Breast Cancer Surgery Choices and Survival Rates

When a woman is diagnosed with breast cancer, her immediate instinct is almost always to want to do anything to stay alive. Most of us hear the words you have cancer and instantly worry about our mortality. Even if our doctors are reassuring and the prognosis is pretty good, it can never be good enough to completely allay our fears. No one ever gets a guarantee, and we all want to do whatever we can to increase our odds of a long and healthy life.

The choice of surgery has always been difficult, and we are guided by our doctors’ opinions as well as by our own thoughts.

Most of the time, a woman who is newly diagnosed with breast cancer begins her treatment with surgery. However, neoadjuvant chemotherapy (chemo before surgery) is the choice in some situations. And during the pandemic when all elective surgeries were cancelled, many women with a new diagnosis of an ER positive breast cancer began with hormonal therapy and went to surgery only when hospitals became more open.

For decades we have been told that, in most cases, survival is just as likely with a lumpectomy/partial mastectomy as with a mastectomy. Since a lumpectomy is almost always paired with radiation therapy, this has been presented as a just-as-safe choice. There have always been circumstances that indicate that a mastectomy is a better option. These times include a large tumor, especially in a small breast when the cosmetic result of a lumpectomy would be poor, or diffuse cancer throughout the breast or the inability of the surgeon to achieve clean margins after several attempts.

Sometimes, even with the reassurance of her doctors, a woman opts for a mastectomy or even for bilateral mastectomies. Her thinking is usually along the lines of: I want the cancer out. I want my breasts off. I never want to have to deal with this again, and it will make me too anxious to keep my breast(s). I have written before about this choice, the evolving trends of more women making this choice, and the decisions about reconstruction or going flat. Many other women, of course, are dismayed by the prospect of losing a breast and are very glad that they can have the smaller surgery and radiation therapy.

As recently reported in JAMA Surgery, a cohort study from Sweden has called this belief into question. Data was collected by Swedish healthcare systems, the National Breast Cancer Quality Register, and the National Board of Health and Welfare. The data included all women who had been diagnosed with T1-2 (T1 tumors are no larger than 2 cm; T2 tumors are between 2 and 5 cm) node negative invasive breast cancers between 2008 and 2017. Three groups were compared: women who had lumpectomies plus radiotherapy, women who had mastectomies without radiotherapy, and women who had mastectomies and radiotherapy.

The surprising, even shocking, result was that women who had lumpectomies plus radiation therapy had better survival rates than those who had mastectomies, with or without radiation. The authors considered comorbidities and lifestyle factors (e.g. smoking, obesity) and recognized that outcomes are also related to these things.

Clearly this is a study that will need to be replicated and that will stimulate a lot of thought and conversation. I have always believed that women make the best choices for themselves and should be supported in their decisions. I also know the intense anxiety that accompanies a cancer diagnosis and that none of us are thinking very clearly in the early days. The choice of surgery has always been difficult, and we are guided by our doctors’ opinions as well as by our own thoughts. Hopefully we all understand that survival from breast cancer is less about the breast(s) itself and more about distant metastases or spread. While no one is eager to have a local recurrence, cancer again in the breast or a second breast cancer, these possibilities are still considered curable. The worry is the spread of cancer cells to other parts of the body. If that happens, it is considered a Stage IV cancer and is treatable, but not curable.

This study gives us one more important piece of information to consider. I always suggest to women who are struggling with this decision to think about the future. What will help you sleep better not just tonight but also five years from now? For yourself, you know the answer to that question.