With the end of chemo approaching, it’s time to remove the evil tumor from my breast. My options: a lumpectomy or a mastectomy.
I’m lucky I have options. Not everyone with cancer is so lucky. The options are great— as one of my doctors told me, there’s no wrong choice. But it doesn’t make this decision any easier. It feels like the biggest decision yet.
Over the past three weeks I’ve met with my oncologist, radiation oncologist, breast surgeon and plastic surgeon. I have wonderful friends who have shared their surgery stories with me and I’ve talked with Jason and my family. Everyone supports me in whatever decision I make. The frequent message I heard was to go with my gut.
Looking at the statistics, a lumpectomy and mastectomy are pretty evenly matched.
- Research has consistently shown that long-term survival from breast cancer is the same between lumpectomy (with radiation) and mastectomy.
- The highest risk of recurrence is from any breast cancer that might have spread beyond the breast before surgery.
- Once you’ve been diagnosed and treated for breast cancer, the risk of developing cancer in the opposite breast is about 1% per year.
- There is a slightly higher risk of developing a local recurrence of the cancer after lumpectomy than after a mastectomy.
- A bilateral mastectomy removes as much of the breast tissue as possible but there’s a very small chance that some residual tissue or cancer cells may not have been removed which could cause a recurrence.
A few decades ago the standard procedure was a radical mastectomy. Then lumpectomies became the preferred treatment because the surgery saves the breast while removing the cancer. Now doctors are noticing more women are choosing bilateral mastectomies when a lumpectomy is an option. If you want to learn more, read “Why are Rates of Bilateral Mastectomies Rising?”.
Choice A: Lumpectomy
During the first two months of chemo, I would feel the tumor to see if it had grown smaller. This hard, large lump is not hard to miss and it didn't seem to change. This disappointment led me to stop checking and start wondering if the chemo was working. Then two weeks ago Dr. C, my breast surgeon, said the tumor is now less than half its original 3 cm size! Hallelujah! It’s an incredible relief to see my body respond to the chemo. This makes all the nasty side effects worth it.
A smaller tumor means Dr. C could perform a lumpectomy to remove it and I get to keep my breast. Sounds good. Of course I’d like to keep my original parts. But there’s a couple caveats.
In a lumpectomy the surgeon also removes normal tissue surrounding the tumor to help ensure that all the cancer is removed. However, there’s a very small chance of accidentally leaving behind a microscopic amount of cancer, just like there is with a mastectomy. Not what I want to hear.
Depending on how much tissue is removed, my breast may not quite look the same. Will it be smaller than the other? Will I need reconstruction? Dr. C is confident he can give me great results but I still worry.
That leads me to the fear of recurrence. Even though I know the survival rates, they don’t completely quiet the fear that I might be the exception. If I choose a lumpectomy, will I worry about the breast tissue that’s left? Right now it’s easy to be paranoid about every little bump and pain in my body.
With a lumpectomy I would still need regular mammograms, unlike a mastectomy. I don’t like the idea of smooshing my boobs in a machine every six or twelve months to hear whether I have a recurrence or not. That sounds like anxiety I don’t need.
A lumpectomy is a much simpler, outpatient surgery with a shorter and easier recovery time in comparison to a mastectomy. After five months of chemotherapy, I feel like I can handle pretty much anything so this doesn’t sway me either way.
Must have: Radiation
Typically if you do a lumpectomy, it’s recommended you have radiation. It’s like an insurance policy against any sneaky cancer cells the lumpectomy might have missed. Unfortunately Dr. R, my radiation oncologist, recommends radiation no matter what surgery I choose.
In August Dr. C found microscopic amounts of cancer in my sentinel lymph node. He could remove more lymph nodes but because the cancer is so tiny, he won’t know how many to remove to get it all. While we can feel good that chemo is doing its job, the lymph nodes have many channels that these evil cancer cells can hide in. Dr. R says radiation is just one more strategy that’s been proven to further reduce the risk of recurrence in my situation and I’m young so my body can handle it. I love it when the doctors say I’m young.
For six weeks I’ll go in for a daily (agghhh!) dose of radiation targeting the tumor area and the lymph nodes on my right side. The appointments are short and it’s not painful. Dr. R says this is the easiest part of cancer treatment. I should get that in writing.
