Topic: lumpectomy vs mastectomy - why did you choose your route?

Forum: DCIS (Ductal Carcinoma In Situ) — Just diagnosed, in treatment, or finished treatment for DCIS.

Posted on: Jun 13, 2013 12:54PM

Posted on: Jun 13, 2013 12:54PM

ealga wrote:

Hi all, 

i was wondering if anyone could elaborate on this question. i have multifocal, grade 3 DCIS, and am contemplating another lumpectomy vs a mastectomy. my surgeon is confident she can clear the margins with another lumpectomy, and recommends radiation afterward.  BUT anecdotally, so many women I’ve talked to, even with a Grade 1 single foci lesion, opted for mastectomy.   I don’t want to undertreat OR overtreat but I am struggling to figure out why women would make this choice and what am I missing?  I'm at a very cutting edge cancer hospital if that matters.  I'd love any perspective on this.  Many thanks in advance. 

Dx 4/4/2013, DCIS, 5cm, Stage 0, Grade 3, 0/0 nodes, ER+/PR-, HER2- Surgery 5/14/2013 Lumpectomy: Right Surgery 7/9/2013 Lumpectomy: Right Radiation Therapy 8/27/2013 Breast Dx 9/23/2020, IDC, Right, 2cm, Stage IIA, Grade 3, 0/3 nodes, ER+/PR+, HER2- Surgery 11/6/2020 Lymph node removal: Right, Sentinel, Underarm/Axillary; Mastectomy: Left, Right; Prophylactic mastectomy: Left; Reconstruction (left): Tissue expander placement; Reconstruction (right): Latissimus dorsi flap, Tissue expander placement Chemotherapy 1/4/2021 CMF
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Apr 10, 2019 05:41PM beesie.is.out-of-office wrote:

jpea, if you are concerned about the cosmetic outcome, you need to consider the type of reconstruction you would have, and look at pictures. Reconstructed breasts, particularly those with implants, don't look and particularly don't feel or move the same as natural breasts. Autologous reconstruction (DIEP, GAP) usually results in more natural looking and feeling breasts, but leaves other scars on the body in other locations.

From this site: https://www.breastcancer.org/treatment/surgery/reconstruction/pictures

From MDAnderson: https://www.mdanderson.org/content/dam/mdanderson/documents/patients-and-family/diagnosis-and-treatment/treatment-options/breast-reconstruction/reconstruction-gallery.pptx

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Apr 16, 2019 08:48AM jpea wrote:

Thank you to all who responded - each reply was helpful in its own way. I am going in for a third biopsy tomorrow which will hopefully shed more light on my situation.

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Apr 16, 2019 02:25PM edwards750 wrote:

I opted for a lumpectomy mainly because my tumor was small and my BS was all about saving the breast. I didn’t think the scar was that bad it’s on the outside so not that visible but my Ob dr thought he did a hatchet job. I don’t think it’s that bad. Anyway I’m glad I elected to do the lumpectomy vs a MX. My sister chose a MX but she had a different kind of BC. I had IDC and she had ILC. My Oncotype score was low, hers was intermediate.

It’s hard to believe but survival rates are the same.

Unfortunately my sister’s came back after 4 years as a local recurrence near the MX scar. I will be 8 years out in August God willing.

Good luck whatever you decide.

Diane

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Apr 17, 2019 11:14AM TammyKh wrote:

I chose mastectomy with delayed reconstruction for some following reasons:

1. I was diagnosed with DCIS, grade 3 and my lump was as big as 4.5cm and very close to my nipple that my breast surgeon didn't recommend me to keep my nipple if I wanted to keep it either for lumpectomy or mastectomy due to its higher risk of recurrence. Eventually, my final pathology after surgery said that I had 0.2cm IDC. I feel like I did a right decision and my surgeon agreed with me. You never know until you have your final pathology after surgery come.

2. My breasts are so small but my palpable lump was so big, so it's likely to have a giant hole left on my left breast if I chose lumpectomy, leading to damage my breast shape. I'm still young (32yrs) and I do care about my look and my breasts very much.

3. My surgeon told me that if I chose lumpectomy, I properly had to come back to the hospital for another surgeries if she couldn't get the margin clear or she found something else in my breast and it could end it up with a mastectomy. I never have gone through any surgery in my life, so I didn't feel I liked to have more than one surgery in a short time. My delayed reconstruction surgery is scheduled in 6 months after my mastectomy.

