Author: Gerlinde Tynan, MD
Surgery is typically included in the breast cancer treatment process. Depending on your situation, you may be able to choose the surgical procedure: either a breast-conserving surgery, called a lumpectomy, or the total removal of your breast, called a mastectomy.
One of the first things you should know is that for early-stage breast cancer, there is no significant difference in survival rates following a lumpectomy plus radiation versus a mastectomy. There are differences between the two surgeries, but one is not necessarily better than the other. Ultimately, it depends on what makes the most sense for you now and gives you the best chance for recovery.
Facts and Feelings about Breast Cancer Surgery
Deciding on which surgery to have starts with facts about your cancer. Breast cancer is a complex disease, and each case is unique. To start, there are many types and subtypes of breast cancer based on the biology of the cells that make up the tumor. Breast cancers are also classified by where they occur in the breast tissue, either in the milk ducts or milk glands.
Some other important aspects include tumor size, location inside the breast, stage, and grade. The stage refers to the size of the tumor, lymph node involvement and how far the cancer has spread from the original site to other parts of the body. The grade is how abnormal the cancer cells look and how fast they are growing.
These factors must be considered to determine which treatments will produce the most successful outcome.
Your feelings are another critical part of the surgery decision. Your breasts can play a significant role in your self-image and sexuality, and you may feel distressed over the idea of losing them. You may also wonder how cancer treatment will affect your life and the lives of those around you. Your family and friends may have opinions about what you should do. All of this can potentially complicate your breast surgery decision.
“There is literally a whole spectrum of choices, and it’s such a very personal choice,” says Dr. Gerlinde Tynan, FACS, board-certified breast surgeon specializing in surgical disease of the breast, mainly breast cancer, at Rocky Mountain Breast Specialists (RMBS). “I think patients need to feel empowered to make the decision that is best for them, rather than being influenced by other people who aren’t living what they’re living.”
Breast Cancer Surgery Options
Before deciding between a lumpectomy or mastectomy, you will need to weigh the potential advantages and disadvantages of each. What is a benefit for you might be a disadvantage for someone else and vice versa.
A lumpectomy removes the tumor and a surrounding “margin” of normal-looking tissue. A lumpectomy is often the preferred choice for early-stage breast cancer when a small tumor has formed but has not spread beyond the breast. Lumpectomy is almost always followed by breast radiation.
- Lumpectomy surgery is less invasive than a mastectomy, and recovery is faster
- More of the natural appearance and sensitivity of the breast is preserved
- If tests following surgery find cancer cells in the margins, you may need an additional surgery to remove these cells.
- The risk of the cancer coming back in the same breast is higher following a lumpectomy. If you have recurrence, your oncologist will likely recommend a mastectomy, as the breast usually cannot be radiated twice.
- Breasts may not match in size or shape after lumpectomy. If this is important to you, reconstruction surgery on the opposite breast can improve breast symmetry and is usually covered by insurance.
A mastectomy removes all breast tissue and a variable amount of skin. Sometimes the nipple can be saved, other time not. Mastectomy may be recommended instead of lumpectomy for various reasons, including larger tumor size, tumors in more than one spot in the breast, a tumor located near or touching the chest wall, or cancer that has spread to the lymph nodes.
- Removing the entire breast can help you feel more confident that the cancer will not return.
- The risk of local recurrence is lower following mastectomy.
- You may not need radiation or other treatments after surgery.
- Mastectomy is invasive and may involve more side effects and a longer recovery time.
- Several additional surgeries may be needed if you choose to have breast reconstruction.
- You will lose the entire breast.
According to Dr. Tynan, it is also important to note that while mastectomy lowers the risk of local recurrence, it cannot guarantee that your cancer will never return. This is why you must follow through with additional therapies, such as radiation therapy, chemotherapy, targeted therapy, or hormone therapy. These treatments help ensure that your breast cancer treatment is successful.
Single vs. Double Mastectomy
You may have a mastectomy to remove one breast in a surgery called a single or unilateral mastectomy. You might have both breasts removed, a surgery called a double or bilateral mastectomy. Some people with cancer in one breast choose to have the other breast removed, a procedure called a contralateral prophylactic mastectomy.
“Some women who could have a lumpectomy choose to have double mastectomies for personal reasons,” said Dr. Tynan. “Sometimes they just have so much to do and other people to take care of that for them, it’s like, OK, let’s just do this. There are fewer other treatments potentially needed, maybe less follow-up, less overall worry.”
Double mastectomies may also be a preventive measure for people with a genetic mutation that raises their risk of developing breast cancer.
“Patients with a genetic predisposition for breast cancer tend to get more aggressive, faster growing cancers, “Dr. Tynan said. “For those patients, prophylactic or risk-reducing mastectomies are considered potentially life-saving.”
Recovery from Mastectomy
Your recovery time varies depending on which mastectomy you had and whether you also had breast reconstruction surgery. Without reconstruction, it could take you a few weeks to heal, and you won’t be able to lift heavy weights or do other strenuous activities.
When you also have reconstruction surgery, your recovery can take several weeks longer, with more significant limitations on upper arm activity. Your doctor may recommend an exercise plan to help reduce side effects and help you return to your daily activities.
Support from friends, family, and others who have gone through similar experiences can be an essential part of the recovery process. Look for support groups in your area to find one that is right for you.
Reconstruct or Not
Breast reconstruction surgery often happens at the same time as the mastectomy. If an immediate reconstruction is not an option, reconstruction can always be done later. If you are undecided about reconstruction, you can always delay it for months or even years.
There are two main types of breast reconstruction:
- Tissue flap surgery, which rebuilds the breast shape using surplus tissue from your body, most often the abdomen, buttocks, or hips.
- Implant-based surgery, which replaces breast tissue with silicone or saline-filled implants.
If you choose not to have breast reconstruction surgery after your mastectomy, you may consider the following:
- Breast forms, which mimic your breast's movement, feel, and weight. These may be worn in mastectomy bras that have a stretchy pocket inside to hold the form. You can also attach them to your body.
- Staying flat. A "flat closure" mastectomy provides the smoothest, flattest result if you decide not to reconstruct. A flap closure does not prevent the wearing of prosthetic bras and breast forms if desired