Mastectomy v. Lumpectomy: Who Decides?

Diana Zuckerman, PhD, National Center for Health Research

Approximately 230,000 women in the U.S. will be diagnosed with breast cancer this year. Over the last two decades, research has regularly provided new evidence that breast cancer patients can live just as long – or even longer – with less radical treatment.

In the 1990s, research indicated that for most early-stage breast cancer (stage 0, 1, 2, or 3a), lumpectomy was just as safe as mastectomy, if the lumpectomy was followed by radiation therapy.1,2 Mastectomy removes the entire breast, but lumpectomy removes just the cancer and a small “margin” of tissue around it. Experts agreed that since survival rates were the same, lumpectomy followed by radiation is the preferable treatment for most women with early-stage breast cancer.3 However, since 2013, we have known that lumpectomy patients live longer than mastectomy patients and in 2021, an enormous study of almost 49,000 breast cancer patients confirmed that women undergoing lumpectomy with radiation were less likely to die of breast cancer or any other cause than women who have a mastectomy, whether or not they underwent radiation. 4,5

This study is great news, because it showed that women with early or later breast cancer lived longer if they chose less radical surgery regardless of their age or other health issues. And it means that women do not need to undergo radiation to live longer with a lumpectomy. Later research showed that was also true for women over the age of 65.6

Here’s the question: Why are so many women undergoing mastectomy when they would live longer with a lumpectomy?  Mastectomies are unnecessary — and in fact more dangerous — for about half of these women. Are these women getting unnecessary mastectomies because they do not understand that lumpectomies are a safer option?

More Mastectomies Related to Poverty, Doctors’ Preferences, Women’s Fear

One reason is economic — surprisingly, a mastectomy costs less than a lumpectomy. That’s because mastectomy surgery takes less time than a lumpectomy and radiation is almost never suggested for a mastectomy. In addition, some insurance plans do not cover all the expenses of the lumpectomy or the radiation therapy, because they are usually outpatient procedures. As a result, studies show that women with private insurance are much less likely to undergo mastectomies than lower-income women.7,8

For years, older doctors were more likely to recommend mastectomies, since that used to be the standard treatment for breast cancer at any stage. Younger doctors may be more likely to understand that lumpectomy is a safer option.

Age of the physician is not the only reason. When women are first diagnosed with breast cancer, most meet with a surgeon before meeting with an oncologist.  Breast surgeons often offer reconstruction of the breast using breast implants after mastectomy, urging women to remove both breasts and “look better than ever” with implants. These surgeries pay the surgeon more, and many women with insurance won’t need to pay for the breast implants. As a result, physician knowledge and attitudes may help to explain why women living in some parts of the U.S. are more likely to have mastectomies than other women.

However, regardless of the physicians’ views, women undergoing lumpectomy will live longer than those having a mastectomy.

Another factor that can help explain why so many American women have unnecessary mastectomies is fear. Some women choose mastectomy because the chances of cancer coming back in the same breast are reduced when the breast is removed, even though that does not affect how long women will live.  Radiation therapy can also reduce recurrence, and some women are afraid of radiation therapy because it is inconvenient (especially in rural areas) and can cause fatigue or cosmetic side effects such as skin irritation. Very infrequently radiation therapy can cause long-lasting problems. Of course, patients do not want breast cancer to return, but if doctors told patients that they would live longer after lumpectomy without radiation than with a mastectomy, surely many women would not choose unnecessary mastectomies.

Breast cancer is still relatively rare among women in their 20’s and 30’s, but there is some evidence that women diagnosed with breast cancer at an early age tend to have more aggressive cancers. Survival rates are lower.9 This does not mean, however, that young women always need mastectomies, and each patient should receive the medical treatment that is best for her, based on her own diagnosis and preferences.

Advice to Breast Cancer Patients Who Want to Live Longer

  • You will live longer with lumpectomy than mastectomy, and longer with mastectomy in one breast than mastectomy for both breasts (called bilateral mastectomy).
  • Radiation will reduce your chances of cancer returning, but that usually means your chances of another cancer will be about 14% instead of 7%.  Don’t be fooled when you hear it “reduces recurrence by 50%”:  7% if half of 14%, but it is not a big difference for you, and it doesn’t affect how long you live as long as you continue to have cancer screenings.
  • Women whose breasts are removed have no sensation in their breasts, with or without breast implants. Implants will change shape and often get hard or leak after several years. Don’t get talked into a surgery you don’t want or need.