4. By undergoing a mastectomy, I didn't need radiation and chemo therapies, so complicated side effects, fatigue, hair loss, etc were avoidable. I was told that all my invasive cancerous cells in my breast were removed out of my body by mastectomy. Fingers cross! Now I am only taking hormone therapy (Tamoxifen).

5. For those who have their small boobs and wish to have the bigger ones without spending a lot of money for cosmetic surgery, you could take this chance to get your new boobs. Although I am NOT a fan of big boobs and my boobs are so small (under A cup), it is free for me to get a new size of my boobs and I told my plastic surgeon that B cup boobs are what I need.

Like someone said decision is very personal in every woman. Listen your body and only you can know what you really want and like. Although choosing a mastectomy is my right decision and I won't regret my choice, I had experienced some its side effects: UTIs, impossible to sleep on my stomach, uncomfortable feelings with tissue expander...


Dx 10/24/2018, IDC, Left, 4cm, Stage IA, Grade 3, 0/3 nodes, ER+/PR+, HER2- Surgery 1/10/2019 Lymph node removal: Sentinel; Mastectomy: Left Hormonal Therapy 3/31/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Apr 17, 2019 02:43PM - edited Apr 17, 2019 02:44PM by beesie.is.out-of-office

Just to provide clarity, for pure DCIS, chemo is never required.

And for those with invasive cancer, if chemo is deemed to be necessary, this remains true regardless of whether the patient has a lumpectomy, an unilateral mastectomy, or a bilateral mastectomy. Surgery is a localized treatment whereas chemo is a systemic treatment, so the choice of surgery does not change whether not chemo is required.

Tammy, have you had your exchange surgery yet? If not, you need to be careful to have realistic expectations so that you are not disappointed - I've been on this site for a long time and I've seen too much disappointment after exchange surgeries. A BMX followed by implant breast reconstruction is nothing like cosmetic breast enhancement. Cosmetic breast enhancement places an implant behind the breast tissue, leaving all the breast tissue in place and therefore resulting in a natural feeling and looking breast. A mastectomy removes all the breast tissue so the reconstructed breast is 100% implant, which is generally firmer and has much less movement (as in, no movement) as compared to a natural breast. An implant reconstructed breast, while in most cases more comfortable and a bit softer than an expander, is probably more similar to an expander that it is to a natural breast. Assuming you have not yet had your exchange surgery, good luck with it!

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Apr 17, 2019 04:05PM meow13 wrote:

To add to Beesie comment, a DIEP reconstruction can give you a natural feeling and looking breast. But this surgery is not for everyone. A good plastic surgeon familiar with the procedure should be able to assess if you are a candidate.

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Apr 18, 2019 09:16AM TammyKh wrote:

I haven't had my reconstruction yet. It's scheduled in June. My plastic surgeon also told me that implant reconstructed breast is completely different from natural breast but he has tried his best to make good symmetric for my breasts. Before that, my breast surgeon gave me a "warning" that my natural breast would be gone permanently and never come back if I opt for mastectomy. So, I totally understand that I will never get my natural breast back but implant reconstructed breast could be "not bad" option for me cause I'm not comfortable to be flat or have a giant hole left on my breast.After getting consulted by my plastic surgeon, I can say that I don't expect to have the perfect result after the reconstruction.

Another good thing is no more double push-up and underwired bras, so I can save a lot of money. lol

Dx 10/24/2018, IDC, Left, 4cm, Stage IA, Grade 3, 0/3 nodes, ER+/PR+, HER2- Surgery 1/10/2019 Lymph node removal: Sentinel; Mastectomy: Left Hormonal Therapy 3/31/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Apr 22, 2019 10:28AM veggal wrote:

Tammykh, if you are wanting small breasts, look into creating mounds using fat grafts alone. It is being done in some women. If you are a candidate you'd avoid implants, big scars in other places like with DIEP, and you'd get other areas of your body "sculpted" during the fat harvesting process. Something to consider...

