When I started out as a breast surgeon in the early 1980’s, most women diagnosed with breast cancer were told they needed to have a modified radical mastectomy—removal of the breast and all of the lymph nodes in the armpit. Many others were still being treated with a radical mastectomy—removal of the breast and lymph nodes and the pectoral (chest) muscle. Why? Surgeons strongly believed that the more they removed the lower the chance of having the breast cancer come back.

Then, in 1981, researchers reported the results of a groundbreaking study conducted in Italy that had randomly assigned women with stage I or II breast cancer to have either a radical mastectomy or a “quadranectomy” (removal of the quarter of the breast containing the tumor, all of the lymph nodes in the armpit, and part of the chest muscle). Much to the surprise of the surgical world, the survival results were the same! This study, published in the New England Journal of Medicine, made it clear that our surgical goal—“get it out” quickly and aggressively—was open to question.

Even so, American surgeons were slow to accept this new data. In fact, many often said to me, “That only applies to Italian women with Italian breast cancer… in America we need a more aggressive approach!”  To my mind, there was no reason that Italian women would be any different, but no one really cared what a young female surgeon thought she knew about women’s breasts.

Then, in 1985, an American study published in the NEJM that compared the two procedures, both with and without radiation, showed the same results. Because this study was conducted on American women, American surgeons began to believe that it wasn’t necessary to remove the whole breast. This idea was reinforced over time as new studies showed that even less of the breast could be removed, leading to today’s lumpectomy. This approach also was supported by other studies that were showing that giving chemotherapy and hormone therapy after surgery (adjuvant therapy) to kill any cancer cells that might have already left the breast could extend survival.

Having performed surgery during this evolution and having fought for a woman’s right to have a lumpectomy and keep her breast, I have been struck by the statistics showing an increase in the number of women choosing to have a mastectomy instead of a lumpectomy. There are multiple reasons this is occurring, from the decrease in the stigma of mastectomy to the improvements in reconstruction, as well as the ongoing and all too understandable anxiety associated with future mammograms and fear of a recurrence.

But while it’s easy to understand why women would perceive more as possibly better, and, if not better, at least the same in terms of the cancer and their peace of mind, we also need to continue to look at what the research shows. And a study published this week online in Cancer gives us a lot to think about.

The study, led by Shelley Hwang, a surgical oncologist at Duke University in North Carolina, looked at what happens in the real world to women who were diagnosed with stage I or II breast cancer and had to decide to have a lumpectomy and radiation or a mastectomy. Their goal was to answer these questions: Does mastectomy affect long-term outcome? Would the women who had a mastectomy have better overall survival or be less likely to die of breast cancer? (Overall survival is how likely you are to die of anything. Breast cancer-specific survival is how likely you are to die of breast cancer.) Is there a difference based on the age you are diagnosed? Does it matter if the tumor is hormone-sensitive (ER+ and/or PR+)?

Using the California Cancer Registry, Hwang and her colleagues identified 112,514 women aged 18-80 who had been diagnosed with breast cancer between 1990 and 2004 and who met the criteria for their study. Within this group, 61,771 (55%) had had a lumpectomy and radiation and 40,383 (45%) had had a mastectomy.

During the 10 years after these surgeries, there were a total of 31,416 deaths; 39 percent (12,252) were due to breast cancer.  Much to everyone’s surprise, the women who chose lumpectomy followed by radiation had the same or better overall survival or breast cancer-specific survival—regardless of age, or hormone status! Breast cancer specific survival favored the lumpectomy group too—and that stayed the same after taking into account tumor grade, proportion of positive nodes, race, socioeconomic status, tumor size, age at diagnosis, and year of diagnosis.

Overall, the best survival advantage was seen in women over 50 with hormone positive tumors. Among this group, those who had a lumpectomy followed by radiation had a 13 percent lower chance of dying of breast cancer and a 19 percent lower chance of dying overall than those who had a mastectomy.

