Deciding Between a Lumpectomy, a Mastectomy

This article originally appeared NewYork-Presbyterian Health Matters.

By Amanda Torres

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NEW YORK - Women diagnosed with early-stage breast cancer will likely have surgery as part of their treatment. Some patients may have a choice between breast-conservation surgery – also known as a lumpectomy – or removing the entire breast, a mastectomy. But the decision for what kind of surgery to get isn’t always simple. Factors that may impact their decision include fear of recurrence, ability to undergo radiation, and having a genetic predisposition for breast cancer.

For patients who have a breast cancer diagnosis, there can be a lot to consider in terms of choices for treatment,” says Dr. Arith Reyes, a surgeon specializing in breast cancer and benign breast diseases at NewYork-Presbyterian/Columbia University Irving Medical Center and NewYork-Presbyterian Westchester. “But the good news is that we have reliable studies that may help guide people in their decision-making process.”

A recent study in JAMA Oncology showed that people with early-stage cancer who were candidates for lumpectomy and mastectomy found that the survival rate remained the same whether patients chose lumpectomy followed by radiation therapy, or mastectomy.

“This is important to understand because there has been a rise in patients with breast cancer who decide to get a double mastectomy when they have cancer in one breast,” says Dr. Reyes. Another study published in JAMA Surgery in 2017 found that one in five women diagnosed with breast cancer chose to undergo a second mastectomy to remove their healthy breast if they already had the other breast with cancer removed.

Over the years, researchers have been studying patients’ decision-making process when opting for more invasive surgery like mastectomy and have found factors that were significantly associated with their choice, such as greater worry about cancer recurrence. “While there is no difference in survival, studies have found that there is a lower rate of recurrence of breast cancer in the other breast after double mastectomy, but the numbers are still low in all the groups,” says Dr. Reyes. “Overall, it is a matter of how much risk a patient is willing to take, and that is a personal choice.”

Health Matters spoke with Dr. Reyes, who shared what to know about breast-conserving surgery like lumpectomy, and scenarios when mastectomy might be the better option.

What is the difference between a lumpectomy and mastectomy? 

A lumpectomy is a breast-conserving surgery that removes cancer and some normal tissue around it, but not the breast itself, so the shape of the breast is maintained. When you do lumpectomy for breast cancer, which is a good option for people with early-stage cancers, it almost always has to be followed by radiation therapy. There are rare circumstances where you don’t have to do radiation after a lumpectomy, such as if you are 65 and older and have a certain type of breast cancer, such as lymph node-negative invasive breast cancer.

In a mastectomy, one or both breasts are removed, and patients may opt for reconstruction. For people with early-stage breast cancer and who have mastectomy, radiation therapy is usually not needed but it is a case-by-case decision. It is important for patients to know that studies have shown no difference in survival if they chose a lumpectomy with radiation or mastectomy. And that is something that we always bring up in discussing those two choices, is to explain that the length of time you live is the same, regardless of which you choose. The JAMA Oncology study followed over 600,000 patients – those who received lumpectomy versus mastectomy in one breast versus mastectomy in both. 

Researchers found that the survival rate after 20 years was the same in all three groups.

Are there instances where a mastectomy would be the better choice? 

It is dependent on the stage of the breast cancer and the type of breast cancer. If they have a more aggressive breast cancer, like inflammatory breast cancer, then a mastectomy is strongly recommended. While this type of breast cancer is rare, it is arguably the most aggressive kind. In general, if the cancer is large, patients would undergo chemotherapy first so that the cancer could shrink before surgery. When cancer is in a large area, it becomes difficult to remove the tumors with good cosmetic results, which is when we recommend removing the whole breast. In addition, patients who have certain genetic mutations, such as mutations to the BRCA1 and BRCA2 genes that predispose women to get breast cancer, are strong candidates for a double mastectomy.

How can understanding risk factors for breast cancer help patients make treatment choices if they are ultimately diagnosed?

Genetic testing is something that we are doing more commonly now. Generally, I would not be recommending double mastectomy if patients do not have genetic mutations.

What do these procedures entail and what does recovery tend to look like? 

With lumpectomy, it is a same-day surgery, and the recovery is quick. Usually, they would have only one cut, unless it is two areas of the breast that has breast cancer, and they are still able to get two lumpectomies without deforming the breast.

For mastectomy, there is an option of no construction, just going flat, and then the option of doing reconstruction, which would be done by a plastic surgeon. And depending on the type of reconstruction, the recovery can be longer. But usually, I would say four weeks of recovery for a mastectomy and for reconstruction at the time of the mastectomy.

What to Know About Types of Mastectomies

For patients who opt for mastectomy, there are options for the type of surgery. “The extent of breast cancer and the shape of the breast determines which mastectomy we do,” says Dr. Reyes.

A patient is eligible for nipple-sparing mastectomy if the cancer is less than two centimeters away from the nipple. Says Dr. Reyes: “The advantage of nipple-sparing mastectomy is it has a better cosmetic outcome.”

Skin sparing and total mastectomy remove the nipple and areola, and more skin is removed in a total mastectomy.

One important point to keep in mind: “Patients need to know that regardless of which mastectomy, sensation is lost, so even with nipple-sparing mastectomy, they do not feel the nipple and the skin. And there is higher risk of complications with mastectomy plus reconstruction than lumpectomy, such as surgical site infection,” says Dr. Reyes.

How do you advise patients while they weigh their options?

There are patients where lumpectomy is not an option, but if they have choices for surgery, then I think it’s important to understand that studies have shown no difference in survival rate between a lumpectomy with radiation and mastectomy. It’s a matter of how much risk you’re willing to take, and that’s a personal choice. For patients who fear the chances of recurrence and they don’t want to go through that whole process again, they may opt for mastectomy. But the bottom line is that either of those two options will give them the same survival.

Arith Reyes, M.D., is a board-certified surgeon specializing in breast cancer and benign breast diseases at NewYork-Presbyterian/Columbia University Irving Medical Center and NewYork-Presbyterian Westchester. She is also an assistant professor of surgery at Columbia University Vagelos College of Physicians and Surgeons. Dr. Reyes performs all aspects of breast surgery, including breast conservation (lumpectomy), mastectomy, nipple-sparing mastectomy, and axillary lymph node procedures.