Surgery for Breast Cancer

After over twenty years, the results are in.

Forty years ago, the only option for women with breast cancer was the radical mastectomy. In the procedure, the entire affected breast is removed. The intense surgery left many women and their physicians dissatisfied with the results. This, combined with an increasing understanding of cancer, led some surgeons in the 1960s to try other approaches. Such options include the lumpectomy, in which the tumor and a limited amount of surrounding breast tissue are removed.

The quadrantectomy or partial mastectomy became a choice as well. Just the tumor and the affected quadrant of the breast are removed. Both the lumpectomy and the quadrantectomy are considered breast-conserving surgeries. But in the total or simple mastectomy, the breast tissue, skin, nipple, and areola are all removed.

In the early 1970s some surgeons only endorsed the radical mastectomy. Others promoted the more limited approaches. Researchers began comparison studies to settle the controversy. The results are now available.

In three separate studies, long-term survival rates were the same, regardless of the type of surgery.

Breast-conserving vs. radical mastectomy

Over 700 women with tumors no larger than two centimeters (cm) took part in a study that compared quadrantectomy with radical mastectomy. They had either a quadrantectomy or radical mastectomy followed by radiation therapy. After 1976, women whose cancer had spread to the lymph nodes also received chemotherapy. The women in the study were followed for an average of 20 years. During that time, roughly 9% of the women in the quadrantectomy group experienced a recurrence in the same breast. For women in the radical mastectomy group, the recurrence was nearly 2%. In both groups approximately 75% of the women were still living after the follow-up period.

New England Journal of Medicine, October 17, 2002

Lumpectomy vs. total mastectomy

Another study involved over 1,800 women with tumors no larger than four cm. They were divided into three groups. Women in the first group underwent a total mastectomy. Those in the second group had a lumpectomy. The third group of women underwent a lumpectomy plus radiation therapy. The axillary lymph nodes were removed for all women, regardless of whether or not the cancer had spread that far. Fourteen percent of those who underwent a lumpectomy plus radiation had a recurrence of cancer in the same breast. Meanwhile, the rate for women who had undergone just a lumpectomy was 39%. After twenty years, roughly 46% of the women had survived in each of the three groups. There was also little difference in the percentage of women in each group (roughly 35%) who were disease-free.

New England Journal of Medicine, October 17, 2002

Total mastectomy vs. radical mastectomy

In a third study, over 1,000 women were randomly assigned to receive a radical mastectomy, a total mastectomy, or total mastectomy plus radiation therapy. None of the women’s cancer had spread to the lymph nodes (node-negative). Also, over 500 women with breast cancer that had spread to the lymph nodes (node-positive) received either a radical mastectomy or a total mastectomy plus radiation therapy. The average tumor size was less than 4 cm. After 25 years, the rates of recurrence and overall survival were similar among the women in the node-negative group regardless of the type of treatment they received. The same was true for the women in the node-positive group. Overall survival was roughly 19%–25% for the women in the node-negative group, compared to 14% for the women in the node-positive group.

New England Journal of Medicine, August 22, 2002

Preliminary results from each of these studies had stated the same conclusions back in the late 1970s. The findings led thousands of women to choose more limited surgery over a radical mastectomy. But many physicians fear a recurrence in the remaining breast tissue. As a result, they have been hesitant to offer breast-conserving surgery. With the final results of these studies, women and their physicians can lay to rest any fears they have about the decision to preserve the breast.

It is important to talk with your doctor about what type of surgery makes the most sense for your situation.

One word of caution: These studies involved women with breast cancers of different sizes and stages. Therefore, it is impossible to compare their survival rates.

March 2003 Update

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