Dx 1/12/2016, DCIS, Left, <1cm, Stage 0, Grade 2, 0/3 nodes, ER+/PR-, HER2- Surgery 3/11/2016 Mastectomy; Mastectomy (Left); Prophylactic mastectomy; Prophylactic mastectomy (Right); Reconstruction (Left): Tissue Expander; Reconstruction (Right): Tissue Expander Surgery 6/9/2016 Reconstruction (Left): Silicone implant; Reconstruction (Right): Silicone implant Surgery 9/7/2017 Reconstruction (Left): Fat grafting, Silicone implant; Reconstruction (Right): Fat grafting, Silicone implant
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Apr 24, 2019 07:52AM jpea wrote:

Update for me: my latest MRI-guided biopsy showed my tumor "growth" was really just bruising from my original biopsy, so not growth at all. My surgery is now scheduled for early May. I am opting for lumpectomy with radiation over mastectomy because my tumor is small (1.4cm) and it feels better to me to conserve as much of my body as I can. I am not concerned about reccurrence - it either will or will not happen and odds are similar for both treatments. My doctor has allowed that should I be unhappy with the looks of the lumpectomy then I can have plastic surgery done a year or more out, once I have healed. I feel comforted having options. But certainly this is a personal choice.

As a side note, I want to clarify how chemo may still be on the table for me, even with DCIS. My surgeon is also doing a sentinel node removal to ensure my cancer has not spread to the lymphs, even though I am currently diagnosed as DCIS. She does not like to rule out invasive cancer as a possibility until the pathology report is done. The lymph node will be analyzed mid-surgery, and if found cancerous then I will get chemo.

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Apr 24, 2019 09:42AM beesie.is.out-of-office wrote:

It is true that invasive cancer cannot be ruled out when DCIS is found in a needle biospy. In about 20% of cases, some invasive cancer will be found in the final pathology. Usually it is just a microinvasion (as I had), which does move the diagnosis up to Stage I but does not usually change the treatment plan.

Normal practice (as per the NCCN Treatment Guidelines, see the link below) for a lumpectomy with DCIS is to not perform a SNB. The risk of lymphedema, even though low when only a few nodes are removed, is higher than the risk that cancer will be found in the nodes when the diagnosis is pure DCIS. In fact should a tiny amount of cancer be found in the nodes (ITC - isolated tumor cells) when the final pathology is pure DCIS, the medical assumption is that the cells were accidentally placed onto the node by the surgical instrument. If there is more cancer than just ITC, then the assumption is that there may be an occult invasive cancer, i.e. invasive cancer in the breast that was not found in the surgery. That situation is extremely rare, and in these cases the diagnosis will no longer be considered to be Stage 0 DCIS. As soon as anything more than ITC is found in the nodes, the staging changes to at least Stage IB.

What is more commonly done with a lumpectomy for DCIS is that if the final pathology shows invasive cancer in addition to the DCIS, a second quick procedure is done for the SNB. In this way, the patient isn't subjected to the risk of lymphedema unnecessarily. Note that while about 20% of preliminary DCIS cases are upgraded because of a finding of invasive cancer, only about 10% or less of those invasive cases end up with positive nodes. So that's about a 2% risk. Having said that, there are some situations where the risk of finding invasive cancer is higher. These would be cases where there appears to be a large amount of DCIS (I had over 7cm) and where the DCIS is aggressive (grade 3, comedonecrosis). Sometimes in these situations, an SNB will be done at the time of the lumpectomy, but that is still not the norm.

As for chemo, jpea, I'm very surprised that your surgeon mentioned that you would be getting chemo if node positive. Yes, this might be the case, but with ITC or micromets to the nodes (which is the most likely possibility if cancer is found after a preliminary diagnosis of DCIS), chemo would usually not be given. Whether chemo is prescribed for invasive cancer depends on many factors including the hormone status of the cancer and the Oncotype score. Triple negative and HER2+ are more likely to get chemo for very small invasive cancers even when node negative; ER+/PR+/HER2- cancers are much less likely to require chemo, even with 1 or 2 positive nodes. The expert on this is the Medical Oncologist; it is not the area of expertise of a surgeon and surgeons do not get a say in this decision.

Lastly, the pathology check of the nodes that is done while in surgery is a preliminary check. It may find cancer in the nodes if the area of cancer is fairly prominent, but if there are just ITC or micromets to the nodes, these could be missed. A final more thorough pathology check is usually done after the surgery.

See page 24 of the NCCN Treatment Guidelines for Noninvasive Breast Cancer (this is the patient's version; there is a much more detailed physician's version) for the recommended treatment options for DCIS.

And here are the NCCN Treatment Guidelines for Invasive Breast Cancer. These would come into play should the final pathology show either invasive cancer and/or positive nodes.

Please note that all the information I've provided is just to allow individuals to ask their medical team the right questions. It's important to be an informed patient (and I am trying to help in that regard) but ultimately we need to trust our doctors and work with our doctors to together make the medical decisions that are right for us.



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