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Publication #FCS8828

Breast Cancer: Making Choices About Surgery1

Martha C. Monroe and Barbara F. Shea2

This is the fourth in a 12-part series on breast cancer. To view the rest of the titles in this series, click here.

Making a decision about breast cancer surgery is always a challenge. In some cases, the diagnosis and data will strongly suggest how to proceed. In other cases, women will have more of an opportunity to decide what is best for them. There are a variety of ways to go about the decision-making process. For some decisions, there will not be much time; for others, there could be years to contemplate your actions. This fact sheet provides information that can help women decide what to do when faced with treatment choices for breast cancer.

Lumpectomy or Mastectomy?

If you have a small tumor and the surgeon believes that breast-preserving surgery is a viable option, you will have a choice between a lumpectomy or mastectomy. Lumpectomy, or partial mastectomy, removes more tissue than just the tumor. A sphere of surrounding healthy tissue, called the margin, also is removed to make sure all of the cancer cells are removed. As you decide between a lumpectomy or mastectomy, you and your doctors will consider the size of the tumor, the breast size, the location of the tumor, your ability to undergo radiation therapy, and your feelings about the surgery.

Choosing a lumpectomy usually means you will have radiation treatment after surgery. Studies comparing lumpectomy to mastectomy show that survival rates for lumpectomy are similar to those for mastectomy only when whole breast radiation follows the lumpectomy. Some women find the prospect of radiation therapy frightening or feel that they don't have the time for daily treatments; these women may opt for a mastectomy. Others do not have radiation clinics within a reasonable distance, and so they must have a mastectomy.

With a lumpectomy, you avoid losing an entire breast to cancer, which is important to many women. Breast-conserving surgery should allow you to wear tops with low necklines, which may be a consideration for some women.

It is worth noting that a breast that has undergone a lumpectomy and radiation will not be the same as it used to be. The tissue will be firmer, some sensation will be lost near the scar, and the shape may be different. Still, many women prefer having an altered breast to having a mastectomy.

Prophylactic Mastectomy or Not?

When faced with the prospect of having one mastectomy, many women wonder if they should keep the other breast. They might be worried about a new breast cancer occurring, thinking that if it can happen once, it can happen again. Others might have a type of cancer or a genetic predisposition that increases their risk of another occurrence. These women may choose a prophylactic mastectomy, which is a mastectomy performed to prevent breast cancer before it happens.

Other women have an avid interest in keeping as much of their body intact as possible. They wish to retain their healthy breast, and they are willing to accept the risk and uncertainty of future breast cancer. They also may feel that recovering from a double mastectomy will extend their period of ill health when they simply want to get on with their lives.

Younger women have more years left in their total life expectancy and may consider a double mastectomy because they have more total years at risk of having breast cancer again. Young women also may consider a double mastectomy because the continued circulation of estrogen through their bodies in the remaining years before menopause increases the likelihood of a new or recurrent cancer. In addition, younger women have denser breast tissue, making it more difficult to detect cancerous tumors in the remaining breast.

Fortunately, this is one decision that you do not need to make immediately. The only reason to decide quickly is to deal with everything in one surgery, limiting exposure to anesthesia. However, recovering from two simultaneous mastectomies is more challenging, particularly for people who are used to taking care of themselves.

There are some questions that may be hard to answer prior to a mastectomy: How important is symmetry? How comfortable is a prosthesis? How does your old wardrobe fit? Some women contemplate a second mastectomy because of the promise of reconstruction, which is the third major decision.

Reconstruction or Not?

Plastic surgeons can rebuild a breast that was removed in a mastectomy. Women who will not have radiation therapy may consider having reconstruction at the same time as the mastectomy. Reconstruction also can happen years down the road, whenever women feel ready.

Skilled surgeons can fashion a breast from muscle tissue (from the back or abdomen) or with a synthetic insert. They then reconfigure the other breast to match. Some women require multiple surgeries to achieve the desired look. On rare occasions, the new breast tissue doesn't survive, and repeat surgeries are necessary. It may be helpful to consider how important the results of the surgery are to you. Will you only be happy with a narrow definition of perfection, or will you live with whatever happens? How many surgeries are you willing to undergo?

Women may choose reconstruction to avoid the hassle of wearing a prosthesis, to regain cleavage, and/or to feel better about themselves. For some women reconstruction is an opportunity to alter the other breast and create a more ideal look.

It is helpful to have an idea of what a reconstructed breast looks like. It is an extensive surgery and should involve careful deliberation. Ask your surgeon to show you pictures, or review those on Dr. Susan Love's Website at http://www.dslrf.org/index.asp?.

Most health insurance covers reconstructive surgery following a mastectomy. Check with your provider to be sure that this type of surgery is covered on your plan.

Summary

Breast surgery decisions can be complicated. As you collect information about your type of cancer and prognosis, you can begin to decide on a course of action that is comfortable for you. For some women, the choices are muddled and confusing, and none may generate that settled feeling of a good decision. In those cases, here are some decision-making suggestions:

1. Ask the doctors about the risks of each choice and how they affect survival rates. Does the surgery change your ability to have an active and healthy life?

2. Consider the package. A lumpectomy usually requires radiation—does your lifestyle allow for radiation treatment? Reconstruction requires a significant period of recovery—do you have that option? Check with your provider to be sure that this type of surgery is covered on your plan.

3. Try to determine what you value the most. Will the option allow you to maintain the lifestyle you are accustomed to? Are you concerned about your body image? Are you interested in the practicality of the "flat" option (mastectomy without reconstruction or use of prostheses)?

4. Collect information. What questions do you still have that might help you lean one way or another? Ask women who have made this decision. Ask your doctor if genetic testing is appropriate for you.

5. If the decision still seems unclear, play out the scenario with each option. Which answer is the safest? Which answer makes you happiest?

6. If you still can't decide, postpone the decision, if you can. Let time and experience help you determine which path is right for you.

Footnotes

1.

This document is FCS8828, one of a series of the Department of Family, Youth and Community Sciences, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Publication date: April 2007. Reviewed August 2010. Please visit the EDIS website at http://edis.ifas.ufl.edu.

2.

Martha C. Monroe, professor, School of Forest Resources and Conservation, University of Florida; Barbara F. Shea, oncologist, Wentworth-Douglass Hospital, Dover, NH. Appreciation is given to Mary Aplin, MD, UF-Shands, and Mandy Robertson, MD, UF-Shands, for helpful suggestions and comments.


The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information and other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual orientation, marital status, national origin, political opinions or affiliations. For more information on obtaining other UF/IFAS Extension publications, contact your county's UF/IFAS Extension office.

U.S. Department of Agriculture, UF/IFAS Extension Service, University of Florida, IFAS, Florida A & M University Cooperative Extension Program, and Boards of County Commissioners Cooperating. Nick T. Place, dean for UF/IFAS Extension.