What is the difference in long-term outcomes between lumpectomy and mastectomy procedures when performed by a skilled surgeon?

A breast cancer diagnosis can bring about an overwhelming amount of decisions to be made. First and foremost on most patients’ minds is what are the treatment options and which have the best long-term outcomes. Choosing a doctor that you feel comfortable having open and honest communication with will help alleviate some of the stress associated with making treatment decisions.

Dr. Gorman is committed to giving her breast cancer patients an advanced, personalized, and targeted approach to breast cancer treatments. In some cases, people with breast cancer can choose between removing the entire breast (mastectomy) or breast-conserving surgery (lumpectomy) followed by radiation. In this article, we will discuss the differences in long-term outcomes between lumpectomy and mastectomy procedures when performed by a skilled surgeon.

What is a mastectomy?

Breast surgery that involves the removal of the entire breast is called a mastectomy. When faced with the choice between a mastectomy and lumpectomy (also known as breast-conserving surgery) plus radiation therapy, some women choose mastectomy. For some women, mastectomy is the only surgery option for breast cancer. Mastectomy is also used to treat breast cancer that has come back after lumpectomy and radiation therapy have been done.

Total (simple) mastectomy and modified radical mastectomy are the two main types of mastectomy. Your diagnosis and cancer type will determine the type of mastectomy you will have.

Total (Simple) Mastectomy

In a total (simple) mastectomy, the surgeon removes the entire breast and the lining of the chest muscle but does not take out any other tissue.

Total (simple) mastectomy can be used to treat:

• Ductal carcinoma in situ (DCIS)
• Paget disease of the breast with underlying DCIS
• Invasive breast cancer
• Breast cancer recurrence

Total mastectomy is also performed on high-risk women who want to prevent cancer based on personal preferences.

Sometimes a reconstruction of the breast is done at the same time as a mastectomy.

Modified radical mastectomy

The breast surgeon takes out the entire breast, the lining of the chest muscles, and the lymph nodes in the armpit area (axillary lymph nodes) during a modified radical mastectomy.

This type of surgery can be used to treat:

• Invasive breast cancer
• Inflammatory breast cancer
• Paget disease of the breast with underlying invasive breast cancer

Sometimes a modified radical mastectomy is done at the same time as breast reconstruction. However, this is not done for inflammatory breast cancer.

What is a lumpectomy?

A lumpectomy is a surgical procedure used to remove breast cancer. In contrast to a mastectomy, a lumpectomy only removes the breast tumor and a small amount of healthy tissue around it. It leaves most of the skin and breast tissues where they are.

The breast looks as close as possible to how it did before surgery after a lumpectomy. Most of the time, the breast and nipple area keep their general shape. Lumpectomy is also called breast conserving surgery, partial mastectomy, and wide excision. This type of breast cancer treatment is used in early breast cancer.

Is there a difference in the long-term outcomes of a mastectomy vs. a lumpectomy?

For women with earlystage breast cancer, there is no difference in overall survival rates between a mastectomy and a lumpectomy with radiation. There are other differences between these two therapies, but neither is better than the other. It just depends on what’s best for the patient.

There have been multiple randomized trials comparing breast-conserving surgery and mastectomy, which found no survival advantage for either surgery option. In 1990, the American National Cancer Institute (NCI) consensus panel came to the conclusion that breast-conserving surgery was the optimal treatment based on these trials in the United States. Since then, the trend in surgical procedures has changed, with breast-conserving surgery first increasing and then dropping since 2006 while mastectomy rates have climbed. Bilateral mastectomies are primarily responsible for the rise in mastectomy rates.

Studies show that women with early-stage breast cancer who have breast-conserving surgery followed by radiation therapy have the same chance of surviving as women who have a mastectomy. This means that if there is no medical reason for you to have one surgery over the other, your doctor will let you choose.

Choosing between surgery to save the breasts and a mastectomy is a very personal decision. In addition, it comes at a very emotional time. Your feelings, preferences, priorities, and way of life all affect your choice. If you want to keep as much of your breast as possible, you might choose breast conserving therapy. Or, a mastectomy, which removes more breast tissue, may give you more peace of mind.

First, talk to your breast physician to find out if you can choose between a mastectomy and a lumpectomy plus radiation therapy. Some women may not have a choice because a mastectomy is the only surgery that can treat their advanced breast cancer. About 25% of women will need a mastectomy, but the other 75% can choose not to have one.

