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Who needs a mastectomy?

Breast cancer occurs in 1 in 8 women in the united states. Great strides have been made in every aspect of breast cancer care from screening to diagnosis to various aspects in breast cancer treatment over the last half a century. And yet the trend in the last decade seems to be leaning back into the ages when mastectomies were the only surgical choice for breast cancer, even unilateral early stage ones. (1)

What drives this phenomenon and which patients really need a mastectomy as opposed to a lumpectomy?

Lets explore…

Surgical Options for women diagnosed with early stage breast cancer (stage 1 and 2)

Lumpectomy: removal of the cancer with a rim of normal tissue around it to achieve negative margins. More than one surgery may be required to achieve negative margins. Lumpectomy is usually followed by radiation therapy to the remaining breast tissue to minimize the risk of recurrence of the cancer within that breast. The most common side effects of radiation have to do with fatigue and a sunburn effect on the treated skin which can easily be treated. Some long term effects can include firmness and some tanning of the treated breast.

This is an outpatient surgery with a short recovery period and potential for early commencement of the multimodality local and systemic treatment of breast cancer.

Mastectomy: removal of all the breast tissue within a breast. This can be done with total skin (and nipple) sparing techniques or skin sparing alone with sacrifice of the nipple areolar complex with immediate reconstruction or a simple mastectomy without reconstruction.

This procedure usually necessitates placement of drains to drain the fluid that collects in the empty space of the mastectomy and is usually an overnight admission to the hospital. Contralateral Mastectomy and reconstruction has the potential to delay further systemic treatment for the index cancer by doubling the surgical risks of infection and bleeding, seroma and hematoma formation.

Radiation therapy may not be completely avoided after a mastectomy and may still be recommended in some instances such as positive lymph nodes or widespread cancer and positive margins found at surgery.

Comparison of Lumpectomy versus a mastectomy for early stage breast cancer:

The survival after a lumpectomy or the mastectomy for breast cancer remains the same. The local recurrence after lumpectomy and radiation therapy in the current era is the same as that of a mastectomy being 2.8% for lymph node negative versus 5.2% for lymph node positive patients. (2)

Surgical Indications for an Ipsilateral Mastectomy for breast cancer:

Multicentric Invasive breast cancer: when breast cancer presents in multiple widely separated areas in a single breast a mastectomy is recommended for the surgical treatment because of the propensity for the intervening at risk tissue to harbor cancer cells that could cause a high risk for local recurrence inspite of multimodality treatment. Currently a national multicenter trial is exploring this issue with multiple lumpectomies followed by radiation therapy and systemic treatments. (3)

  1. Widespread Noninvasive cancer within a breast (Ductal Carcinoma in Situ) has been detected in the breast upon biopsy of Malignant appearing microcalcifications on the Mammogram and the tumour to breast tissue ratio prohibits an acceptable cosmetic result after a lumpectomy.
  2. The breast has been previously treated with lumpectomy and radiation therapy and has now developed a recurrence
  3. Multiple attempts at a lumpectomy for the breast cancer have failed to achieve a negative surgical margin.
  4. There is a contraindication to radiation therapy of the breast such as in patients with scleroderma or systemic lupus erythematosus
  5. Presence of a certain genetic mutation that significantly increases the lifetime risk of breast cancer for the patient such that lumpectomy and radiation would be inadequate treatment to address that risk.

Surgical Indications for a Contralateral Risk Reducing (Prophylactic) Mastectomy:

1.Presence of a genetic Mutation or a very strong family history of breast cancer that increases the risk of breast cancer significantly over a lifetime. For average risk women the surgery offers little benefit

If this is so why are so many women (1 in 6) with early breast cancer in one breast choosing to have both their breasts removed?

1. Emotional rather than rational Decisions made in the immediate aftermath of the diagnosis of breast cancer Women are at their most vulnerable right after a diagnosis of breast cancer is made and the days of anxious waiting from an abnormal mammogram call back to the biopsy and eventual diagnosis is a harrowing experience for most. Having an MRI of the Breast and additional biopsies can compound the issue. Getting a diagnosis of breast cancer propels them to try to do everything in their power to not have the experience repeat ever again in their lifetime- and that “everything” is a perception of an empowered decision to have a bilateral mastectomy performed on them for their early unilateral and unicentric breast cancer.

2. Perceptions and Ingrained beliefs from anecdotal bad experiences with radiation therapy Personal narratives are powerful and one such poor experience of a friend or relative in the past with radiation therapy is enough for some women to decide it is not for them and that it is better to have a mastectomy rather than a lumpectomy with radiation therapy for their breast cancer.

3. A desire to achieve bilateral breast symmetry after cancer surgery. There is fear of being lopsided after a lumpectomy and the perception is a bilateral procedure will achieve perfect symmetry. The reality is no two breasts even native ones are exactly alike in size and form and an expectation of perfection immediately after mastectomy and reconstruction can lead to disappointment with the results. An alternative to contralateral mastectomy for achieving bilateral symmetry could be a mastopexy and reduction mammoplasty.

