For many (but not all) women with breast cancer that requires surgery, there is an option to choose between mastectomy and breast-conserving surgery (BCS). Mastectomy is the removal of the entire breast, whereas BCS preserves the breast, removing only the cancer with a small margin of normal tissue. BCS is also known as lumpectomy or wide excision. This article explains in simple terms how to make the choice between mastectomy and BCS.
First and foremost, it is important to understand that the choice of mastectomy versus BCS does not change the survival outcome of the disease. The prospect of long-term survival primarily depends on the stage of cancer at diagnosis and the sub-type of cancer, and is not influenced by the type of surgery performed. In other words, a woman has the same chance of cure irrespective of whether she opts for mastectomy or BCS.
Organ conservating surgery for cancer of other organs (the limbs, kidney, rectum, urinary bladder) is primarily done to retain the physical function of the organ. In the case of breast cancer, the reason to preserve the breast is not so much to maintain its physical function, but rather to retain form and cosmesis, and to prevent psychological and emotional distress arising from the removal of a breast. However, each woman can have a different sense of the importance of preserving the breast. Some can be deeply affected by the sense of loss of a breast. For others, it may not be a major concern.
In addition, BCS is a relatively smaller surgical operation since less tissue is removed.
What then, are the disadvantages of opting for breast conservation?
Firstly, after breast conservation surgery, there is a small chance that the final histopathology may show that the surgical margins are involved with cancer. If this happens (this is known for certain only a few days after the operation), a re-operation will be required. A re-operation usually involves further removal of a small portion of breast tissue, but rarely (in case of extensive margin involvement), a mastectomy may be recommended.
Secondly, following breast conservation surgery, the majority of women (except the very elderly) require post-operative radiation therapy. Although breast radiotherapy is well-tolerated, it entails additional cost and daily travel to a radiotherapy center. Radiotherapy is typically given over a few minutes at a time, five days a week for about six to eight weeks, although for some women shorter durations can be offered. With mastectomy, radiotherapy is not required, provided the lymph nodes in the armpit are free of cancer (women undergoing mastectomy will also need radiotherapy if their lymph nodes are involved with cancer).
Thirdly, women whose breast has been preserved have a slightly higher chance (when compared with those who have undergone mastectomy) of developing a local recurrence in the preserved breast. However, recurrences can be treated, and as highlighted earlier, this does not change survival outcomes.
To summarize, a woman with breast cancer who desires to preserve her breast can safely do so, without worrying if it will reduce cure rates. It is in fact a smaller operation. She has to keep in mind, however, that she will definitely require radiation therapy later, that there is a small chance she may require re-operation after a few days, and that there is a slight chance that a recurrent cancer may develop in the preserved breast. A woman opting for mastectomy has to accept the loss of the breast (although reconstruction options are available – the subject of a different post), and undergo a slightly bigger operation. But she does not have to worry about a re-operation for positive margins, may be able to avoid radiotherapy if her lymph nodes show no cancer, and the chances of a local recurrence are very low.
Thus, depending on each woman’s individual preference, she can opt for breast conservation (if preserving the breast is the important priority for her) or mastectomy (if the possibility of avoiding radiation therapy/ second surgery/ local recurrence is more important).