A breast cancer diagnosis can be overwhelming; a woman must make highly personal decisions with respect to her treatment, particularly when considering surgery. Surgery is needed for nearly all people with breast cancer. Treatment is usually a combination of surgery, radiation therapy and drug therapies.
Depending on the extent of the cancer in the breast, the surgical oncologist may recommend a mastectomy, which is surgery to remove nearly all breast tissue. However, for a woman with early-stage cancer (breast cancer that has not spread beyond the breast or the lymph nodes), there are typically several options, and with those options, more choices. As appropriate, a woman may choose breast-conserving surgery, a mastectomy of one or both breasts and breast reconstruction surgery. If she desires reconstruction, there are several types of implants, or the surgeon could use tissues from other parts of the body to recreate the breast.
Surgical Options
There are short and long-term factors to consider when deciding which surgery is right for you. Ask your doctor about the expected recovery time for each option, restrictions after surgery and if more surgeries or other follow-up treatment will be needed.
- Lumpectomy — Surgery removes only the part of the breast containing the cancer. A lumpectomy is breast-conserving surgery.
- Mastectomy — Surgery removes the entire breast, including diseased and healthy tissue. A double, or bilateral mastectomy is when both breasts are removed. A double mastectomy may be recommended if there is cancer in both breasts. Some women prefer this option if they have a genetic mutation, such as the BRCA1 or BRCA2 mutation, that can predispose them to a new breast cancer in either breast or future cancers such as ovarian cancer.
If there will be reconstructive surgery, a nipple-sparing mastectomy may be an option. All the breast tissue is removed but the surgeon preserves the nipple, areola and skin envelope of the breast. This type of mastectomy can be appropriate if there is no cancer in or near the nipple or areola and the cancer is not large or aggressive, so there is not a risk of leaving residual cancer when preserving the nipple and areola.
- Implant-based reconstruction — Surgery uses implants to restore shape to the breast after a lumpectomy or mastectomy.
- Autologous tissue reconstruction — Surgery uses a person’s own tissue (skin, fat, muscle) from another part of the body (typically the abdomen or back) to reconstruct the breast.
- Oncoplastic reconstruction — Surgery removes the breast cancer with a lumpectomy followed by reconstructive surgery to minimize any cosmetic defects in the breast, such as a different shape or size compared to the other breast or displacement of the areola. Generally, oncoplastic surgery is suitable for women who have tumors that allow preservation of healthy breast tissue that can be re-arranged to restore the breast’s natural appearance.
- Aesthetic flat closure — means deciding against breast reconstruction after a mastectomy. Instead, the surgeon creates a smooth, flat surface for your chest. It is a valid personal choice, and your care team will help you understand the surgery and physical and emotional effects to consider if you are interested in this option. Women choose it for a variety of reasons, including having existing conditions that could make reconstruction a safety risk or the desire for a simpler recovery. Some women just don’t like the idea of implants or other reconstruction options. If you choose a flat surgical closure instead of breast reconstruction, your care team will fully support your decision.
Additional Treatments
There is a risk of recurrence of breast cancer after lumpectomy or mastectomy. The risk depends on different tumor characteristics, but it is less than 10%. Your doctor will recommend other treatments you may need and will help you understand their role in your outcome.
Radiation Therapy
Research has shown that outcomes for mastectomy and lumpectomy are similar if lumpectomy is followed by radiation therapy. While a lumpectomy only involves partial removal of the breast, the surgeon will recommend it be followed by four to six weeks of radiation therapy to eliminate any remaining cancer cells and reduce the risk of recurrence. Radiation therapy may or may not be needed after a mastectomy, depending on the number of cancer-positive lymph nodes discovered during surgery and other factors specific to your breast cancer.
Chemotherapy or Other Drug Therapies
Your care team may recommend drug therapy before surgery to reduce the tumor’s size if it is large, or after surgery. This could involve chemotherapy, targeted therapy, hormonal therapy or immunotherapy. The recommendation will depend on pathology results (tissue biopsies), which will reveal your breast cancer’s type, stage and whether or not your cancer’s growth and development is driven by hormone receptors (like estrogen), certain proteins on the surface of the cancer cell or genetic mutations.
Pathology results may reveal that drug therapy is optional because your cancer is early stage or has a very low risk of recurrence. Your care team will carefully evaluate this option and will discuss risks and benefits with you.
Clinical Trials
Ask your doctor about clinical trials that may offer additional treatment options.
Post-Treatment Disease Surveillance
Follow-up appointments will include a visit with your care team, imaging, bone health monitoring, and sometimes, blood tests. Monitoring for cancer recurrence, treatment-related side effects or emotional difficulties like anxiety and depression are important for your ongoing care, even after you have completed treatment or are on maintenance therapy. Be sure to tell your doctor or clinician about any symptoms, lumps or other changes.
- You will continue to have follow-up appointments for many years, although they will become less frequent.
- If you have had a lumpectomy, you must continue to get mammograms of the affected breast — and the other breast (if present).
- If you have a mastectomy, you will no longer need routine breast imaging on the side where breast tissue has been removed.
- Regardless of the type of surgery you have, you will still need regular physical exams to check for new lumps or masses in breast tissue, the chest wall, the lymph nodes or lungs. You will also need mammograms where any breast tissue remains.
Understanding Family History
About 5% to 10% of breast cancers are hereditary. Gene mutations (abnormalities that occur when cells divide) can be inherited from a parent. If there is a history of breast cancer in your family, your doctor may recommend meeting with a genetic counselor and having genetic testing to determine if your disease is linked to an inherited genetic abnormality. Women with certain genetic mutations have an increased risk for developing breast cancer. These women still have the option of breast conservation surgery but may opt for a mastectomy because of a higher risk of recurrence. Depending on the type of genetic mutation, additional ways of managing increased risk, such as preventive removal of the ovaries, may be recommended.
Making Informed Care Decisions
It is important to meet with the members of your treatment team (surgical oncologist, radiation oncologist, medical oncologist and plastic surgeon) to understand all your options, your risk of recurrence and how treatment will affect your life and that of your family in the future.
After your medical team has determined your options based on factors such as the stage of your cancer, type of breast cancer, imaging scans and any gene mutations, they will explain recommended surgery and other treatments. Consider the information, ask questions and take the time you need to gain clarity. You can also seek a second opinion if it will make you feel more comfortable and give you peace of mind in knowing you have explored every option available to you. By taking these steps, you will have the knowledge you need to make the right decisions.