Surgical Treatment Disparities for Early-Stage Breast Cancer

These are a few examples of the studies of thousands of patients, published in major medical journals, which indicate that:

  • Mastectomies are especially likely to be unnecessary for most non-invasive breast cancers, such as ductal carcinoma in situ, and very early-stage cancers, yet many women with those cancers undergo mastectomies.10,11
  • Breast-conserving surgery with radiation is somewhat more expensive than mastectomy in the short run, but breast-conserving therapy is less expensive than mastectomy after 5 years.12 Breast-conserving therapy is much less expensive than mastectomy with reconstruction.13
  • Low-income women and those who are less educated are less likely to have breast-conserving surgery. Patients without private insurance are also less likely to have breast-conserving surgery.14

References:

  1. Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM. Reanalysis and Results After 12 Years of Follow-up in a Randomized Clinical Trial Composing Total Mastectomy With Lumpectomy With or Without Irradiation in the Treatment of Breast Cancer. N Engl J Med 1995 Nov 30;333(22):1456-61.
  2. Agarwal, S et al.  Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surg. 2014;149(3):267-274.
  3. Abrams JS, Phillips PH, Friedman MA. Commentary: Meeting Highlights: a Reappraisal of Research Results for the Local Treatment of Early Stage Breast Cancer. J Nat’l Cancer Institute, 1995 Vol. 87. No. 24, Dec 20.
  4. 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.
  5. de Boniface J, Szulkin R, Johansson ALV. Survival After Breast Conservation vs Mastectomy Adjusted for Comorbidity and Socioeconomic Status: A Swedish National 6-Year Follow-up of 48 986 Women. JAMA Surg. Published online May 05, 2021. doi:10.1001/jamasurg.2021.1438.
  6. Kunkler, I. H., Williams, L. J., Jack, W. J. L., Cameron, D. A., & Dixon, J. M. (2023). Breast-conserving surgery with or without irradiation in early breast cancer. New England Journal of Medicine, 388(7), 585–594. https://doi.org/10.1056/nejmoa2207586
  7. Dolan JT, Granchi TS. Low Rate of Breast Conservation Surgery in Large Urban Hospital Serving the Medically Indigent. Am J Surgery 1998 Dec;176(6):520-4.
  8. Kotwall CA, Covington DI, Rutledge R, Churchill MP, Meyer AA. Patient, Hospital, and Surgeon Factors Associated with Breast Conservation Surgery. A Statewide Analysis in North Carolina. Ann Surg 1996 Oct;224(4):419-26.
  9. Carey K. Anders et al., “Young Age at Diagnosis Correlates With Worse Prognosis and Defines a Subset of Breast Cancers With Shared Patterns of Gene Expression,” Journal of Clinical Oncology 26, no. 10 (2008): 3324-3330.
  10. Katz SJ, Lantz PM, Zemencuk JK. Correlates of Surgical Treatment Type for Women with Noninvasive and Invasive Breast Cancer. J Womens Health Gend Based Med 2001 Sep;10(7):659-70.
  11. Gomez SL, et al. Increasing mastectomy rates for early-stage breast cancer? Population-based trends from California.  J Clin Oncol. 2010 Apr 1;28(10):e155-7.
  12. Barlow WE, Taplin SH, Yoshida CK, et al. Cost Comparison of Mastectomy versus Breast-conserving Therapy for Early-stage Breast Cancer. J Natl Cancer Inst 2001 Mar 21;93(6):447-55.
  13. Desch CE, Penberthy LT, Hillner BE, et al. A Sociodemographic and Economic Comparison of Breast Reconstruction, Mastectomy, and Conservative Surgery. Surgery 1999 Apr;125(4):441-7.
  14. Roetzheim RG, Gonzalez EC, Ferrante JM, et al. Effects of Health Insurance and Race on Breast Carcinoma Treatments and Outcomes. Cancer 2000 Dec 1;89(11):2202-13