Is it necessary to remove the breast once diagnosed with breast cancer? Is Mastectomy better than Lumpectomy? How should women choose the right treatment while being overwhelmed with the bad news? Clinical oncologist Dr. Choy discusses the four stages of breast cancer and answers common questions pertaining to breast cancer stages and breast cancer surgeries.

Q1: Is breast removal necessary for treating breast cancer?

Dr. Choy: Frequently, the patient’s world is turned upside down once diagnosed with breast cancer. They often feel hopeless about the necessity of Lumpectomy or Mastectomy and believe that they cannot be cured. However, such thinking is not entirely correct, as the surgery is definitely not the last resort. On the contrary, surgery is the first step in treating breast cancer. For women with early-stage breast cancer, Lumpectomy — also known as breast-conserving surgery — is the first option in most cases.

Cancer Staging*

Stage 0
(or, carcinoma-in-situ)
The earliest stage of breast cancer. The cancer cell is still in the outermost layer of skin.
Stage 1The cancer is smaller than 2cm and not yet found in lymph nodes close to the breast.
Stage 2The cancer is 2-5 cm or smaller and affecting nearby lymph nodes.
Stage 3The cancer is larger than 5cm and might’ve spread to lymph nodes close to the breast or chest wall.
Stage 4Cancer has spread to distant parts of the body, such as brain, bones, lungs or liver. It is also known as Metastatic Breast Cancer.

Source: Hong Kong Cancer Fund

*AJCC (American Joint Committee on Cancer 7th edition 2010) TNM 系統

Performing Lumpectomy involves the removal of the breast lump and some surrounding tissue. Patients will be treated with radiation therapy afterward to disrupt the growth of cancer cells, hence reducing the recurrence of cancer. However, there won’t be much help if the cancer has reached Stage IV (please refer to the Cancer Staging), as cancer has spread to other organs.

Q2: Is it safer and better to receive Mastectomy? How do I choose between Mastectomy and Lumpectomy?

Dr. Choy: The decision making for Mastectomy and Lumpectomy is complex, involving the consideration of the site, size and any spread of the tumor, as well as the nature of the tumor and whether it is hormone receptor-positive or HER2-positive. As a doctor, it is not uncommon to find patients subscribe to the idea that “the more removed, the better”, as they fear cancer might spread or recur.

In fact, earlier studies show that there is no difference in survival regardless of whether a woman choose to have a Lumpectomy or Mastectomy. Therefore, the idea that “the more removed, the better” is not correct. There are both pros and cons when it comes to Mastectomy and Lumpectomy, and both involve risks. Common complications include wound infection, lymphedema, shoulder and back pain, and reduced mobility due to nerve damage. In general, these effects are more common after undergoing a total Mastectomy.

Side Effects of Breast Cancer Surgery

LumpectomyMastectomy
Common
Complications
Mild and wound-related complications such as infection or inflammationLymphedema, imbalance of body posture that might cause shoulder pain, nerve damage which leads to partially reduced mobility, etc.
RecoveryOutpatient surgery
Overnight hospital stay is not needed. Shorter recovery time.
Larger wound area and longer recovery time 
Postoperative treatmentRadiotherapy is given after surgery for a period of time.Early-stage breast cancer patients usually do not need to receive Radiotherapy after surgery, especially cancer patients with immune system diseases, avoiding serious complications caused by Radiotherapy
AppearanceAble to conserve the breast and maintain the appearance of size and shape of the breastUnable to conserve the breast.
Breast prosthesis or breast reconstruction is needed in order to help the body be symmetrical again and remain in balance. There will be a horizontal scar on the chest.
TouchHard scar tissue may form in the surgical site after Radiotherapy, hardening and thickening the breastBreast and nipple numbness after surgery
RecurrenceNo guarantee that there will be no risk of recurrenceNo guarantee that there will be no risk of recurrence

Source: Dr. Choy Tim Shing, Specialist in Clinical Oncology, HKIOC

Q3: Is there any other way for breast-conserving?

Dr. Choy: The tumor-to-breast volume ratio is an important factor for breast conservation. In recent years, receiving chemotherapy prior to surgery can reduce the size of the tumor before the tumor removal, thus increasing the chance to conserve breast tissue. This method is usually suitable for patients with Stage 2 or above, those with a larger tumor area, especially the more aggressive and patients with invasive tumors such as Triple-Negative Breast Cancers and HER2-Positive Cancer. For instance, about 20% of breast cancers are HER2-positive.

Almost all women with breast cancer want to keep their breasts. In the past, many patients expressed anxiety about the changes in appearance of their breasts after surgery. For instance, many women fear losing their breasts will affect their female identity adversely cause them to be less attractive to their partners, affecting their intimate relationships. There are also patients who suffer tremendous psychological pressure due to their low self-esteem. In fact, the doctor will communicate with the patient to assess and analyze the impact of the surgery in regards to the patient’s everyday life and potential psychological impact.

After discussions with the doctor, the decision ultimately is between Mastectomy and Lumpectomy. Generally, I would recommend Lumpectomy if the patient’s condition allows it. Of course, there are no doctors who want to perform surgery for the same patients over and over again. If the patient wants to change her mind, it is still not too late to perform an additional surgery after Lumpectomy. However, it is not possible to change your mind once a Mastectomy is performed.

Q4: Are there risks of recurrence after breast removal?

Dr. Choy: There is no guarantee that there will be no risk of recurrence after all types of breast cancer surgery. In order to prevent the recurrence effectively, regular check-up and monitoring are still needed. Except for patients who test positive for a BRCA1/2 or other high-risk gene mutations, the chances of recurrence and the risk of spreading are generally low. Take Mastectomy as an example, the risk of postoperative cancer appearing on the skin or chest is usually about 1% to 3%, but this does not mean all the risks can be ruled out. According to clinical experience, there have been cases of relapse even after 20 years.

Q5: When tested positive for BRCA gene mutation, is it necessary to remove breasts to prevent cancer?

Dr. Choy: Although BRCA gene mutations are associated with breast and ovarian cancer, it does not imply the gene mutations cause cancer. Among the general population, less than 1% of people will have BRCA1 or BRCA2 gene mutations. About 10% to 15% of patients who have been diagnosed with breast cancer are found to have one of the gene mutations. Currently, only about 3% of breast cancers associated with BRCA mutations will be diagnosed before the age of 30. Therefore most women tend to consider preventive surgery after the age of 30.

Studies have shown that preventive Mastectomy can reduce the risk of associated breast cancer by more than 90%. However, it is important to emphasize that a Mastectomy is an invasive and irreversible surgery. Patients should consider their overall health, BRCA mutation status, and family history of cancer before opting for Mastectomy.

When you find out about BRCA mutation, don’t be over-stressed. It is recommended to perform a breast self-examination every month, a clinical breast examination every six months, and a mammogram and magnetic resonance imaging (MRI) every year to help detect the lesion early. It is also an alternative to preventive mastectomy.

Source: Hong Kong Cancer Fund

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Dr. Choy Tim Shing

SPECIALIST IN CLINICAL ONCOLOGY