Surgery for Breast Cancer: Complex Options, Difficult Decisions

Choosing between a lumpectomy and mastectomy isn't as easy as looking at a few study findings.

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WASHINGTON - OCTOBER 26: A large pink ribbon hangs from the North Portico of the White House on October 26, 2009 in Washington, DC. The pink ribbon is a reminder that October is Breast Cancer Awareness Month.

In a fitting send-off to breast cancer awareness month, the White House's North Portico this week sports a massive pink ribbon. And at a Friday event for breast cancer, first lady Michelle Obama said, "We have a healthcare system in this country that simply is not working for too many people with breast cancer." While it's nice that so much attention has been paid to this disease, I think women—myself included—still need a lot of education on the topic. Two weeks ago, I reported on a study that found that about 25 percent of breast cancer patients who qualify for breast-conserving surgery aren't getting it. I wondered why they insist on getting mastectomies when research shows they're not getting an increased survival benefit.

Well, I got some answers from astute readers who had personally faced the dilemma. One woman wrote: "I am in the middle of making these decisions for myself. My DCIS [ductal carcinoma in situ, potentially a precursor to invasive cancer] is large and the Dr. has given me a choice between lumpectomy and mastectomy and explained that the survival rate is close to 100 percent in either case. It's the fear of recurrence and that the NEXT cancer would be invasive and deadly that spurs me and other women to [have] mastectomy and reconstruction." Another wrote that having a mom and two aunts previously diagnosed with breast cancer, "I did what many women do with families like mine, they fight it hard and fast. I did double mastectomy with reconstruction." Others told me that they would have faced reconstruction even with a lumpectomy given the amount of tissue that needed to be removed; what's more, some were told the radiation treatments necessitated by a lumpectomy could make the surrounding skin more fragile and harder to stretch for reconstruction. All in all, in one woman's words, "The decision to have a mastectomy 'against medical advice' might seem illogical, but sometimes it is based on reasons that are very legitimate for a particular patient."

Joel Aronowitz, chief of plastic surgery at Cedars-Sinai Medical Center in Los Angeles, commented that "every woman is entitled to her own decision." I gave him a call and found out that he started a nonprofit organization 18 months ago to educate breast cancer patients about their options for surgical treatment and breast reconstruction. He gave me some important pieces of information that I thought could be useful for women newly diagnosed with the disease.

First of all, lumpectomies and mastectomies can both be disfiguring and may, indeed, require some sort of reconstructive procedure if women are concerned about the cosmetic appearance of their breasts. For this reason, he recommends meeting with a plastic surgeon before the operation to discuss the options. "A plastic surgeon should be part of the equation from the get-go. We frequently see women after the fact," Aronowitz tells me, "and have to clean up the mess made by breast surgeons and general surgeons."

For example, he says, women can often have skin- and nipple-sparing mastectomies instead of the traditional modified radical procedure that leaves a giant, lancet-shaped scar and makes achieving a natural look via reconstruction very difficult. A 1995 study found that survival rates with the skin-sparing procedure are similar to those with the radical procedure as long as the tumor isn't penetrating through the skin. Retaining the nipple, Aronowitz says, is somewhat more controversial since some breast tumors originate in milk ducts that lead to the nipple, but the latest research suggests it's not risky if the tumor is located far away. (Unfortunately, those who have the nipple- and skin-sparing procedure may still lose sensation in those areas, a problem that I previously blogged about in this post on sex after breast cancer.)

Aronowitz says newly diagnosed breast cancer patients should be aware that they might be able to have reconstruction at the same time as the surgery to remove their cancer, sparing the need for a second operation. Insurance usually covers procedures on both breasts to achieve the desired cosmetic result. "Some women need breast reduction or a breast lift" to achieve symmetry, he explains, while others with naturally small breasts may opt for implants in both if they want a larger cup size.

All in all, the decision over what type of breast surgery to have is very individual, and women need to discuss all their options—preferably with a coordinated team of doctors that includes an oncologist, breast surgeon, and plastic surgeon. "If a patient is concerned about the cosmetic outcome, she needs to open her mouth and ask where the incisions are going to be made and what they're going to look like afterward," Aronowitz says. And, yes, women should be informed about studies showing similar survival rates among lumpectomy and mastectomy patients with early-stage tumors, and they should also be told that neither surgery will remove 100 percent of their breast tissue. Even mastectomies, he says, leave at least 5 percent of breast tissue behind. For more information about reconstruction options, check out the Breast Preservation Foundation website run by Aronowitz. It can also provide a referral to surgeons who perform skin-sparing mastectomies.

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