Lumpectomy or Mastectomy? Is there a Choice?

lump or mast

After being diagnosed with Breast Cancer, some women will have a lumpectomy (or breast conservatory surgery), whereas others will have a mastectomy (this is the full removal of the complete breast). Sometimes there isn´t a choice, and the oncologist´s decision is firm: they must remove the whole breast. But there are occasions where women are actually able to choose what type of surgery they want, and this, although definitely positive, it is something that can provoke more than a headache. It is a tough decision that has to be made in very little time, so keep reading to know the pros and the cons of each type of surgery.

In the past, when you had Breast Cancer, onco surgeons started by performing surgery, and this was removing the whole breast without contemplation, as keeping the breast was too risky; this is because around a tumour there could still be cancer cells even after removing the lump. After cleaning the area, they would give you some chemotherapy, which is a systemic treatment (it reaches your whole body), to make sure all cancer cells got wiped.

Nowadays, surgery can also be done at the beginning of the process, like in the old days, if the tumour is small and the breast is large. In such a case, surgeons would always perform a lumpectomy straight away, which is usually not aesthetically noticeable. This would make the surgery be your neo-adjuvant therapy (the first action taken in your treatment plan).

After that, as adjuvant therapy, they could give you some chemotherapy sessions and perhaps radiotherapy as well (this will usually depend on how advanced is the Cancer at the time of diagnosis and the type of Breast Cancer; not all types require chemotherapy).

Click here to know the different types of Breast Cancer:

https://healthyanatomy.me/2019/06/05/there-is-not-just-one-type-of-breast-cancer-so-there-is-not-a-single-chemo-that-fits-all/

On the contrary, if the tumour is big and the breast is small, it is common practice today to give chemotherapy or radiation first (as neo-adjuvant therapy), to try to shrink the tumour(s). Thank God (or science), things have changed, and doctors now will try their best to save your breast.

I had to try chemo before surgeons could remove my two tumours, as the area where they were was big (4.1 cm) and the breast, small. Luckily for me, my seven sessions of chemo worked wonders and, even from my third chemo, my oncologist used to say: “Where did this thing go?” (after touching the area).

The problem is that, when I finished chemo, I encountered a difficult decision that I had to make immediately: Shall I keep my breast or remove it all?

When I was diagnosed, I remember that I told them: Take my boob out now! We are all so scared of cancer and we know so little of it… I thought the thing would spread quickly, as it was grade 3 (maximum growth), but the truth is that a tumour, even if it is grade 3, takes a considerable amount of time to develop and grow.

However, the more I was into my Cancer journey (when I understood that my cancer was treatable, with a good chemo for it, targeted therapy and hormonal therapy), the more strongly I wanted to save my breast, especially after understanding that the nipple would have to go as well! It is no joke to lose a breast. One thing is to have your own tissue and a small implant under the muscle, and another very different one is to have everything removed, and have a huge implant without nipple and areola, which later would need to be tattooed into your skin.

The truth is that at the time of diagnosis you are not yourself; you need more information and perspective to make a sensible decision. You are just concerned about saving your life, no matter the consequences. But to look at a mutilated breast is tough, and it can be very difficult to accept your new body, after a mastectomy.

But things aren´t that easy, and the more information I had, the more confused I was.

If I kept my breast, I would need to do radiotherapy, to decrease the risk of recurrence, and, by the time you finish chemo, you are so tired that many patients don´t even want to consider the option of receiving radiotherapy as well.

Besides the effort to receive radio after surgery (which is given daily, for 15 to 30 sessions), a Spanish plastic surgeon told me that radiotherapy would destroy my skin, so I could never have a reconstruction surgery later on if I wanted.

As I said, a lumpectomy doesn’t change a breast much aesthetically, but if your breast is already small, it can indeed be noticeable. Besides that, I also read that radiotherapy would shrink my breast as well, so the fact that this plastic surgeon told me that nobody would be able to fix my breast after receiving radiotherapy, as the skin would lose elasticity, made me want, all of a sudden, a mastectomy.

Besides the aesthetic point of view, I was scared to leave in place my breast, as I thought that, in such case, cancer could come back. And who wants cancer coming back? Not only because once you are done with chemo, you don´t want to do that ever again, but also because, if it came back, it would do so, spreading everywhere and being more aggressive than before.

I had to talk to four different professionals, and read a lot, in order to make up my mind.

I did like the advice of the head oncologist surgeon at UCL (who has just retired), the phenomenal Ms. Jennifer Gattuso. She said to me: “You have fought really hard with chemotherapy to save your breast, and now you tell me that you want a mastectomy?” True. She was damn right, but at that point, when the tumour was gone, I was concerned about the aesthetic result. After all, I am 38 years old, and I (hopefully) have a long life before me, where I want to be able to be naked and happy, and if my breast shrunk and I couldn´t be able to fix it, then I didn´t want to have the option of lumpectomy+radiotherapy.