Most of the time, the size of the tumor compared to the size of the breast is the main thing a breast surgeon looks at to decide if a lumpectomy is a good option for the treatment of cancer. Whether lumpectomy is a realistic possibility is related to the % volume of the breast which requires excision to remove the cancer with adequate pathological margins, in comparison to the overall size of the breast, also taking into account where the tumor lies within the breast, as some areas of the breast are more cosmetically sensitive to volume loss than others.

Chemotherapy or hormone therapy may be suggested before surgery, especially if you have a large tumor or if your lymphatic system is involved. This is called neoadjuvant therapy, and it will help shrink the tumor before surgery to remove breast cancer.

Sometimes a woman can have a lumpectomy but should avoid radiation therapy, and in this case, she will need to have a mastectomy instead. Radiation therapy is not for everyone. Radiation therapy can be dangerous if you are pregnant or if you have certain health problems.

Since radiation can hurt the baby, it is not given to women who are pregnant. Depending on when the woman found out she was pregnant and when she was told she had breast cancer, she may be able to have a lumpectomy and put off radiation therapy until after she gives birth.

Some serious diseases of the connective tissues, like scleroderma or lupus, may make you more sensitive to the side effects of radiation therapy. However, in some women at higher risk of breast cancer recurrence, radiation therapy may still be used.

Radiation therapy to the same breast or the same side of the chest in the past may make you ineligible for radiation therapy if there is a recurrence. In most cases, breast radiation therapy can only be done once. After careful discussion with your radiation oncologist, radiation therapy may be given to the same breast again in very rare cases.

If you have a choice, you should carefully consider all of the outcomes before making a decision. A short delay before surgery won’t hurt your prognosis. Think about the risks and benefits of each surgery and choose the one that is best for you. No matter which choice you make, the chance of survival is the same.

How do patients choose between a mastectomy versus lumpectomy plus radiation therapy?

People with breast cancer can sometimes choose between the total removal of a breast (mastectomy) and surgery to save the breast (lumpectomy) followed by radiation. If there is only one site of cancer in the breast and the tumor is less than 4 centimeters, a lumpectomy followed by radiation is commonly a treatment option and is likely to work just as well as a mastectomy. Clear margins (no cancer cells in the tissue surrounding the tumor) are also a requirement for a lumpectomy.

When given the option, most women choose the less invasive lumpectomy, but there are a few things to consider before making the decision between lumpectomy and mastectomy. Consider how you feel about these factors:

• How important to you is it to keep your breast? If keeping your breast is important to you, you might choose to have a lumpectomy with radiation instead of a mastectomy and avoid having the entire breast removed.
• Do you want your breasts to be as close to the same size as possible? Most women look good cosmetically after having a lumpectomy. When a larger area of tissue needs to be removed, which happens very rarely, a lumpectomy can make the breast look smaller or distorted. There are different types of reconstruction for both lumpectomy (if there is a lot of distortion) and mastectomy. It is up to you and your health care provider to determine the best course of action if you require a significant amount of tissue removed and want breasts that are the same size.
• How concerned are you about a recurrence of breast cancer? If removing the entire breast would make you less worried about your chances of recurrence, you might want to get a mastectomy.

Ultimately the decision to have a lumpectomy plus radiation therapy or a mastectomy is a very personal decision that should be made with the guidance of your skilled surgeon. Dr. Gorman at Texas Breast Center is a breast surgeon who specializes in surgical oncology and surgical diseases of the breast. She treats each patient as an individual and tailors their treatment plan to their unique needs knowing that no two people are the same and, therefore, treatment cannot be either.

Dr. Gorman has a vast amount of knowledge and experience when it comes to the treatment for breast cancer. She always considers and evaluates all of the treatment options and their likelihood of success before contemplating surgery. When surgery is needed, she implements a breast-conserving surgery when possible to reduce the impact on cosmetic appearance post-operation. For more information about Dr. Gorman and the breast cancer surgery treatments available at Texas Breast Center, visit our website or call our office to schedule a consultation.

https://pubmed.ncbi.nlm.nih.gov/7477145/
https://journals.lww.com/aosopen/Fulltext/2022/12000/Breast_Conserving_Surgery_or_Mastectomy___Impact.6.aspx
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504664/