Why?  We don’t actually know. There were some things the study couldn’t account for, such as health care access or other health issues that may have led women to choose a mastectomy over a lumpectomy. But it certainly gives us something to think about as we ponder why, when it comes to breast cancer, so many women continue to believe “more is always better.” It should also help women newly diagnosed with a stage I or stage II breast cancer who are trying to decide what is best for them.

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16 Responses to More is (Again) Not Always Better

  1. Suzy says:

    What about women with a BRCA1 or BRCA2 mutation? If cancer was just in one breast, isn’t the risk of a new cancer in the other breast high enough that a bilateral mastectomy would be the wisest choice?

  2. Sue Beem says:

    Some women may choose mastectomy because of tumor type (invasive lobular: increased risk of CA in other breast; lumpectomy likely to miss margin of tumor, MRI not 100% accurate in preoperative assessment of extent of invasion). Also women with increased risk of cancer due to radiation exposure to chest still at risk in same breast and other after lumpectomy. There are other BRCA mutations out there that women haven’t been tested for, plus other familial cancer syndromes with mutations on other genes. We need less expensive testing, or find the markers that go along with these mutations to truly understand risks and causes.

  3. Elayne Mazol says:

    my first diagnosis of DCIS in 1989 required a total mastectomy due to the cancer being very aggressive( comedo type??) I had no choice, with no further treatment. Actually I was not permitted to see an oncologist for follow-up at the premier cancer center where I had surgery (I was told that DCIS is not considered CANCER??) then why remove my breast (size 40D)? Ludicrous! 22 years later I’ve been diagnosed with Stage II invasive intraductal cancer. It was recommended that I DO NOT have a mastectomy as it would not benefit me anymore (maybe less) than a lumpectomy. I chose a mastectomy which my gut told me had to improve my chances over lumpectomy. As it turned out I would of had to go back into surgery and have a mastectomy since the tumor was 50% larger than originally diagnosed. I wonder what the next study shows on lumpectomy vs mastectomy. Funny (not ha ha) how some follow-up studies seem to change. You can’t convince me that, in general, lumpectomy is better than a mastectomy. Especially being there are reasons women have to go back into surgery resulting in mastectomy.

  4. Pam says:

    The mri did not show that I had another tumor at the bottom of my breast. If I would of had a lumpectomy, I would of had to go back in surgery again. I think everyone’s decision is unique. The mri did not confirm if the cancer was in my lymph nodes. It was found during surgery and I believe I made the write decision in having a matsectomy. I thank my surgeon because he guided me into the right decision.

  5. Laura Patterson says:

    I was dx with invasive lobular carcinoma which was not detected by mamogram. Ultrasound detected one small tumor at 9 oclock. MRI detected another at 5 oclock. Not really a candidate for lumpectomy as it was in two areas (multi focal?). After decision to have bilateral mastectomy the pathology report indicated my entire breast was involved. 11cm area (5 inches). I concur with Elayne.

  6. Elizabeth says:

    I chose a mastectomy although I was offered a lumpectomy because I didn’t want radiation therapy in addition to surgery and chemo. I also saw no benefit to a misshapen breast over no breast.

  7. deborah wolf says:

    my stage 2 IDC “garden variety” came roaring back less than 6 months after chemo, lumpectomy, and radiation. I refer to my breasts as “Claymore 1 and 2″- set to finish me off in the near future- At this point I`d advocate for all women to take them both off as soon as they are finished breast feeding and not be one of the 108 dead today.

  8. In l992 I was dx with invasive lobular through a biopsy on my right breast..(.the mamo did not show a lump but I felt it) and went to a breast surgeon who diagnosed breast cancer in my right breast.through the biopsy..At that time period I did try to have a lumpectomy but could not get clear margins…was sent into surgery next day with my breast surgeon for a (quad)…but could not get clear margins…Finally had a mastectomy with plastic surgery reconstruction beginning on the Operating Table. (the first part)..They suggested mild chemo even though my lymph nodes were “negative” (as was the thing to do in l992)…but only took 4 rounds …then completed my reconstruction to my right breast! ~ Then on to 5yrs Tamoxifin (which replaced my chemo treatment)..
    In the 7th year….(1999)…I was told I had calcification in my left breast and had a sterotactic biopsy to confirm this….BUT made the decision to have a “simply mastectomy” (no lymph nodes were taken) and (no chemo was offered)…I proceeded with reconstruction of my left breast…(but the Plastic Surgeon exchanged the right (silicone) breast also at the same time .
    So Now…It is 2013 and I have survived breast cancer since l992! (And Am Proud of my Decision to have a Mastectomy)!!

