Very often, the decision about what breast cancer surgery to have is driven by fear. As a young woman, your first impulse may be to get rid of both of your breasts. Dr Lucienne van Schalkwyk offers perspective on this important decision.
A cancer diagnosis can be traumatic, and it’s definitely not an experience that you would care to repeat. You might think that you would do whatever it takes to be healthy for the sake of your family. You may also be anxious about making the wrong decision and regretting it down the line, because the decisions you make about breast cancer surgery in the moment can have far-reaching consequences in the future.
We have two options available when it comes to breast cancer surgery: mastectomy (removal of the whole breast), or lumpectomy (removal of only the cancer along with a little rim of normal breast tissue surrounding it). When your surgeon makes a recommendation about what they believe to be the best option for you, they consider cancer-related factors (size of cancer, where it’s located, one abnormal area vs a few abnormal areas in the same breast) and patient-related factors (age, chronic medical conditions and lifestyle).
The type of surgery doesn’t influence survival
Many young women ask their surgeon for a mastectomy, believing this to be safer than a lumpectomy. This question was recently investigatedin a large study in the US, which followed a group of nearly 600 young women who had been diagnosed with early breast cancer before the age of 40. Some of them had a mastectomy, while others had a lumpectomy.
The researchers found that there was no difference in survival between the women who had undergone mastectomies and the women who had lumpectomies.
In other words, a mastectomy didn’t guarantee that a young woman with breast cancer would live longer.
In short, the type of breast cancer surgery you undergo doesn’t influence your survival. Rather, factors such as the personality (sub-type or behaviour) of your cancer and the oncology treatments you receive, do.
The options women choose and why
Some women reason that the less breast tissue they have, the lower the risk of developing another cancer in future and opt to have a double mastectomy. Removing the breast that doesn’t contain a cancer preventatively is known as contralateral prophylactic mastectomy. This has been increasing in frequency, not just in SA, but all over the world, and especially in younger women.
In certain women, removing the opposite breast as a precaution makes sense. Take, for example, women with a genetic abnormality that causes familial breast cancer, such as the BRCA mutation, or those with a strong family history. These women have a very high risk of developing another breast cancer if the opposite breast isn’t removed.
For women that don’t have any of these risk factors, the risk to the opposite breast is often overestimated. The risk can also be further reduced by oncology treatments, such as chemotherapy and endocrine therapy. Studies have shown that while removing the opposite breast does decrease the risk of a new cancer developing there in young women, there is no proof that it prolongs life.
Remember, removing the opposite breast doesn’t change the outcome of the tumour you have already been diagnosed with. It also doesn’t prevent the cancer from returning in another area, such as the lungs, liver, brain or bones. And unfortunately, there is still a small risk of developing cancer in the breast after a mastectomy. This is called a local recurrence, and can develop in the mastectomy scar, the skin, or the underlying chest wall. Despite all this information, the majority of women who decide to have both breasts removed report that they feel less anxiety about the possibility of the cancer returning, and that they would make the same decision if they had to choose again.
It’s important to keep in mind that a mastectomy is a big procedure. The perception of increased safety comes at the cost of longer time in the operating theatre and a longer hospital stay. Likewise, the recovery time from a mastectomy is longer, which means you’ll be restricted in terms of what you can do for a longer period: driving, child-minding, exercising and housework. If you’re a breadwinner, it may be impossible for you to take an extended period of leave from work to recover from the mastectomy. Because it’s a bigger procedure, a mastectomy runs a greater risk of developing complications, and even more so if it’s a double mastectomy, double the likelihood of wound and drain complications, as well as chronic pain.
Body image and self-esteem
Breast cancer surgery has a significant impact on body image and self-esteem. The surgery leaves scars, the appearance of the breasts change, and the skin may be numb. Dealing with these changes can have a negative effect on social and sexual relationships.
An interesting American study asked women who had a mastectomy and women who had a lumpectomy to complete a questionnaire about the experience and compared the responses. The women who had a mastectomy were less satisfied with what their breasts looked like after the operation and reported more difficulty in social situations and with their sexual relationships than the women who had had a lumpectomy. We have to be careful when interpreting the results of this study though, as they only looked at American women, and our situation in SA may well be quite different.
Making the right decision for you
So, how can you ensure that you’re making a decision that is right for you?
A crucial step is communication with your treatment team. You should feel comfortable enough to have an open discussion with them regarding your surgical options. Your team should discuss the risks and benefits of all the options with you and answer any questions you may have.
Don’t feel pressured to make a decision. You should be given the time to think about the information, and to discuss it with your family, should you wish to do so. It’s after all a decision that may impact you for many years to come. Beware of Facebook syndrome, you will receive advice from well-meaning acquaintances (or total strangers) on what they think you should do. But, at the end of the day every person’s body is different, every tumour is different, and every person’s situation is different. Only you can decide what is best for you.
Note, I’m not advising against having a mastectomy. For some women, a mastectomy, or even a double mastectomy is absolutely the right operation. All I advise is to do your research. Arm yourself with all the knowledge you can lay your hands on, to help you make a decision that is both safe and appropriate for you.
MEET THE EXPERT – Dr Lucienne van Schalkwyk
Dr Lucienne van Schalkwyk is a general surgeon with a special interest in breast surgery. Her practice manages the entire spectrum of benign and malignant breast disease, and her specific interests include breast-conserving surgery and oncoplastic surgical techniques.
Header image by Adocbe Stock