Decisions and available research

The breast cancer diagnosis is early stage (grade 1, <2cm), ER+/PR+, HER- in right breast. There is a family history of breast cancer (all early stage, after age 50).

Many questions come to mind and difficult decisions have to be made.

0. Decision-making process

It is important to be aware that women make decisions about mastectomy not necessarily on the basis of tumor factors and scientific studies, but about patient factors and psychological reasons.

References:

• Covelli et al. ‘Taking Control of Cancer’: Understanding Women’s Choice for Mastectomy. Ann. Surg Oncol (2015) 22:383-391
• Boughey et al. Contralateral Prophylactic Mastectomy Consensus Statement from the American Society of Breast Surgeons: Additional Considerations and a Framework for Shared Decision Making. Ann Surg Oncol (2016) 23:3106–3111

1. Lumpectomy or Mastectomy?

Typical treatment for early stage breast cancer like this is lumpectomy and radiotherapy. Recovery after lumpectomy is clearly easier than after mastectomy, but it is lumpectomy plus several weeks of daily radiotherapy, which carries its own problems. Depending on breast and tumor size, there can be differences in breast sizes after lumpectomy.
Due to a family history I considered bilateral mastectomy, which has a longer recovery time and can have more complications. This seemed over the top given this type of cancer and surgeons will talk to you about mastectomy vs lumpectomy, but it should really be mastectomy vs lumpectomy+radiotherapy.  Statistically the recurrence and survival rates are similar.
There is a trend that more women, especially younger, Caucasian, with high level of education, choose mastectomy over lumpectomy.

References: 

• Hoskin et al. Use of immediate reconstruction and choice for contralateral  prophylactic mastectomy. Surgery April 2016, 1199-1209.
• http://ww5.komen.org/BreastCancer/PreventiveSurgery.html

2. Reconstruction?

Breast reconstruction carries the risks of longer recovery, more pain, more complications, possibly multiple surgeries. It is likely that reconstruction may severely limit competing in athletic events.
I did not hesitate to reject this option. If I later feel I need props, the health insurance company pays for prosthesis that can be worn in a bra or camisole.
Women choosing no reconstruction: http://breastfree.org  or http://www.flatandfabulous.org

3. Adjuvant therapy?

For early stage breast cancer and mastectomy I was fortunate not to need radiation nor chemotherapy.  But there will be hormone therapy (tamoxifen, if premenopausal) for 5 years. These drugs are on the prohibited list, and competitive athletes may need to file a Therapeutic Use of Exemption with the US Anti Doping Agency.

• http://www.usada.org/substances/tue/

4. Lymphedema?

Lymphedema is a risk that can occur possibly months or years after surgery. It is crucial to be informed about this before surgery, so that precautions can be taken. Authors of a recent paper conclude that sentinel lymph node biopsy should not be routinely done (see Boughey et al under 0. above).

• http://www.stepup-speakout.org/

5. Surgery specifics?

• Lymph node disection. Removal of lymph nodes, including sentinel lymph nodes, carries the risk of developing lymphedema later on. The clinical trial ACOSOG Z0011 came to the conclusions that for women with early stage breast cancer and lumpectomy with radiotherapy and axillary lymph node dissection was not needed, even if sentinel lymph nodes are positive. It is helpful to discuss this with the surgeon and also the possibility of reverse mapping so that no lymph nodes of the arm will be taken.
• Reference: Boughey et al. Annals of Surgical Oncology 2014 21:8-10

• Drains. There will be drains for a couple of days. This carries the risk of infections. Careful stripping and changing of dressing reduces this risk. In a randomized trial the investigators found a reduction in infections when using a chlorhexidin disc (Biopatch® (Ethicon, Inc., Somerville, NJ)).
• Reference: Degnim et al. Annals of Surgical Oncology 2014 21:3240-3248

• Reverse Mapping. Axillary reverse mapping helps identify lymphatic drainage from the breast versus nodes from the arm. Thus it is possible to reduce the lymphedema risk. Studies are underway to weigh the lymphedema risk with the risk of missing metastases in lymph nodes.
• Reference:  Ahmed et al. Br. J. Surg. 2016 103:170-178
• Flap Necrosis. This is more an issue for reconstruction. SPY angiography has been helpful in reducing this risk.

• Extend of Surgery. Will fascia be removed from the muscles during the mastectomy?