Although 80% of women today are good candidates for lumpectomy (breast-conserving) surgery, we continue to see nationally a smaller number of women actually having this procedure and instead undergoing mastectomy procedures. Making sure that your patient understands the decision-making process when offered a choice between these 2 procedures is important. Some patients choose mastectomy out of fear. They are so frightened having just been diagnosed that they commonly will say "take them both off." A natural reaction at a time of panic. Others may say "Do a mastectomy so I don't have to have chemotherapy." Oops, that's not the trade here. So, a few facts to make sure your patients are empowered with information so they can confidently participate in the decision making about their surgical treatment:
Women who need to undergo mastectomy fall into the following clinical categories:
- Had previous mantle radiation or breast radiation in the past (childhood cancers, previous diagnosis of breast cancer for which lumpectomy with radiation was performed.)
- Has multicentric disease—multiple cancers in the breast that occupy different quadrants.
- Has a large tumor and small breast volume making lumpectomy cosmetically not possible.
- Carries a BRCA gene.
- Is unable to have radiation therapy after lumpectomy surgery.
It's important that patients understand that from a survival perspective, lumpectomy with radiation is equal to mastectomy. So, she isn't going to live longer by having a mastectomy, even if she develops local recurrence down the road. This is always a surprise to patients.
Some women opt for bilateral mastectomies. These can be women who are really fearful. It isn't necessarily wrong to do such a procedure as long as the patient knows the facts. In the absence of a BRCA gene she only has a 5%-10% risk of getting breast cancer in her other breast (again, something women are surprised to hear).
If mastectomy is the final decision, discuss the options she has for reconstruction. With the exception of locally advanced disease (inflammatory breast cancer being an example and T3 tumors), she should be a candidate for some type of reconstruction: implants or flap surgery. Autologous flaps are growing in popularity. Today, DIEP (deep inferior epigastric perforator) flap is superior to TRAM (transverse rectus abdominis myocutaneous) flap. (See separate blog article about this option)
I like to give patients an analogy-a single weed in your front yard, a dandelion perhaps. You can dig it up by the roots and it is gone (lumpectomy). The yard may need to be treated with insecticides (radiation) to prevent it from returning. Or you can dig up your whole front yard and it is still gone (mastectomy). Whether any seeds from the dandelion blew away and landed in your backyard determines if chemotherapy or other systemic treatment may be needed.
Empowering patients with information is one of the best things you can do. You want them to look back years from now and say, "because I was taught about my breast cancer surgery options, I got to choose the type of surgery I had done, and I'm happy with my choice."