4. Overestimation of risk for contralateral breast cancer and a poor understanding of the lack of benefit of risk reducing surgery: risk for a breast cancer to develop on the opposite site is very low between 3-10% over 10-15 years based on individual risk factors. Women typically focus on the 10% and decide that the mastectomy of the opposite breast is the best way to minimize the risk of another cancer while losing sight of the fact that risk reducing surgery has no impact on their survival from the already diagnosed cancer, that there is a higher risk of systemic recurrence of their existing cancer than the potential for developing a new cancer in the other breast  and that endocrine therapies that can be used in the treatment of their existing cancer will reduce the risk of contralateral cancer as well.

5. A Breast cancer that was hard to find on mammogram: This can create a surveillance issue for the future where women feel they cannot trust a mammogram alone to diagnose a recurrence or a new cancer and hence desire bilateral mastectomy. Several diagnostic tools such as 3 d Tomosynthesis , MRI , contrast enhanced mammography are here to help make the screening process have a much better diagnostic yield than in the past and make the leap to a radical leap for a radical procedure like a contralateral mastectomy unnecessary

6. Inadequate exploration and discussion of psychosexual issues that may arise after a bilateral mastectomy. Women can during the vulnerable decision making time for surgery for breast cancer completely discount/ignore the psychosexual aspect of the presence of their own natural breast and its role in arousal and satisfaction with sex. Even after a nipple sparing mastectomy most women will lose most of not all of the sensations and erectile function of the nipple thus losing its role in future sex with their partners. 45% women after mastectomy and reconstruction reported dissatisfaction in their sexual life as compared to 29% for lumpectomy alone. (4) In a simple or skin sparing mastectomy the nipple areolar complex itself is removed such that the reconstructed breast is a mound onto which an artificial nipple and areola is then grafted or tattooed which is devoid of sensation.

7. Availability of reimbursement for immediate contralateral procedures and plastic reconstruction. For symmetry. Since this legislation was passed there has been a significant rise in the number of contralateral mastectomies for symmetry.

8. Lack of understanding of the complexities of breast reconstruction, especially bilateral procedures and how complications that can arise during or after the surgical procedures can delay further treatment of the index cancer.

9. Lack of awareness of alternatives to mastectomy for achieving bilateral breast symmetry such as Oncoplastic breast surgery, mastopexy and reduction mammoplasty, delayed fat grafting of lumpectomy defects all of which can be used to achieve a good cosmetic result after breast conservation surgery (lumpectomy)

What can physicians do to help women make more informed decisions?

In a recent study of recently diagnosed patients with breast cancer done in Georgia and Los Angeles, only 38% knew that a risks reducing mastectomy does not improve survival for all women with breast cancer. The study also found that after a detailed discussion of the pros and cons of the risk reducing surgery with their surgeons less than 2% were likely to pursue it. (5) This puts surgeons in a delicate situation where they need to involve the patient in decisions regarding their own care while also educating them about the rational scientific basis for their recommendations regarding various procedures and the benefits or lack thereof and potential for real harm with some of them in delaying further treatment of their index cancer.

Frank and open detailed discussions with the patient in a multidisciplinary setting are the best way forward to help patients make well informed rational decisions regarding their breast cancer surgery. Also a discussion regarding the timing of the risk reducing surgery and reconstruction may be prudent so that patients are aware that elective procedures for symmetry could be deferred until after complete treatment of the index cancer and achievement of the final look and appearance of the treated breast.

Written by: Rashmi Pradhan Vaidya MS, MD, FACS

Double Board Certified in Surgery, practicing exclusively Breast Surgical Oncology since completing her Breast Surgery Fellowship from the Cleveland Clinic in 2009.

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1. Nationwide trends in mastectomy for early stage breast cancer. JAMA Surg 2015 jan 150(1) 9-16 DOI 10.1001 jama surg 2014.2895

2. Breast cancer subtype, age and lymph node status as predictors of local recurrence following breast conserving therapy.

Braunstein LZ, Taghian AG, Niemierko A et al Breast cancer research and  Treatemnt 2016 Nov 3

3. Breast Conserving Therapy and Radiation therapy in Treating patients with Multiple Ipsilateral Breast Cancer https://www.cancer.gov/about-cancer/treatment/clinical-trials/search/view?cdrid=728605

4. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors

Rowland JH, Desmond KA, meyerowitz  BE, belin TR, Wyatt GE, Ganz PA

J national cancer institute 2000 sep6, 92(17) 1422-9

5. Contralateral Prophylactic Mastectomy decisions in a population Based Sample of patients with Early Stage Breast CAnmcer

Reshma jagsi, MD, Dphil, Sarah Hawley PhD MPH; Kent A Griffith MS

JAMA Surg online Dec 2016, DOI 10. 1001/jamasurg.2016.4749