Lumpectomy vs. mastectomy: what this expert says might surprise you

Angelina Jolie changed everything.

That’s what Dr. Lori Gentile, an oncological breast surgeon with Novant Health Cancer Institute - Elizabeth in Charlotte said about the impact the actress had when she announced in a 2013 New York Times op-ed that she’d undergone a double mastectomy as a preventive measure.

Carrying the BRCA gene meant Jolie had a high risk of breast cancer — greater than 60%. And when she had her breasts removed she was following standard medical advice. It triggered a wave of women seeking genetic testing and double mastectomies after a breast cancer diagnosis. And 13 years later, the trend continues.

It’s called “The Angelina Effect.”

But a key fact got lost along the way: In the general population, fewer than 1% of women have the BRCA gene. And there is no research to suggest that women who’ve had breast cancer should get double mastectomies to improve their chances of survival.

And yet, studies have shown that 70% of women in the U.S. cite fear of recurrence as the driving factor in their decision, Gentile said. While there may be good reasons for some women to receive mastectomies, Gentile wants us to know this: Mastectomies don’t necessarily prevent a recurrence of cancer, and lumpectomies, usually along with radiation therapy, can be just as effective. Moreover, lumpectomies can be less emotionally and physically taxing for some women.

We asked Gentile about mastectomies, lumpectomies (otherwise known as breast conservation therapy, or BCT) and the risks and benefits of each.

Ever since Angelina Jolie’s announcement, all the women I know — including me — have considered mastectomies a guarantee against a recurrence. But I recently learned from a breast cancer survivor that it isn’t true.

It makes sense to think a mastectomy would be a safeguard since the breast is gone. But in reality, the entire breast is not gone. Surgeons take between 90% and 97% of the breast tissue, but some still remains — under the arm, for instance.

So, cancer can come back in that small percentage of breast tissue still left?

Yes, but breast cancer recurrence can happen in two ways:

• A distant recurrence is when breast cancer recurs in another part of the body — the bones, lungs, liver, brain — and the risks of distant recurrence depend on the stage of the tumor and not on which surgery was performed.
• A local recurrence is when breast cancer recurs on the “chest wall,” which includes any of the skin, soft tissues or lymph node regions. This is the type of recurrence a woman who’d had a mastectomy could get.

The rates of local recurrence range from 1% to 3% after mastectomy for Stage 0 cancer up to 15% in more advanced-stage cancer even after completing radiation therapy. These rates are equivalent to women who undergo a lumpectomy and radiation therapy.

I’m astonished. I don’t think this message is being circulated widely.

Right. Every day, I correct misinformation. Many women say, “I’ve already finished having children and I breastfed them all. I don’t need these anymore; take ‘em.” And I have to say, “Not so fast.”

Women need to know that, when comparing cancers of the same stage, mastectomies and breast conservation (the clinical name for lumpectomies accompanied by radiation) have equivalent survival rates. The earlier the stage, the better the survival rate. Lots of data from clinical trials confirm that. Newer studies even suggest lumpectomies have a slight edge in survival rates.

After a lumpectomy, women should continue to be monitored for breast cancer. Most women return to having annual routine screening mammograms. Some women may be recommended for high-risk screening that includes an annual breast MRI.

When does a woman have a choice between lumpectomy and mastectomy?

While lumpectomy — which is typically accompanied by radiation therapy — is generally the preferred treatment, any woman with early-stage cancer is typically given an option. The only absolute contraindications (medical reasons not to pursue a treatment) to lumpectomy are:

• A very large tumor-to-breast-size ratio.
• Diffuse malignant calcium deposits.
• And inflammatory breast cancer, a rare, but aggressive, cancer in which cells block lymph vessels in the skin, causing the breast to appear red and swollen.

When is a mastectomy the only option?

Patients who really need a mastectomy, rather than a lumpectomy, are:

• Those with inflammatory cancer or extensive disease at the time of surgery.
• Women not eligible for radiation — because of a high risk of complications, for instance.
• Patients at higher risk of new primary cancers, which includes mutation carriers like Angelina Jolie, and women who were on the younger side — say, younger than 50 — when diagnosed.
• Women with a strong family history of breast cancer.

Are there any advantages to a mastectomy?

Yes, in some cases. Mastectomies reduce the risks of future unrelated cancers, especially for younger women or patients with high-risk gene mutations. And they can also eliminate the burden of high-risk screening.

Clearly, there are lots of benefits to a lumpectomy — more than many of us realize.

When we look at quality-of-life measures following lumpectomy and mastectomy — things like depression, anxiety, satisfaction with your body and with your sex life — lumpectomy leads in every category.

There is increasing evidence that lumpectomies offer an equal, or better, survival benefit than mastectomies. Of 12 large clinical trials comparing outcomes between the two, six show equivalent survival, and six show improved survival with breast conservation (lumpectomy and radiation therapy).

Lastly, Novant Health is certified by the National Accreditation Program for Breast Centers (NAPBC). They do site visits to monitor a number of factors, one being the percentage of lumpectomies performed versus mastectomies. They want to ensure there aren’t an outsized number of mastectomies, which could indicate surgeons are performing unnecessary surgeries.

So, not only is a lumpectomy the course most surgeons recommend, it’s what our accrediting body recommends.

When faced with a choice of lumpectomy versus mastectomy, what should a woman consider?

If your top consideration is risk of recurrence — as it is for most women — it’s a toss-up. You need to look at other factors. Consider that lumpectomies mean:

• Decreased surgical time.
• Lower cost.
• Fewer surgical complications.
• Fewer side effects.
• Lower risks of long-term impacts to quality of life and daily functioning.
• Great cosmetic results, thanks to modern techniques like "hidden-scar" and oncoplastic surgery, which combines tumor removal with plastic surgery.

Women who have mastectomies are more likely to report:

• Diminished quality of life.
• Negative body image.
• Lower self-esteem.
• Difficulty coping.
• More effects on sexual well-being than women who undergo lumpectomies.

What’s the most important thing for women to take away here?

Unfortunately, mastectomy rates are increasing despite improved methods of early detection, more targeted radiation techniques and more therapies that can decrease the extent of surgical interventions, when it’s needed.

Patients are often driven to mastectomy by unfounded fear of recurrence and societal pressure, despite medical evidence supporting lumpectomy being, in most cases, the better option. Lumpectomies lead to better physical and psychological well-being for most patients.