  9. Mary says:

    I had a mastectomy in 1991 and a second tumor was found in the breast tissue the existence of which no one suspected. I had radiation, chemo (CAF and CMF), tamoxifin, and local recurrence ten yrs later. Surgery, Aromasin and local recurrence 9 yrs after that. At that point I had chemo to reduce the tumor size and the chest muscle removed and the latissimus dorsi (SP?) brought around to protect the rib cage. Am now on Arimidex and figure I have another 8 -10 yrs before some other recurrence comes about. By then I’ll be in my 80’s – I think a lumpectomy would not have served me well at all.

  10. Ellen says:

    I wish there was much more research around how to more accurately understand how exactly how DCIS and other early stage cancers progress (or not) so women can make better informed decisions about treatment. In my case, I was simultaneously diagnosed with DCIS (comedo necrosis) in one breast and LCIS in the other. I chose double mastectomy (clear margins and no lymph node involvement) with immediate reconstruction, and 10 years out, I don’t regret this. I was able to avoid both radiation and chemo, and I’m still free of breast cancer.

  11. Laurie says:

    In 2006 I was diagnosed with stage 1 IDC and the first surgeon I went to was pushing me to have a lumpectomy, saying there was no need to overtreat myself. But I didn’t like his personality and went for a second opinion. The second surgeon saw that I was triple negative and although they were just starting to learn about that then, he told me how aggressive it was. He took one look at my family history and urged me to see a genetic counselor before making any decisions. Turned out I was BRCA1+ on top of the triple neg. Even though the tumor was small and in only one breast, I chose a double mastectomy with chemo and never looked back. I don’t feel that I would still be here if I had chosen a lumpectomy….

  12. Bev says:

    In 1994 I went to see my doctor for a bloody nipple discharge. Mammogram showed calcification throughout the breast and so I went to Duke Medical Center for a needle biopsy. Results came back positive for DCIS. I was 38 years old. Here’s where it gets interesting – having grown up reading “Our Bodies- Our Selves” I was very aware of Dr. Love’s research and I quoted this to my team of surgeons and basically told them my first choice was no surgery at all. This prompted a series of phone calls from frenzied doctors trying to persuade me it was the only thing to do. I was however open to the literature so I went to the public library and read every medical journal article I could find about DCIS. I came across one study that showed of women diagnosed with stage 1 or higher breast cancer, over 60% of the tumors started as DCIS. I considered the odds and decided to have a mastectomy and I have never looked back.

  13. Patt Olesky says:

    In 2001, diagnosed with DCIS and a lumpectomy performed. Afterwards, it was found that clear margins had not been achieved. Another lumpectomy performed and a misshapen breast resulted. Again, no clear margins. I had done due diligence to locate best surgeon in my area. Was my surgeon incompetent or were the cells growing faster than the doctor believed? A visit to another doctor, out of state this time at a major metropolitan hospital, was made. He offered the choice of another lumpectomy (& repair to my misshapen breast) followed by 6 weeks of radiation or a mastectomy with simultaneous reconstruction. I felt it was a no brainer – elected mastectomy and reconstruction over 6 weeks of trekking for daily radiation & the resulting tiredness. Eleven years later still feel I made the best decision. The plastic surgeon who performed the reconstruction was a genius. And, the surgeon who performed the mastectomy – he’s so competent & caring that he gives his patients his home phone number.

