as much as possible about their unique diagnosis and make decisions based not on what the latest headlines are touting, but on what will work best for them. When you are fighting for your life, it’s important to do your homework so you will be here in 30 or 40 years when the media will be saying, “Angelina who?”
Institute, Dana-Farber Cancer. “Mastectomy Often The First Choice For Young Breast Cancer Patients.” Medical News Today. MediLexicon, Intl., 3 Jun. 2013. Web. 12 Jun. 2013.
Buckley JM, Coopey S, Samphao S, et al. Recurrence rates and long-term survival in women diagnosed with breast cancer at age 40 and younger. In: Proceedings from the 2011 Breast Cancer Symposium of the American Society of Clinical Oncology; September 8-10, 2011; San Francisco, CA. Abstract 70.
Mahmood U, Morris CG, Neuner GA, et al. Equivalent survival with breast-conservation therapy or mastectomy in the management of young women with early-stage breast cancer. In: Proceedings from the 2011 Breast Cancer Symposium of the American Society of Clinical Oncology; September 8-10, 2011; San Francisco, CA. Abstract 85. – See more at: http://www.onclive.com/web-exclusives/Breast-Conserving-Therapy-Outcomes-Deemed-Similar-to-Mastectomy#sthash.yktAQbDu.dpuf
Survival after lumpectomy and mastectomy for early stage invasive breast cancer†‡The effect of age and hormone receptor status: E. Shelley Hwang MD, MPH1,§,*, Daphne Y. Lichtensztajn MS3, Scarlett Lin Gomez PhD3, Barbara Fowble MD2, Christina A. Clarke PhD3 Article first published online: 28 JAN 2013 DOI: 10.1002/cncr.27795
Dr. Freya R. Schnabel, CBS News, Jan 28, 2013 – New study could help women decide.