Breast cancer surgery: What are the advantages of a lumpectomy over a mastectomy?

Following breast cancer diagnosis, many patients may have to take complex decisions about their next steps and which surgical approach they prefer. We invited highly esteemed consultant oncoplastic breast surgeon Mr Kelvin Chong to share his expert insight on lumpectomy surgery, a type of breast conserving surgery also known as wide local excision, and the advantages it can offer over mastectomy. The revered specialist also details which patient profiles are suitable for lumpectomy surgery in this, his first article in a series providing expert guidance for patients facing breast cancer surgery.

Which type of breast cancer surgery is right for me: lumpectomy or mastectomy?

One of the most commonly asked questions from my patients following a breast cancer diagnosis relates to deciding whether to opt for a lumpectomy or a mastectomy procedure. As there are numerous factors involved in this decision, this discussion can be lengthy. I’ve created the following article to outline the key aspects to consider for patients facing this decision about their treatment. Knowledge is power and I hope that my articles will help give patients awareness and confidence about their treatment and in some cases, help them to decide on the best treatment option.

Initially, patients should note that only there are only two types of surgery for breast cancer: breast conserving surgery, where only a section (or sections) of tissue are removed, and mastectomy, in which the whole breast is removed. A wide local excision operation, also known as a lumpectomy, is the most commonly used breast conserving surgical approach and generally, is the intuitive choice for most breast surgeons and patients with breast cancer. There are a number of reasons for this, as detailed below.
 

Why do some patients prefer to opt for a lumpectomy procedure?

Lumpectomy procedures are less radical operations, which aim to remove only the tumour and not the unaffected breast tissue. As more breast tissue is conserved with a lumpectomy, many patients are less affected by body image concerns after surgery as compared to those undergoing a mastectomy, where the entire breast is removed. Innovative surgical techniques have enabled breast surgeons to achieve improved aesthetic results and better breast symmetry with lumpectomy surgery.

Although it takes a similar amount of time to perform a mastectomy and a lumpectomy, the recovery time required and associated risks following the procedures differ. Post-operatively, mastectomy patients require a longer recovery period as the scale of trauma to the body is significantly increased. Additionally, for the first few weeks after mastectomy surgery, issues such as seroma (a build-up of fluid under the scar) can commonly occur, which requires needle drainage in clinic. Although this can also occur following lumpectomy surgery, it is far less common.
 

A surgeon’s perspective: What to consider when deciding between a lumpectomy and a mastectomy

All patients with a breast cancer diagnosis should be counselled on what is involved in both lumpectomy and mastectomy procedures before making a decision about which surgical approach to opt for. It’s important to consider the following information when considering your options.

From a surgeon’s perspective, the most important factor in this decision making is the size of the breast cancer in relation to the size of the breast.

Cases of a solitary cancer in the breast

Generally speaking, patients with only one small sized breast cancer in a moderate or large breast are suitable for a lumpectomy procedure; for example, a patient who wears a 32B sized bra with a cancer of around 2 to 3 centimetres in size.

However, with a cancer of the same size in a patient with very small breasts (such as a bra size of 30AA), a lumpectomy procedure may not be suitable as there is not sufficient residual tissue to reconstruct the breast with good aesthetic results. Therefore, for this patient profile, most surgeons would recommend a mastectomy, with or without reconstruction according to the patient’s preference.

For the same reason, lumpectomy procedures with a larger cancer (4 -5 cm) may not be suitable in patients with small or moderately sized breasts, as there would not be enough residual tissue to reconstruct the breast with good cosmetic results. In addition, the likelihood of finding cancer at the margins of the lumpectomy tissue would be higher in this scenario and would therefore mean that further surgery would be required. However, patients with a larger breast size, such as 36DD, would be suitable for a lumpectomy to remove this larger cancer, as the remaining tissue would be sufficient for good reconstructive results.

Your breast surgeon and the multidisciplinary committee should be able to assess and advise you about which operation is the more appropriate operation in your case.

At the time of writing this article, another new surgical technique called ‘perforator artery flaps’ has been developed. This technique enables a lumpectomy to be performed in patients with small-sized breasts with large-sized and/or multifocal breast cancers. In this operation, once the breast cancer has been excised using a standard lumpectomy, the remaining cavity will be filled by a flap (wedge of subcutaneous fat tissue) that is harvested from the skin and fat tissue just below the axilla (armpit) or just below the breast. This is achieved by harvesting a flap with the artery-vein vessels still preserved to maintain tissue viability. The flap is then rotated into the cavity to replace the tissue that was removed during the lumpectomy. Not all patients are suitable for this operation but it should be explored with your surgeon so as to avoid a mastectomy.
 

Cases of multiple cancers in the breast

Historically, all patients with multiple cancers in one breast were treated with mastectomy, regardless of the size of the breast. More recently, however, innovative surgical techniques, such as therapeutic mammoplasty, have made breast conserving surgery possible for patients with a larger breast size. In therapeutic mammoplasty surgery, the surgeon removes sections of the breast tissue which contain cancer and then uses breast reduction techniques to reconstruct the breast from the remaining tissue.

Although this technique gives a well-shaped breast, it often results in asymmetry as the newly constructed breast is smaller than the unaffected breast on the other side (contralateral breast). As a result, contralateral breast reduction is often performed to correct this asymmetry. You can see some of my therapeutic mammoplasty case studies by visiting my website.

If you require breast cancer surgery and wish to schedule a consultation with Mr Chong, you can do so by visiting his Top Doctors profile.