  14. Cyndi says:

    I chose to have a double mastectomy with reconstruction in 2006 because my Stage 0 was all over my right breast and I didn’t want to spend the rest of my life monitoring the left breast. Unfortunately for me, I had Stage IV in my lungs at the same time I had Stage 0, but because it was so small, it was thought to be “junk that everybody has on their lungs.”
    I don’t regret my decision to have both breasts removed & my Stage IV was slow growing so I was able to knock it back with chemo and hormone therapy last year after it finely got big enough to confirm its nature.
    The only regret I have is having lymph nodes removed this past year (long story as to why that happened.) That surgery REALLY should be a last resort. The side effects from that do NOT go away and I TRULY wonder is it REALLY necessary???? Can’t there be another way?
    I, like Deborah Wolf, am seeing the value in proactive breast removal, ESPECIALLY if you’ve been on birth control pills for an extended period of time or plan on it. Otherwise, you’re just asking for trouble. IMHO

  15. Carol K Guler says:

    Diagnosed with DCIS in August 1992. Lumpectomy and tamoxifen. The next August we found another spot, same breast, slightly different location. Opted for mastectomy as I didn’t want to spend every Fall recovering from breast cancer surgery. No lymph nodes taken. 1994, spot found on mammon on opposite breast – biopsy non-cancerous. Continued the tamoxifen for a total of 4 years, then stopped it as depression can arise from the battle of hormones (read a men’s breast cancer study showing this relationship). In 2010 a digital mammo and subsequent needle biopsy showed cellular changes in my remaining breast. Saw the oncologist and told him I didn’t want to wait for something else to happen and requested a mastectomy, with immediate reconstructive plastic surgery on that breast and the other side. I have a heavy duty CA hx on my father’s side and was angry at these recurrences. If you haven’t been there, you don’t know what the waiting is like between mammos and oncology visits. Didn’t want to deal with that ever again. Also had the BRCA 1 and 2 studies which showed negative. Wouldn’t do differently if I had it to do over, except maybe to do a bilat mastectomy at the first diagnosis. I have a great Tshirt that says “Of course these are fake, my real ones tried to kill me!”

  16. Sharon says:

    Routine mammo in 2011 (at age 53,)showed highly suspicious lesion right breast. steritactic biospy confirmed stage 2 invassive ductal cancer ER and PR positive, Her2 negative. Extensive family history of breast cancer, though BRACA 1&2 neg. Pre-op MRI of both breasts showed the tumor that had been confirmed on biopsy on the right side, and also showed “multiple areas of suspicious irregularities – cannot rule out tumors”, in the left breast, in areas that were not easily accessable for biopsy. So I elected double mastectomy with tissue expanders placed immediately, later replaced with silicone implants. Pathology report of mastectomy right breast showed infra mammary nodes were clear – this influenced treatment decision. If the entire breast was not taken, these nodes would not have been examined. This, along with a good oncotype report, and Her2 negative, lead to no chemo, only 5 years on Arimidex (which is not without it’s own set of difficulties, but worth it if it prevents recurrence)
    Also, even though I had mastectomy, there was a positive anterior margin ( not seen on pre-op MRI) requiring radiation, which complicated reconstruction, but had to be done.
    Left breast pathology report showed no cancer but multiple areas of fibrocystic disease. I know I would have spent my life having scans and biopsies of that breast, and probably eventually having it removed as well. So I figured, why not do both at the same time and get “matching” new ones?
    This is one of the most difficult things when you are in the initial stages of breast cancer – there are so many conflicting opinions, all the doctors keep telling you ” here are the options but you have to make the decision you are comfortable with”( ridiculous – I’m not comfortable with any of it!), and there is a sense of urgency – you can’t take forever to make these decisions. So you pray for guidance, talk with your loved ones, and make a decision that seems like the lesser of all the evils, and pray some more. Then when it’s over and done, you read all these studies that make you doubt your decision! Ughhh! I think bottom line is that everyone’s situation is different. I am grateful for all the new tools available to help inform treatment decisions, such as oncotype tests. My advice? Ask other women with breast cancer for doctor recommendations (just because someone says they are a “breast surgeon” does not necessarily mean they are the best person for the job – ask around), get at least two opinions, and ask God for wisdom.

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