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 treatment.1,2,3  At a 1990 Conference sponsored by the National Institutes of Health, 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.4   However, by 2013, a study indicated that lumpectomy patients live longer than mastectomy patients5 and in 2021, an enormous study that followed almost 49,000 breast cancer patients for a median of 6 years confirmed that women undergoing lumpectomy with radiation were less likely to die of breast cancer or any other cause than women undergoing mastectomy, whether or not they underwent radiation.6 The benefit of lumpectomy was maintained regardless of tumor characteristics, treatment, demographics, other health issues, and socioeconomic background.  And in 2023, a study was published indicating that for women over 65, women who choose lumpectomy lived just as long whether or not they had radiation.7

Half of the U.S. women that are eligible for lumpectomy, however, will undergo mastectomy instead. Why remove the entire breast in a mastectomy if it is safer to just remove the cancer and a “margin” of tissue around it?  Why are so many women undergoing medically unnecessary mastectomies? We’ve known since 2013 that lumpectomy is preferable because women live even longer than mastectomy patients with the same diagnosis. Could it be that many women eligible for breast-conserving surgery are getting 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, it is less expensive to perform a mastectomy than a lumpectomy. In addition to a more time-consuming surgery, radiation adds to the cost of lumpectomy but is rarely required for mastectomy. Moreover, some insurance plans do not cover all the expenses of the lumpectomy or the radiation therapy, because they are usually outpatient procedures. According to a study of one large urban hospital in Texas serving mostly indigent women, 84% of the women with early-stage breast cancer had mastectomies and only 16% had lumpectomies.8 Similarly, a study of 20,000 breast cancer patients in North Carolina reported lower lumpectomy rates among patients who did not have private insurance.9 In some hospitals, all breast cancer patients have mastectomies, regardless of their diagnosis. Now that research shows that radiation is not necessary for many older lumpectomy patients, that should make lumpectomies more affordable, convenient, and desirable for many women.

For years, older doctors were more likely to recommend mastectomies, since that used to be the standard treatment for breast cancer at any stage. A study of 157 hospitals in North Carolina found that patients were more likely to undergo breast-conserving surgery if their surgeons were trained after 1981.10 One logical explanation is that doctors trained after 1981 were trained to do lumpectomies and are more knowledgeable about the research showing the safety of lumpectomy.  Researchers also believe that physician knowledge and attitudes are a likely explanation for the dramatic regional differences they have documented in breast-conserving surgery.

Another factor is fear. Some women are very afraid of recurrence and choose mastectomy because the chances of recurrence in the same breast are reduced when the breast is removed, even though that does not affect how long women will live. Some women are afraid of radiation therapy, which can cause fatigue or cosmetic side effects such as skin irritation or more permanent dimpling. Very infrequently radiation therapy can cause long-lasting problems. And, there is the issue of access to radiation. In rural areas, patients sometimes must travel hundreds of miles five days each week for 5-8 weeks to get radiation treatment after lumpectomy.  As noted earlier, now that research shows that many older lumpectomy patients do not need radiation, that could reduce the number of 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.11,12,13 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.

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, yet many women with those cancers undergo mastectomies.14,15,
  • 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.16 Breast-conserving therapy is much less expensive than mastectomy with reconstruction.17
  • 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.18

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. Gangi, A et al.Breast-Conserving Therapy for Triple-Negative Breast Cancer. JAMA Surg. 2014;149(3):252-258.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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
  8. 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.
  9. 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.
  10. Kotwall, CA, Covington D, Churchill P, Brinker C, Weintritt D, Maxwell JG. Breast Conservation Surgery for Breast Cancer at a Regional Medical Center. Am J Surg 1998 Dec;176(6):510-4.
  11. Xiong Q, Valero V, Kau V, Kau SW, Taylor S, Smith TL, Buzdar AU, Hortobagyi GN, Theriault RL. Female Patients with Breast Carcinoma age 30 Years and Younger Have a Poor Prognosis: the M.D. Anderson Cancer Center Experience. Cancer 2001 Nov 15;92(10):2523-8.
  12. Carey K. Anders et al., “Breast Carcinomas Arising at a Young Age: Unique Biology or a Surrogate for Aggressive Intrinsic Subtypes?,” Journal of Clinical Oncology 29, no. 1 (2011): e18-e20.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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