Right after that, I talked to another young English surgeon, whom I explained all my concerns, and she said: “That is nonsense. You are young; you have responded very well to chemo, and your body is probably going to respond well to radiotherapy, so after a year, you will probably be able to put small implants, if you want”.

Talking to that young surgeon almost convinced me. Later on, something I read on Facebook ended up convincing me fully: That day I came back home and read that some girls, despite having a double mastectomy, had their cancer coming back in their chest wall and lymph nodes. So I understood that if cancer wants to come back, it will. If there aren´t breasts, it will come back elsewhere.

The big truth and the way I see it is that…

Your breasts aren´t giving you cancer. On the contrary, your breast was kind enough to allow those stupid fast-dividing cells to camp in there.

Of course, if you have a genetic condition, and a high chance of getting breast cancer that is a different story altogether, and in such cases, many women decide to do a double mastectomy.

That is something that you will need to test before taking any decision. If you test positive for BRCA1 and/or BRCA2, oncologists will recommend you to remove both breasts and, later on, the uterus and ovaries as well. It is still, of course, your decision; nobody will make you remove any parts of your body, but if you have an 85% chance of getting Breast or Ovarian Cancer, you might want to seriously consider removing all. Ovarian Cancer is one of the deadliest, as there is no screening available (that can catch it soon).

So what should I choose?

If you can choose the type of operation, first of all, you are lucky; freedom is always a gift. I would always choose a lumpectomy + radiotherapy, as the operation itself and the final result aren´t traumatic at all.

But you might find it impossible to attend the hospital daily for a month to receive your radiotherapy (for economic or physical reasons), or you might have a genetic predisposition to have breast cancer, in which case, it is understandable to choose a mastectomy over a lumpectomy. In any case, your decision will always be the right one, as long as you read, ask and be super informed about all the possibilities that you have.

Here are a few questions to ask yourself and a few tips to help you decide.

– How important is it for you to keep your breast? How will it affect your confidence if you remove it/them?

– Do you want your breasts to match each other in size? A lumpectomy can make the treated breast smaller, but a mastectomy + reconstruction will make them uneven as well unless you do a bilateral (double) mastectomy.

-How anxious are you about cancer coming back? If having a mastectomy is going to let you live in peace, then perhaps this is the option for you.

What are the pros and the cons for each type of surgery?

Lumpectomy Pros:

-Surgery is really easy. Nothing hurts when you wake up from the operation, and you can go home the very same day of the operation (something priceless).

-The recovery time is really short. You need to be careful while lifting weights, but I was travelling and carrying luggage after only a week.

-Your breast almost doesn´t change aesthetically (you conserve the nipple, the areola,  the tissue, and the skin).

– You don´t have any weird sensation due to having implants, and the breast is as sensitive as before.

-Some people believe that leaving the breast can make cancer come back, but many studies show that, after receiving radiotherapy, the risk of cancer coming back is the same as having a mastectomy.

Lumpectomy Cons:

-You will need radiotherapy daily for about a month (the exact number of sessions depends on each individual case), and that is certainly exhausting unless you live very close to the hospital. But even so, you will always have to be in the waiting room for about an hour or even two.

-Radiotherapy can burn your skin and slightly shrink your breast.

– Radiotherapy can damage the elasticity of your skin, so it cannot hold well an implant if you wish to reconstruct the breast later on.

– Even if radiotherapy doesn´t damage much your skin (and you can actually have a surgery to put implants), you will need to wait for at least one year and a half after finishing your radiotherapy.

– Radiotherapy can cause fatigue, which isn´t great because you are already quite exhausted from all the chemo and the surgery.

– In the long run, radiotherapy can provoke another Cancer.

– The breast treated with radiation won´t be able to tolerate any more radio sessions, so if there is a recurrence in the same breast, oncologists will recommend a mastectomy.

Single Mastectomy Pros:

– Low probability of Cancer coming back in the breast removed (same as with radiotherapy – about 5%).

– For some women, removing the entire breast provides greater peace of mind, so they feel less anxious about cancer coming back.

– Sometimes, having the whole breast removed means that you won´t need radiotherapy (although this will depend on how spread is your cancer at the time of diagnosis i.e., was it in your lymph nodes?)

Single Mastectomy Cons:

– It is a longer and more complicated operation than a lumpectomy, as they have to remove all the tissue, nipple, areola and some skin (although they will leave enough skin in place for a possible later reconstruction).

-Recovery time is longer (it is a more extensive surgery than a lumpectomy; wounds are bigger, and more tissue is removed).

