Mastectomy versus breast conservation: What treatment options fit?

Mastectomy, a surgical procedure used to treat breast cancer, has evolved significantly since its origins in the 18th century. Today, it remains a vital treatment option, especially for patients diagnosed with early breast cancer.

"When we talk about early breast cancer, we are referring to stages 0, 1, and up to stage 2B," says Prof Ronald Wasike, a breast surgical oncologist and general surgeon at Aga Khan University Hospital. "One of the upfront options for treatment is a mastectomy, but breast conservation surgery, such as lumpectomy, is also an option," he says.

Mastectomy involves removing the entire breast, while breast conservation surgery removes the cancerous lump, preserving the rest of the breast.

Prof Wasike explains, “A modified radical mastectomy is one of the options we offer for early-stage breast cancer. This is usually chosen when there are multiple breast lesions or the tumour size is large compared to the breast. However, we sometimes administer chemotherapy beforehand to reduce the tumour size, allowing for breast conservation."

Breast Conservation Surgery

Prof Wasike pioneered breast conservation surgery in Kenya in 2008 after returning from training in Canada. "Initially, even doctors were hesitant to accept it as a valid treatment option for breast cancer," he recalls, "We conducted a study here and found that patients who underwent breast conservation surgery survived longer than those who had mastectomies."

According to Prof Wasike, this improved survival rate may be due to psychological factors. "How you feel about yourself can influence your health and your life. When you look in the mirror, that sense of self-worth drives you," he explains.

The psychological impact of mastectomy is significant, and many patients struggle with their self-image after losing a breast. "Suicide is often linked to a loss of hope, a loss of self-worth," he says, "So preserving the breast can play an important role in the patient's mental health and overall survival."

Process of Mastectomy

When a patient decides on a mastectomy, it is essential to set realistic expectations and prepare for the procedure. "We don't rush patients into a decision. We encourage them to think about their options, whether it's breast conservation or mastectomy," Prof Wasike says, adding that some patients fear that keeping the breast may increase the risk of cancer recurrence, so they choose mastectomy for peace of mind.

Once the decision for mastectomy is made, patients are informed about what the surgery entails.

"Before surgery, we explain everything thoroughly, including how we are going to remove the breast tissue, and what post-surgery recovery looks like," he says, "It is important to understand that once the breast is removed, it can’t be restored unless we opt for reconstruction."

During the surgery, the breast tissue, a portion of the lymph nodes, and some skin are removed. The skin is closed and a drain inserted to collect fluid from the surgical site. The drain may need to stay in place for one to three weeks, depending on how the body heals.

"For some patients, particularly those who are larger, fluid drainage might take longer."

He emphasises the importance of post-operative care, which includes arm and breathing exercises to prevent stiffness in the shoulder and alleviate numbness caused by lymph node removal. "You also need to inform patients about the possibility of complications, like bleeding or infection, though these are rare," he explains.

Types of Mastectomy

Different types of mastectomy are performed depending on the stage of the cancer and the patient's circumstances. "The most common type is the skin-tight mastectomy, where the skin is tightly closed over the surgical site. This is often used for large tumours where reconstruction is not planned immediately," says Prof Wasike.

For smaller tumours or patients undergoing prophylactic mastectomies due to genetic predispositions, a skin- or nipple-sparing mastectomy may be performed. "Skin-sparing mastectomies remove the breast tissue but preserve most of the skin for future reconstruction," Prof Wasike says. "For nipple-sparing mastectomies, the tumour must be at least two centimetres away from the nipple to ensure it can be safely preserved."

Recovery and Postoperative Care

The typical recovery time for a mastectomy is about two weeks. "Patients can expect to be in the hospital for two days, and the surgery itself takes around one and a half to four hours, depending on the surgeon," Prof. Wasike says. After surgery, patients need to follow a structured recovery plan, which includes regular checkups. "We see patients one week, two weeks, and one month after surgery, and then continue follow-up visits at three months, six months, and annually."

For patients requiring additional treatment, mastectomy is often followed by chemotherapy, hormonal therapy, or radiation therapy. "Healing from the surgery takes about four weeks, and then we assess whether they are ready for the next stage of treatment," he says.

Reconstruction after mastectomy

Reconstruction can often be done immediately after a mastectomy, but not in every case. "If the cancer is in its early stages, we can perform an immediate reconstruction," Prof Wasike explains.

"However, if the cancer has spread to the lymph nodes, and the patient will require radiation, we prefer to delay reconstruction. Radiation can damage implants and make the results less aesthetically pleasing."

When reconstruction is performed, both breasts are typically involved to ensure symmetry. "Even if only one breast is affected, we work on both breasts during reconstruction to maintain balance and symmetry," he notes. "It’s important for the patient’s mental health that the reconstructed breast looks as close as possible to the other one."

Risks and complications

While mastectomy is a safe procedure, there are risks involved. "The most common complications are bleeding and infection, but the biggest concern is nerve injury, which can lead to arm swelling or lymphedema," he says. "We take every precaution to avoid nerve damage and excessive lymph node removal, but patients need to be aware of these risks."

Prof Wasike advises patients to avoid using the affected arm for tasks like measuring blood pressure or lifting heavy objects, as this can exacerbate lymphedema. "We give this information repeatedly before and after surgery to ensure patients fully understand how to care for themselves," he says.

Male breast cancer and mastectomy

Male breast cancer is rare, but the procedure for treating it is largely the same as for women. "For men, we don't perform breast conservation because the breast tissue is too small," Prof. Wasike says. "We always opt for mastectomy, and reconstruction is typically not requested by male patients."

In cases where the cancer has spread from one breast to the other, a double mastectomy may be necessary. "It's rare, but sometimes cancer moves from one breast to the other, usually in later stages," he says.

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