Do I Need a Mastectomy?
Thoughts from a Breast Surgeon

Gabriel Kaufman, MD, St Peter’s Hospital, SPHP

I recently gave a lecture regarding the indications both absolute and relative regarding the decision-making process for performing a mastectomy to a large group of breast imagers, radiologists, administrators and physicians at the St. Peter’s Hospital annual Breast Conference.

The goal of the lecture and this outline is to provide background information to help facilitate discussion and decision when working through treatment options for breast cancer so, when a patient has finished consultation with a Surgeon regarding the results of a recent biopsy or genetic testing, they will have a better understanding of the decision making process and feel more confident in their decision.

The conference began with a question to the group. “When should mastectomy be performed and what are the indications?”  The first answer and by far the best and most poignant was “when the patient decides.” What better response than patient preference could there have been?

So I agreed with the statement, and discussion followed on the various indications for mastectomy, but based on the premise that ultimately the patient decides.

This short essay on indications for mastectomy follows the same tenet that ultimately the decision is with the patient and ideally treatment choice should be arrived at through a non-biased educated discussion with not just their surgeon, but also with their medical oncologist, radiation oncologist and trusted family physician.

At this point, I must note that both mastectomy, and breast conservation surgery followed by whole breast radiation, provide the same effective rates of regional control with an overall 5% risk of local recurrence. In general, one approach is not superior to the other, taking all things into consideration.

This opinion is based on a recent large study from the Netherlands looking at over 40,000 women treated with either mastectomy or breast conservation that were followed for over 10 years. In this large population based study, mastectomy and breast conservation had the same degree of local control and mastectomy was not found to reduce risk more than a breast preserving procedure. More importantly, there appeared to be a small but potentially significant overall survival advantage for patients undergoing breast conservation followed by radiation. There has been discussion that radiation therapy may provide not just local regional benefit but also impart a whole body protective effect.

As we can all appreciate, the decision making process is complex. However, once certain considerations are de-mystified based on current scientific evidence, the discussion can flow in a more pragmatic and less fearful pathway.

This discussion regarding surgical treatment has been centered on an either/or decision. Either preserve the breast through breast conservation surgery or remove the majority of breast tissue by mastectomy.

Each surgical option has advantages and disadvantages. The major advantage offered through breast conservation is maintaining the native breast tissue and contours of a natural breast shape. This in turn allows for preservation of body image and satisfaction with the breast outcome without the requirement for additional reconstructive operations. However, it is not always possible to achieve breast conservation, and a mastectomy will be indicated.

Often, one’s decision is affected by the outcome or decisions made by close friends or family who have taken a similar journey. In my opinion, having the background and benefit of experience of other patients is helpful and serves as a framework for discussion, and family history can play a leading role in the discussions regarding surgical approach.

All of this information, combined with your “gut” feeling culminates into a gestalt or feeling of what is right for you. In this there is no wrong or right decision.

There are some guidelines however, that your surgeon will keep in mind during the discussion, that are helpful in minimizing risk and maximizing treatment. The National Comprehensive Cancer Network (NCCN) clinical practice guidelines for Breast Cancer provide accepted standards for recommending mastectomy or breast conservation surgery.

There are a few situations where the need for a mastectomy is absolute (essential) but more often the decision is relative - meaning that options are weighed and compared based on various situations. The absolute indications are: diagnosis in early pregnancy (when radiation therapy is not recommended), diffuse calcifications seen on imaging, positive surgical margins from a prior lumpectomy, a homozygous mutation in the ATM gene (genetic issue), and likelihood of poor breast shape after surgery due to size and/or location of tumor(s).

With regard to absolute indications, they are infrequently seen in practice and constitute less than 1% of my practice on an annual basis. I would also argue that the last indication referring to a poor breast outcome is almost always avoidable with advanced surgical techniques borrowing from plastic surgery.

Two other indications that lead to discussions of mastectomy vs breast conserving surgery relate to situations where separate locations of breast cancer are found in disparate locations in the breast, also known as multi-focal or multi-centric breast cancer. Another is when a patient who was previously diagnosed with a malignancy had surgery performed and then years later another a new primary develops in the same breast after whole or partial breast radiation. There are also relative indications for mastectomy that include either genetic pre-dispositions or a prior diagnosis of either lupus or scleroderma.

Most of the absolute indications for Mastectomy involve the need to remove tissue in order to prevent further spread of cancer. Most of the relative indications involve a mastectomy on the assumption that the specifics of the surgery would result in a deformed breast. As a board certified general surgeon with a specialty in breast surgery and further board certification in Plastic Surgery, I find that I have a bias towards doing the best surgery for the cancer involved and whenever possible doing my best to conserve the natural breast.

In my practice I have been consulted by a number of patients for second opinions who have been persuasively told that they need mastectomy despite a strong desire for breast conservation.

Both the absolute and relative indications for mastectomy will play a role in the surgical decision making process, but at the end of the consultation, it is the patient who decides how to proceed. The clinician’s role is to try to ensure that the surgical decision is based on sound principles and practice along with patient preference, but not on fear or misinformation.

October 2018

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