Lumpectomy versus Mastectomy

Surgery for breast cancer often involves surgery of: 

1. The breast  

2. Arm pit (axillary) lymph nodes

Surgery of the breast is broadly divided into two types: 

1. Lumpectomy (also called Breast conservative Surgery (BCS), partial mastectomy, or wide local excision) 

2. Mastectomy   

As the name implies lumpectomy involves removal of the breast cancer with a margin of healthy breast tissue around it (hence technically called wide local excision). On the other hand, in mastectomy the aim is to remove the entire breast tissue. If you are having a mastectomy, you may choose to have your breast reconstructed using an implant or your own tissue, or alternatively decide to go flat. 

Before we delve into your decision-making process between the two, you must know that lumpectomy for breast cancer comes in a package with radiotherapy. The combination of lumpectomy and radiotherapy is often referred to as Breast Conservative Therapy. Although occasionally radiotherapy can be safely omitted after lumpectomy, in most cases you will need 3 to 5 weeks of radiotherapy to the breast after you have had your cancerous breast lump removed. On the other hand, after mastectomy radiotherapy may or may not be advised depending on the extent of the cancer and lymph node involvement. 

There are plenty of resources on the web that try to help you decide between the two. I went through some of them before writing this blog, including official international government resources and I realised that unfortunately most of them are based on old data. 

There are now a plethora of studies that show breast conservative surgery is better than mastectomy regarding cost, psychosocial well-being, and patient reported outcomes. Even if you have the best breast reconstruction (often requiring multiple procedures), the reconstructed breast never feels and moves the same as your own breast. It will be insensate and depending on the type of reconstruction will inevitably require ongoing upkeeping and/or be associated with donor site morbidities (complications).  

But how about the cancer outcome? From a cancer treatment point of view (oncological outcome) combination of lumpectomy and radiotherapy is at least equivalent to mastectomy. In fact, in the last few years large population-based studies have been published that suggest patients who have had lumpectomy and radiation have a better survival than patients who have had mastectomy with or without radiation. Although this observation could potentially be due to confounding factors not measured in these studies, nevertheless we can confidently say that mastectomy does not offer you a better oncological outcome than breast conservative therapy. 

So, shouldn’t you always go for lumpectomy? Yes, yes, yes! However, you are not always given a choice! There are situations that breast conservative therapy (i.e., lumpectomy + radiotherapy) is not possible and your only options is to have a mastectomy. We will now go through these scenarios.

Situations where breast conservative therapy is not an option

1. When radiotherapy is contraindicated. As mentioned above lumpectomy is often part of a package with radiotherapy. Therefore, when you cannot have radiotherapy, often lumpectomy is not an option. The most common scenario is when you already have had radiation to the breast previously as repeat radiotherapy to the same breast is not advisable.  Moreover some skin conditions such as active lupus and scleroderma are contraindications to radiotherapy.  

2. When there is widespread calcification or multicentric cancer within the breast.However note the difference between multicentric and multifocal cancer. A multifocal cancer where multiple cancer foci exist in the same quadrant of the breast may still be amenable to lumpectomy.  

3. Inflammatory breast cancer, a condition in which breast cancer presents with infection-like redness over the breast associated with skin thickening and oedema.  

4. When the cancer size is large relative to the size of your breast and lumpectomy may be associated with a poor aesthetic outcome. This one is a bit trickier to decide and to a large extent dependant on (a) the location of cancer within your breast, and (b) the skillset of your surgeon. Generally a lumpectomy can be done for a relatively larger tumour in the upper outer part of the breast without causing breast distortion as opposed to a tumour in the upper inner or lower parts of the breast. Traditional teaching was that a tumour to breast size ratio of > 20% often indicates poor aesthetic outcome with lumpectomy and therefore mastectomy should be considered. This is no longer true. With modern breast conservative techniques (also called oncoplastic techniques) as much as 50% of the breast tissue can be removed via lumpectomy and still be left with a pleasing aesthetic outcome. However not all surgeons are equally trained in these techniques (more on this topic later). The other advancement in the recent years is the use of so called neoadjuvant systemic therapy to shrink the tumour before surgery so that you can have lumpectomy instead of mastectomy. The availability of this option is largely dependent on the cancer subtype.

Another situation is when mastectomy is recommended for risk reduction (often bilateral), e.g. in women who carry a pathogenic BRCA or other high-risk familial breast cancer gene mutations. In this scenario even if lumpectomy is possible, due to high life-time risk of recurrent breast cancer in the ipsilateral or contralateral breast, we recommend mastectomy and reconstruction as a risk-reduction strategy.  

The drawbacks of lumpectomy

Now that we have established, if given a choice, breast conservative therapy is better than mastectomy, we should also point out to potential drawbacks of lumpectomy that may in your case be enough to swing your decision towards mastectomy.  

Picture 1. Lumpectomy margins: During lumpectomy your surgeon aims to remove the cancer with a healthy margin of normal tissue around it (hence technically called wide local excision). However in 10-15% of cases the cancer may extend to the resection margin, requiring re-excision to achieve clear (negative) margin.

1. Involved/close margin and need for re-excision: As mentioned above during lumpectomy for breast cancer the surgeon aims to also remove a margin of healthy breast tissue around the tumour to make sure there is no residual tumour left in your body (hence technically called wide local excision). However there is 10-15% chance that there is microscopic disease beyond what could be palpated or seen on imaging that extends into or close to the resection margin (picture 1). This will be picked up on the formal pathological assessment of the resected specimen and discussed with you in your postop appointment. Unfortunately, this means that you will need to have a second procedure to achieve clear margin. Depending on the situation this may be a simple shaving of the involved margin in a day procedure or a more complex oncoplastic procedure. Bear in mind that occasionally even after a second procedure we may not be able to achieve a clear margin and at this point we generally recommend resorting to mastectomy.  The only way that you can eliminate a potential need for re-excision is to have a mastectomy in the first place.

2. Need for radiotherapy: As pointed out above, in most cases lumpectomy must be followed with adjuvant radiotherapy. It will involve going to the radiotherapy unit 5 days a week to get treatment for a few minutes usually for 3 to 5 weeks. This of course may be associated with its own short- and long-term side effects that will be discussed with you in detail by your radiation oncologist. Please note that having mastectomy does not guarantee that you will not need adjuvant radiotherapy. The need for adjuvant radiotherapy after mastectomy is often known before surgery and your surgeon will discuss that with you. However occasionally the final pathology is more extensive than appreciated on preoperative imaging and you will be advised to have radiotherapy unexpectedly.  

3. Need for ongoing mammographic surveillance: After lumpectomy for cancer, you will need ongoing annual mammographic surveillance of your breasts. Some women see this as an anxiety provoking burden and wish to have mastectomy, specially if they already have had mastectomy on the other side.  

In summary while there are plenty of studies showing that, if given a choice, lumpectomy is better than mastectomy, this is a completely individual decision that you should make in discussion with your surgeon. At the end of the day, it is your body and you are autonomous to make a decision that best suits your desires and wishes.