Total Mastectomy and Breast Conservation Surgery

        Charles M. Balch, MD, PhD (h.c.), FACS

        (Professor of Surgery,University of Texas Southwestern Medical Center,Dallas,USA)

        Editor-in-Chief, Annals of Surgical Oncology

        Breast cancer patient usually have a choice about the type of mastectomy that is best for them.With multidisciplinary breast cancer treatment planning, each patient can have a “personalized therapy” approach that takes into account the stage and biology of their cancer, their anatomic size of the breasts, and their own perception of an acceptable cosmetic outcome, which at a minimum, achieves symmetry of the breasts that allows them to comfortably wear their usual clothing after their treatment is completed. This decision, with guidance from their physician, should account for both the best medical treatment plus the patient’s own “quality of life” issues with regard to their own body image, partnership relationship, style of dress and other factors. The choices are either: 1) total mastectomy with the option for breast reconstruction, or 2) partial mastectomy (lumpectomy) with breast irradiation. Both treatment approaches have the same survival rates, but the outcomes may be very different based on a perception that belongs to the patient! The many advances being made that enable us to better customize our multidisciplinary management to improve the quality and quantity of breast cancer patients regardless of their presenting stage of breast cancer.

        In circumstances where a total mastectomy is recommended—either for medical reasons or the patient’s own choice—consideration should be given to performing a “skin-sparing mastectomy” that preserves the skin envelope over the breast tissue (including the nipple areolar complex in some patients) through smaller incisions and then using either a breast implant or an autologous flap (usually from the abdominal wall) to fill in the cavity where the mastectomy was performed.

        The skin-sparing mastectomy achieves the most natural appearance of the reconstructed breast and the best cosmetic results, compared to a delayed reconstruction performed some weeks or months later. Even patients who have locally advanced breast cancers who are responding to neoadjuvant chemotherapy, or those who have had prior radiation therapy to the breast, can successfully have breast reconstructive surgery without any increased risk for a recurrence in the reconstructed breast. Recurrences in the reconstructed breast are 5% on the average, with higher rates in women with more aggressive biological characteristics of their breast cancer. Reconstructive breast surgery has some risks for postoperative complications, which are usually relatively modest and manageable. Patients at increased risk for skin or infectious complications after reconstructive surgery are those who smoke >10 cigarettes a day, those who are obese, who have anemia or diabetes.

        In circumstances where breast conservation therapy is recommended –usually because of the patient’s choice- a partial mastectomy (lumpectomy) is performed with clear margins followed by 6 weeks of whole breast irradiation. The magnitude of the “safe” surgical margin is controversial, but all agree there should be no tumor at the surgical margins.

        The goal of making the final decision about surgical management of the breast cancer—in partnership between the physician and each breast cancer patient—is to maximize the long-term results with regards to local disease control, symmetry of the breasts, cosmetic appearance, and emotional state. The patient must take the responsibility to be an informed about the pros and cons of these treatment options in order to participate in decision-making with regard to their breast management. To do this, we need to ensure that all women have access to educational material that is evidence-based, understandable, and balanced.

        In conclusion, surgeons are constantly making recommending to are cancer patients that balance both quantity and quality of life; nowhere is this more important in breast cancer.