Surgical Options

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Next week we are meeting with Dr. Funk on Tuesday and Dr. Giuliano on Wednesday. At this point, I'm very close to making the decision to have a double mastectomy, but I want to keep an open mind until I have had those two consultations. However, I also want to be able to explain my thinking to both doctors, so I've spent this week trying to clarify my position:

 1. Because I am so young, I am concerned that my risk of recurrence is higher than average, based on data such as the following: 

 - A 2011 study of 1,210 Spanish patients found that non-metastatic breast cancer diagnosed at a young age (≤40 years) is correlated with higher recurrence rates. 
- A 2010 Canadian study of nearly 600 younger women with a very early stage of breast cancer found that cancer recurred in the affected breast of 18% of women under 45 by an average of nearly eight years after treatment, compared with 11% of women aged 45 to 50. 
- A 2010 Israeli study of breast cancer patients from 24-35 years of age found that after an average follow-up period of 6.5 years, 23% developed secondary breast cancer and 7% were diagnosed with breast cancer in their other breast.

 Even though in general recurrence is supposed to be the same with either surgery, I fear that in my particular case a lumpectomy will not protect me as well as a mastectomy, since local recurrence rate is higher in young women (under 40) treated with lumpectomy compared to their older counterparts, and because young age is an important risk factor in the development of a contralateral breast cancer. 

 Even if I did have a recurrence, I think I would be glad that I did everything that I could now to prevent it – whereas with a lumpectomy I would always question if I could have prevented the recurrence by being more aggressive now.

 2. I am concerned that the irregular shape of my tumor, possible multifocality, and calcifications in my breast will make a lumpectomy less likely to be successful (i.e. I won’t have clean margins). I don’t want to have an unsuccessful lumpectomy and then have to ultimately have a mastectomy anyway.

 3. After meeting with a reconstructive surgeon and reviewing photos of lumpectomy and mastectomy patients, I believe that I will be most satisfied in the long-term with the cosmetic results of a mastectomy. When I finish my treatment next year, and for the rest of my life, I want to be happy with how my body looks.

 4. Of the reconstruction options, I strongly prefer breast implants to flap reconstruction. If I have a lumpectomy now and a recurrence requiring mastectomy in the future, I will no longer be eligible to have implants, because of the damage to my pectoral muscle caused by the radiation.

 5. I prefer to avoid radiation therapy, which will be required if I have a lumpectomy, for a number of reasons:
  • Time involved in treatment (five days a week for approximately seven weeks) 
  • Delay to start of adjuvant chemotherapy 
  • Potential side effects during treatment 
  • Potential long-term effects, including heart damage (the increased lifetime risk for a heart attack or other major heart event in women who have had breast cancer radiation is between 0.5% and 3.5% and is highest among women who get radiation to the left breast)
I may still have to have radiation if I have a mastectomy, if cancer cells are found near the chest wall or if I am node positive. However, I like my chances better with mastectomy.

 6. According to the report from my first mammogram, my "breast tissue is extremely dense, which could obscure a lesion on mammography". At that time, "no definite masses were seen on mammogram", even though the ultrasound on the same day clearly showed the tumor. Because of this, I'm concerned that if my cancer recurs, it won't be detected until the tumor is palpable, as with this one, and that it may metastasize before it is found.

I understand that a mastectomy has downsides, as follows:
  •          Longer recovery from surgery
  •          Additional surgery for reconstruction
  •          Potential complications from mastectomy and/or reconstruction
  •          Partial or total loss of breast/nipple sensation
  •          Additional future surgeries to replace the implants
To me, these are serious, but not enough to outweigh the advantages. I look forward to hearing what the surgeons have to say.

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