Surgical Options for Breast Cancer Patients
This article is part of an informational series with Dr. S. Brenda Moorthy and her patient, breast cancer survivor, and Sedona resident, Magdalena Romanska. It was originally published in Sedona Monthly magazine.
What are the surgical options?
Surgical options fall into two categories: breast conservation and mastectomy. Breast conservation typically includes a lumpectomy (removing just the cancer with normal tissue surrounding it) with radiation treatment. This strategy can often provide the same result as a mastectomy. With a mastectomy, the entire breast is removed with options for reconstruction. Both the mastectomy and lumpectomy include simultaneous lymph node removal so they can be tested for cancer cells. A bilateral mastectomy is also an option for some patients, but not all.
Magdalena: When I was diagnosed, I was pretty enthusiastic about the surgical options. I realize that it was pretty drastic to go for a double mastectomy with stage 0 DCIS, but I had my mind set on that even before meeting Dr. Moorthy.
Lumpectomy vs. mastectomy?
Every case is different. Some deciding factors include a genetic predisposition for breast cancer, how much of the breast needs to be removed, if there are multiple tumors, and patient preference. If too much tissue needs to be removed, a mastectomy may make more sense or oncoplastic breast surgery may be an option.
With a lumpectomy, there is always a risk that you will need a second surgery to remove more tissue, though this is changing with new technologies. With a mastectomy, the reconstruction may also require a second surgery. It is important to note that even with a mastectomy, the risk of recurrence is not 0. The risk is 2-3% with an elevated risk in some cases because it is not possible to remove every single breast cell from the body.
Is radiation always included after a lumpectomy?
In general, yes, though there are some exclusions. With DCIS (ductal carcinoma in-situ), there are genomic tests to run on the tumor itself that assess the risk of the cancer coming back. If it is low, radiation treatment can be omitted. There are recent studies on omitting radiation, but they show a higher rate of the cancer returning.
Is radiation necessary after a mastectomy?
With a mastectomy, there may not be a need for radiation treatment. However, for large tumors, cancer in the lymph nodes, or unclear margins, your team may still recommend radiation.
How are radiation and chemo different?
Chemotherapy is medication that is given via an IV and radiation uses high-energy beams (like x-rays or proton therapy) to target and kill cancer cells at a specific tumor site.
What is oncoplastic breast surgery?
When a tumor is very large but a patient prefers a lumpectomy, oncoplastic breast surgery techniques allow us to rearrange the tissue so the shape of the breast can be conserved even with the loss of tissue. There are many characteristics of an ideal oncoplastic breast surgery candidate. For more information, check www.drbrendamoorthy.com.
Magdalena: I really appreciated the aesthetic options CBCAZ offers. Some centers and hospitals do not coordinate with plastic surgeons, but Dr. Moorthy’s team works closely with renowned plastic surgeons like Dr. Walsh. Together, they were able to remove the cancer and insert implants during the same intervention.
Can the nipples be preserved with a mastectomy?
They can be with certain stipulations. The tumor can’t be too close to the nipple, and the nipple placement and size and shape of the breast are all factors. Some surgeons are exploring techniques to maintain nipple sensation after surgery, including nerve grafts, though a reliable technique isn’t yet available. Nipple tattooing is also a great option if nipple removal is necessary.
Magdalena: My skin and nipples were preserved and look great. I have scars only between the armpits and the nipples and they are fading each month. I am very pleased with the results. I did lose nipple sensation, but it is a small price to pay for my health!
What other types of mastectomy are there?
Skin-sparing mastectomies are a common technique. For this, the nipple is removed, but most of the skin is maintained so reconstruction can occur using implants or tissue from other parts of the body. The patient must be in good general health for this to be an option and not all surgeons specialize in this technique.
Why might a patient consider a bilateral mastectomy when the cancer is only in one breast?
This may happen for several reasons:
Genetic Mutations: Patients with genetic mutations like BRCA1 or BRCA2 have a higher risk of developing breast cancer in the other breast.
Symmetry: Achieving better symmetry during breast reconstruction is often easier when both breasts are removed and reconstructed at the same time.
History of Mantle Radiation: Patients who received radiation to the chest or neck for Hodgkin's lymphoma before the age of 30 have an increased risk of developing breast cancer, leading some to opt for a bilateral mastectomy as a preventive measure.
However, there are misconceptions about bilateral mastectomy:
Cancer Recurrence: A bilateral mastectomy does not eliminate the possibility of cancer recurrence. Cancer can still return in the skin or metastasize to other parts of the body.
Survival Rates: Undergoing a bilateral mastectomy does not improve overall survival rates.
Need for Additional Treatments: Patients may still require treatments such as chemotherapy to protect against cancer recurrence or spread.
To meet with a surgeon specialized in these procedures, you can contact the Comprehensive Breast Center of Arizona.
*The information contained in this article is very general. Every patient is unique and not every person is a candidate for every surgical option. Factors like age, genetics, number of tumors, tumor size, and breast size can all impact how a treatment plan comes together, but this article provides a general overview of what some of those options might look like.