-Mastectomy means a permanent loss of your breast. Your image changes a lot (they remove your whole breast), even if they do reconstruction straight away, the result will never be as natural as when you had your own breast; but also because they cannot finalise the work in one go (nipple reconstruction will have to occur at a later stage).

-Usually, reconstruction happens later on, in several procedures.

-Breasts can be very different from one another, even after they finish the whole process.

– Many girls report a weird and cold sensation due to having implants.

Double Mastectomy Pros:

-It reduces the risk of having Breast Cancer come in both breasts by 5% (but it is important to know that it can still happen!)

– The final result of the reconstruction is better than with a single mastectomy (breasts will be similar to each other).

Double Mastectomy Cons:

– Cancer can still come back to the chest wall and lymph nodes.

– Operation is quite long and complicated.

-Recovery time is long, and drainers (which you have to wear for about 10 days) are very uncomfortable, not only because they restrict your moves, but also because they get liquid from your body, that you have to empty. When I saw the bottles they give you I got really scared.

– The results of this type of surgery are permanent. Your body will not look the same as before; you might be unhappy with it and feel less confident sexually.

Even though the cons for Radiotherapy are quite a few, for me it was the best option. I recommend you searching for images of all these procedures and read as much as you can about it, so you can also find the right solution for you.

If you decide to go for a mastectomy and would like to have a reconstruction, keep reading…

Types of Breast Reconstruction

Breast reconstruction aims to make the shape of the breasts as natural as possible, but it is key that you have realistic expectations. There are several options if you want your breasts to be reconstructed, although some women chose not to.

Immediate reconstruction leaves fewer scars (than delayed reconstruction), and the results usually look better. However, the areola and the nipple will always be reconstructed at a later stage.

Types:

– Reconstruction using breast implants: these are put under the muscle and skin of your chest.

-Reconstruction using your own tissue: fat, and sometimes muscle and skin, are taken from another part of your body to make the new breasts.

– Reconstruction using implants and your own tissue (both of the above take place).

Reconstruction with Breast Implants:

Breast implants have a silicone cover with silicone gel or saline water inside. They can be round or teardrop-shaped.

The implants can be put in one-step procedure, where the surgeon puts fixed-size implants, or they can put expandable implants to adjust the size later on (after a few weeks, when the wounds are cured, a nurse will inject saline into the implants through a port under the skin of your underarm).

Benefits of this type of reconstruction:

It is an easier operation than other types of reconstruction, with fewer scars on the breast and no scars in any other part of your body. It can have a good result, especially in women with small breasts or who operate both breasts.

Disadvantages of this type of reconstruction:

– You may need several visits to the hospital for tissue expansion.

– Implants do not feel as soft and warm as breasts made using your own tissue.

– To get the best result you will probably need more than one procedure (to reposition the implants or to add fat over the implants).

– The implants may change in shape over time.

– Reconstructed breasts do not feel very natural.

– Some data indicates that 1 in 10 women will need to have an implant taken out within the first three months after surgery. After nine months, it will go up to 1 in 7 women. This can happen because the wounds aren´t healing properly.

-Around the implants, there could also be hardening of tissue (this is called a contracture).

-The implants could rupture, although this is difficult. 1 in 20 women will have an implant rupture within 10 years after surgery.

Reconstruction using your own tissue: 

This is called flap reconstruction and it is more complex than breast reconstruction. It consists of moving a flap of skin, fat, and muscle from another part of your body to your chest wall to create a breast shape. Usually the tissue taken is from the abdomen, but it can be taken from the back, buttocks or thighs.

It is a complicated surgery because the reconstructed breasts need a good blood supply to keep them healthy. The surgeon can do this with a free flap reconstruction or with a pedicled flap reconstruction.

In the first one, the surgeon takes a flap from another part of your body and they disconnect it from its blood supply. Then they move it to your chest and connect it to a new blood supply there.

In the second one, the surgeon takes a flap of tissue from the back or abdomen. They keep it connected to its original blood supply.

Not everyone can have a reconstruction using their own tissue. If you don´t have enough fat you won´t be able to do it, and when I say fat, I mean that they need a quite considerable amount of fat.

Benefits of this type of reconstruction:

-The main one is that it can create a very natural breast where the look and the feeling of it can be absolutely natural like it was your original breast.

Disadvantages of this type of reconstruction:

-You will have an additional scar on the part of the body where they took the flaps.

-You may have a patch of skin in your reconstructed breasts. This can happen because the place they took the flap from could have a different texture and colour from the breast´s skin.

-The operation is long and more complicated.

-The recovery will also be long and more complicated.

-Even though you don´t have an implant, the feeling of the new breasts will still be different from your original breasts.

Remember to read as much as you can about all these surgeries to take the right decision, and good luck on your journey!

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