Brandel France de Bravo, MPH and Diana Zuckerman, PhD
Experts have long advised that lumpectomy patients live as long as mastectomy patients. But the latest research, based on hundreds of thousands of women, indicates that women with early-stage breast cancer are more likely to live longer, healthier lives if they choose less radical surgery.
Three studies indicate that lumpectomy patients live longer.
A study of 37,207 women, reported at a medical conference in December, 2015 found that 77% of women with early-stage breast cancer who underwent lumpectomy with radiation were still alive 10 years later, compared to 60% of women who underwent mastectomies[end Sabine Seisling, Ph.D., senior researcher, Netherlands Comprehensive Cancer Organization, Utrecht; David Euhus, M.D., chief, breast surgery, Johns Hopkins Hospital, Baltimore; Dec. 10, 2015, presentation, San Antonio Breast Cancer Symposium, San Antonio, Texas]. Since the risk of getting breast cancer increases with age, it is important to understand that not all the deaths were from breast cancer. So, the researchers, from Johns Hopkins Hospital and a university in the Netherlands, did an additional analysis and concluded that 83.6% of the women who underwent lumpectomy and radiation were still cancer-free 10 years later, compared to 81.5% of those who had mastectomies. This was true even when age and factors that could influence survival were taken into account.
Dr. Shelly Hwang and her colleagues published a study in the medical journal Cancer in 2013 that concluded that women who had lumpectomies to remove their early-stage breast cancer were more likely to be alive and free of breast cancer 5 years after surgery than women who had mastectomies. [end Hwang ES, et al “Survival after lumpectomy and mastectomy for early stage invasive breast cancer: The effect of age and hormone receptor status” Cancer 2013 April 1; 119(7); DOI: 10.1002/cncr.27795.] The researchers studied more than 112,000 California women diagnosed between 1990 and 2004 with either Stage 1 or 2 breast cancer. All of them had either a lumpectomy with radiation or a mastectomy. After surgery, their health was monitored for an average of 9 years (the women were all studied for 5-14 years). The women who had a lumpectomy and radiation tended to live longer than the women who had mastectomies, when controlling for age at diagnosis, race, income, education levels, tumor grade or the number of lymph nodes with cancer. Lumpectomy with radiation was especially effective for women who were 50 years and older with hormone-receptor positive tumors: they were 19% less likely to die of any cause during the study than women just like them who had mastectomies. Perhaps more surprising, they were 13% less likely to die of breast cancer than women just like them who had mastectomies.
Dr Allison Kurian and her colleagues at Stanford studied 189,734 California patients diagnosed from 1998 to 2011 with early-stage breast cancer in one breast, ranging from Stage 0 (DCIS) to Stage 3.[end Kurian, Allison W., Daphne Y. Lichtensztajn, Theresa H. M. Keegan, David O. Nelson, Christina A. Clarke, and Scarlett L. Gomez. “Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998-2011.” The Journal of the American Medical Association 2014; 312(9): 902-914. DOI:10.1001/jama.2014.10707.] Published in JAMA, the study showed that the rate of women having both breasts removed even though only one breast had cancer (called bilateral mastectomies) increased dramatically, but the results showed no advantage to that more radical approach. Instead, the women who underwent lumpectomies (removing only the cancer, not the entire breast) lived longer and were more likely to be alive 10 years after diagnosis compared to women undergoing a mastectomy. Women who had both breasts surgically removed did not live longer than those undergoing a mastectomy on one breast.
Compared to women in other countries, women in the U.S. who are diagnosed with early-stage breast cancer are more likely to remove both breasts even if only one has cancer. It is not known why bilateral mastectomy provided no medical advantage in study by Kurian and her colleagues, but new research by Dr. Fahima Osman at the University of Toronto indicates that having a healthy breast removed in addition to the breast with cancer increases the chances of medical complications. While removing a healthy breast greatly lowers the risk of getting cancer in that breast in the future, the risk of cancer in that healthy breast was already less than 1% per year unless the woman has a BRCA gene or some other very high risk factor.[end National Cancer Institute. Breast Cancer Treatment (PDQ®). http://www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional/page1] Hormone pills such as tamoxifen or aromatase inhibitors can further reduce that already low risk. In a study of more than 4,000 women, removing the healthy breast (“contralateral breast”) doubled the chances of having wound complications in the first month after surgery: from about 3% for women who had only the breast with cancer removed to about 6% for women who also had the healthy breast removed. About 4% of women who had a single mastectomy experienced some kind of complication (not necessarily wound-related) in the 30 days after surgery, compared to 8% of women who had both breasts removed. Dr. Osman presented these findings at the 2013 meeting of the American Society of Breast Surgeons.[end Osman F., University of Toronto. Abstract. Increased Postoperative Complications in Bilateral Mastectomy Patients Compared to Unilateral Mastectomy: An Analysis of NSQIP Data. Presented at 2013 Annual Meeting of the American Society of Breast Surgeons.]
The Bottom Line: these enormous studies of women in the U.S. and other countries make it clear that women with DCIS or early-stage breast cancer should undergo surgery to remove only the DCIS lesion or cancer, not the entire breast. The women who undergo lumpectomy with radiation usually live longer than those who undergo mastectomy or bilateral mastectomy. In addition, mastectomy patients who have breast implants are more likely to kill themselves compared to mastectomy patients without implants. Unfortunately, the fear of breast cancer and desire to “get rid of the problem” has resulted in too many women undergoing mastectomies or bilateral mastectomies that threaten their lives. Physicians and breast cancer advocacy groups need to make sure that patients understand why lumpectomy with radiation is a better idea.