Choice B: Mastectomy
When I was diagnosed six months ago, I felt strongly that I wanted to cut off the boobs. It’s not an uncommon reaction. Suddenly faced with a disease that could shorten your life, you’re ready to do whatever it takes. It’s not like I was that well-endowed to begin with and after 3 kids, enough said. I was ready to do them in before they did me.
Dr. C reminded me that it’s not the cancer in the breast that can kill me, it’s if the cancer spreads throughout my body. He says chemotherapy is about saving my life while surgery is about the quality of my life.
A mastectomy would be a major change to my body. In a mastectomy the surgeon scoops out all the breast tissue along with all those useful nerves that give you sensation. It’s rare to regain sensation. Wow. Could I live with a numb chest?
To make it worse, they usually remove the nipple and areola too. Dr. M, my plastic surgeon, showed me “after” photos and it is a bit weird to see scars where nipples used to be. My tumor is positioned far enough away from the nipple that I could have a “nipple-sparing” mastectomy. It’s exactly what it sounds like. However if cancer is found near the nipples, they would have to remove them. There’s also a small chance of losing them if they don’t heal properly. Damn risks.
Then there’s the question of removing one (unilateral mastectomy) or both breasts (bilateral mastectomy). I have friends who are very happy that they removed just the one. For some women they see no reason to remove a healthy breast— like why remove both arms if only one is bad? Not quite apples to apples but you get the idea.
The procedure to remove a healthy breast is called a contralateral (opposite breast) prophylactic (preventive) mastectomy or CPM. It’s normally recommended only for women at high risk of breast cancer, such as those who carry genetic mutations. Only 5-10% of breast cancers are related to genetic mutations. Thankfully I’m not in this category but the surgery is an option for me.
Dr. C cautioned me that a mastectomy is a big surgery that provides more peace of mind than health benefits. I asked, “If I do a lumpectomy, what happens if we find cancer in my breasts again?” He replied, “We remove it.” I didn’t like that answer. I want to do whatever I can so I don’t ever hear I have cancer in my breasts again— or anywhere else. But how far do I want to go?
Let’s talk about peace of mind. That’s why we have car, home, and medical insurance right? It’s highly unlikely something could go wrong, but if it did, you’re protected. Having peace of mind isn’t some naïve hope that nothing can go wrong or making a decision driven by fear. Many articles I read by doctors about breast surgery don't seem to get this. For me, peace of mind is knowing I made an informed decision that fits my values.
For a while I contemplated what life would be like if I chose to not have reconstruction after a mastectomy. The feminist in me said I didn’t need boobs to feel good about myself. No post-surgery nightmares. No foreign foobs in my body. I was ready to burn my bras! And hey, going flat is actually becoming a little trendy. No, I wasn’t imagining a huge chest tattoo.
But over time I gave up the flat dream. It’s just too drastic for me. These months of chemo have made me feel twice my age. It’s important to come out of this experience feeling healthy, strong and whole.
We went back to the fancy, white, modern plastic surgeon’s office to talk to Dr. M about reconstruction. After Dr. C removes the breast tissue, Dr. M would perform an immediate reconstruction and insert expanders. Typically Dr. M adds saline to to the expanders over time to fit the final size of the implants. I’m not planning to go bigger so I may need only one fill.
After I’ve recovered from surgery I would start radiation therapy with the expanders still in place. You get better cosmetic results when your skin is expanded before radiation begins.
Once radiation is complete, Dr. M would swap out the expanders for “gummy bear” silicone gel implants in a quick, outpatient surgery. These latest generation silicone implants get their nickname because they retain their shape better. In an ideal world, that’s it, I’d be done. However, breasts aren’t perfectly round and the implants are, so there’s a small chance an unintended indentation would require additional surgery.
I never imagined myself getting foobs. It doesn’t feel like me. But then I recall what Dr. M told me the first time we met: “This isn’t about vanity. This is about recovery.”
For a while all of this information was racing through my head and I went back and forth in my decision.
And then I met with Dr. R my radiation oncologist last week. Remember he told me that I should do radiation, no matter which surgery I choose. It’s not that I’m high risk. He thinks at my young age, let’s not mess around. Let’s do what we can to kill any possible remaining cancer cells.
It clicked. My whole approach to this has been to do what I can to kill the cancer. We’re not messing around with chemo or radiation, why mess around with surgery? I want to feel that I did everything I could to live happily ever after.
So I have decided to do a bilateral mastectomy with immediate reconstruction. Surgery will be sometime in February. I'm ready.
Okay, enough talking about boobs— for now.