Although many patients may prefer to opt for a lumpectomy procedure, a mastectomy procedure may be more suited for some patients who require breast cancer surgery. In this informative guide, the second in his series on breast cancer surgery, consultant oncoplastic breast surgeon Mr Kelvin Chong sheds light on the common reasons why some women with a breast cancer diagnosis opt for mastectomy surgery instead of a lumpectomy. The leading specialist also dispels common misconceptions about mastectomies and discusses cases where mastectomies may be necessary.
Why do some patients opt for a mastectomy instead of a lumpectomy?
To avoid more than one operation – “One & Done!”
For patients who have lumpectomies, there is a one in five chance that their post-operative histology report will show that the cancer is close or present at the excision margins. In order to obtain clear cancer margins, these patients will have to undergo a second operation to excise more breast tissue (re-excision) or even a complete mastectomy.
Some patients, especially elderly patients may find this risk of a second operation physically and emotionally stressful. Moreover, for patients with significant medical problems, more general anaesthetic operations would mean higher risk of a complication such as heart attack, stroke and pulmonary embolism (clots in the lung) during the operation.
However, if patients undergo a mastectomy at the first operation, that will most likely be the one and only operation as the whole breast including the breast cancer will be removed with clear margins. It is rare that a mastectomy patient will require a second operation.
To avoid radiotherapy
Depending on a patient’s medical history and personal circumstances, some patients may wish to avoid treatment with radiotherapy and instead opt for a mastectomy. You can find more information on whole breast radiotherapy on Breast Cancer Now’s website. The main drawbacks to radiotherapy are detailed below.
Radiotherapy can cause redness and swelling of the breast and chest-wall skin which gives the appearance of sunburn (radiation dermatitis) which eventually settles down after radiotherapy. For a small proportion of patients, breast radiotherapy can lead to hardening of the breast which can sometimes lead to chronic pain. This however, resolves within a few weeks in most patients.
Many years later after radiotherapy, scarring of the lung and heart can develop especially for patients who receive radiotherapy to the left breast. In the majority of patients, this radiation-related scarring is unlikely to cause any long term side effects to patients who do not have lung or heart conditions. However, these risks become significant in elderly patients and in patients who have pre-existing heart conditions such as coronary heart disease, previous heart attacks and heart failure or lung conditions such a COPD, bronchiectasis and lung fibrosis. Radiotherapy is likely to worsen these conditions. These patients should discuss these risks with their surgeon before deciding which treatment path to follow. In patients with a history of significant medical problems, a mastectomy should be recommended so that they can avoid radiotherapy.
Whole breast radiotherapy involves daily visits and treatment for at least fifteen days in a row, though recently new shorter five-day regimes are now in practice. Daily radiotherapy may be especially challenging for patients who are elderly and immobile or patients without appropriate transport to attend their radiotherapy sessions. Under these special circumstances, your breast surgeon may agree to do a mastectomy to avoid radiotherapy.
Patient personal preference
Sometimes younger patients who are otherwise fit and healthy may wish to undergo a mastectomy, even if they are deemed suitable for a lumpectomy which is a less radical procedure. In many cases, this is because they wish to avoid the stress of undergoing radiotherapy and get back to their normal life as quickly as possible.
Some patients opt to have a mastectomy because they perceive a mastectomy is the safer operation that improves prognosis and decreases breast cancer local recurrence. However, this is a common misconception.
In some patients, this decision is partly due to information gathered in the media (i.e. the Angelina Jolie effect) but for others, there is a psychological reassurance that after a mastectomy, there is no residual breast tissue that could become cancerous later on. Even though, I will happily conform to the patient’s request for a mastectomy, it is imperative that they understand that having a mastectomy does not increase the overall survival rate from breast cancer compared to a lumpectomy and radiotherapy and this has been proven in many studies. Hence, there is no benefit in having a mastectomy over a lumpectomy in terms of survival or local recurrence and patients should not use this criteria to decide on which operation to pursue.
Previous history of radiotherapy
This applies to patients who have developed recurrent breast cancer in the same breast (ipsilateral recurrence). If the previous breast cancer was treated by lumpectomy and radiotherapy and a local recurrence develops several years later, it is likely that the next operation will be a mastectomy. This is because if a lumpectomy is performed for a recurrence, radiotherapy cannot be readministered for a second time. Repeated radiation to the same tissue will lead to significant complications. Please note that omitting radiotherapy after a lumpectomy for recurrence will likely lead to further local recurrence in the near future.
A mastectomy is also recommended for breast cancer patients who have had previous mantle radiotherapy for lymphoma treatment for the same reason.
When is a mastectomy procedure necessary?
Aside from patient preference, there are other reasons why some patients should have a mastectomy instead of a lumpectomy. As discussed in my other article on breast cancer surgery procedures, this can sometimes relate to the size or number of breast cancers a patient has. In addition, a mastectomy may be required in the following cases:
Inflammatory breast cancer
Inflammatory breast cancers are a rare but aggressive form of breast cancer which spreads through the lymphatics of the breast, as well as the skin. This form of cancer is very likely to recur and therefore, most breast surgeons would recommend a mastectomy to mitigate this risk.
Family history of breast cancer
Patients who have an established family history of breast cancer and those who carry associated gene mutations (such as BRCA1 and BRCA2), have an elevated risk of developing another breast cancer later in life, both in the same breast (ipsilateral) and the other breast (contralateral). Although a lumpectomy procedure is still possible in this scenario, some patients who carry breast cancer-related gene mutations may decide to opt for a double mastectomy. This is called a risk-reducing mastectomy which will reduce their lifetime risk of developing further breast cancer in future (usually to less than one per cent lifetime risk)
What are some common misconceptions about having a mastectomy?
Will having a mastectomy improve my chances of survival or extend my life expectancy?
Patients need to be aware that many studies have repeatedly proven that a mastectomy does not improve breast cancer prognosis compared to a lumpectomy with radiotherapy.
If I have a lumpectomy, must I also undergo subsequent radiotherapy?
Recently, some studies have found that patients pre-invasive breast cancer (mainly older patients with low or intermediate grade DCIS) are able to avoid radiotherapy if they fulfil certain criteria.
If I have a mastectomy for breast cancer, will my risk of local breast cancer recurrence reduce to zero?
No, in spite much efforts there is a still a risk of local breast cancer recurrence and the figures are much the same in both mastectomy and lumpectomy patients. Local recurrence refers to breast cancer returning in the same part of the body - the breast or chest wall and it often recurs in the scar or just under the skin near the scar.
Please note: distant recurrences/metastasis refers to cancer recurring in organs distant to the breast and these include the bone, liver, lung or brain.
The risk of local recurrence depends on the type of breast cancer (ER/PR/HER2-status), grade and presence and the number of lymph nodes that contain cancer. Hence, this will vary from one patient to another. Speak to your breast cancer specialist to get an accurate local recurrence risk calculation.
After a mastectomy, it is possible that breast cancer can recur locally, either in the mastectomy scar or under the scan. For this reason, it is important that all patients continue to perform regular self-checks, even after undergoing a mastectomy.
You can find more of Mr Chong’s expert insight on lumpectomy procedures and patient suitability in his other informative article for patients on breast cancer surgery.
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.