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When deciding between a lumpectomy and mastectomy, what are the differences between survival rate and recurrence rate?

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Topics (Tags):

Breast Cancer Recurrence Rate Survival Rate Breast Cancer Breast Surgery Lumpectomy Surgery Breast Cancer Survival Rate Mastectomy Cancer Recurrence Rate

Diseases:

Breast Cancer

Diseases:

Breast Cancer

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Answers (3)

DrAttai (Physician - Surgery - Breast (Verified) ) - 01 / 23 / 2012

1 vote(s) by murray

It's very important to realize that there is NO difference in overall survival if a woman undergoes mastectomy versus lumpectomy + radiation therapy - this is why we can offer women with relatively small breast cancers the option of breast conservation. It is still thought by many women that they will live longer if they undergo mastectomy, but this simply is not true.

With modern treatment, the risk of local recurrence (in the skin or chest wall) after mastectomy is approximately 1-3%. After lumpectomy and radiation therapy it is slightly higher, but with attention to obtaining clear margins, it can be less than 5%.

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member4039 (Survivor (5 - 10 years)) - 01 / 25 / 2012

Follow up question for Dr. Attai....

Interestingly enough, I JUST posted something in my blog about understanding the difference between recurrence and a 2nd primary breast cancer.....

I remember now that I opted for a bilateral mx not for fear of recurrence, but because I was calculating my risk factors for a new breast cancer. There were so many factors to elevate my risk, it seemed the right choice for me with the information available in 2006 when I made my decision.

Can you explain a bit about about recurrent disease and developing a 2nd primary breast cancer. I understand they are two different things-I am being monitored for recurrence and with only traces of breast tissue likely left behind, there is minimal "screening" for a new cancer....

I hope this question makes sense...if not, you can hop over to my blog and get a better understanding of what I'm trying to say....

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2 Replies

Great question @chemobrainfog :)

Would greatly appreciate if you would ask it as a separate question and we will notify @DrAttai.

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murray
- 01/25/2012

Hi there - I read your blog post - You are absolutely correct - there is a difference between recurrence (the initial cancer coming back) and new primary disease (a whole new cancer developing). In a woman that has had a lumpectomy, there is about a 5-10% risk of recurrence (maybe less given modern surgical and radiation therapy techniques, and significantly reduced by the use of anti-estrogen medication) and over her LIFETIME there is about a 10-20% risk of a new breast cancer developing (depending on age at initial diagnosis). The surgery and radiation do not reduce the risk of a whole new breast cancer developing, but anti-estrogen medication does.

In a woman that has undergone a bilateral mastectomy, her risk of recurrence or new primary disease is approximately 1-3% assuming that the majority of breast tissue was removed. Hope this helps!

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DrAttai
- 01/25/2012

member1136 (Caregiver) - 01 / 25 / 2012

And with lumpectomy and clear margins without radiation what is the risk of recurrence? Difference in mortality from mastectomy?

What do you find is the rate of breast lymphedema (not upper limb lymphedema) and delayed breast cellulitis among your lumpectomy + radiotherapy patients?

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3 Replies

For invasive cancer, if no radiation therapy is performed after lumpectomy, the risk of local recurrence (the cancer coming back in the breast) can be as high as 30-50%. One in 4 patients that locally recur will die from their disease (because they go on to develop metastatic disease). No mortality difference between lumpectomy and mastectomy. I hope this clarifies things for you.

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DrAttai
- 01/25/2012

I would find it more understandable if the statistics given were all in the same terms, i.e. absolute and not relative, and on the same basis, e.g. "is approximately", "can be less than", "can be as high as" and for the same patient population, i.e. "small breast cancers" or "invasive cancer". The inclusion of post-mastectomy hormonal therapy in the mix can also significantly change the picture. Let me explain my position:

Take the population of patients with "relatively small breast cancers":

What is the mortality of those who undergo (BCS) alone VS (BCS + RT) VS (BCS + HT) VS (BCS + RT + HT)?

My real concern is that many of the patients with "relatively small breast cancers" might do quite well with breast conserving surgery (lumpectomy) and hormonal therapy without radiotherapy. And the real forgotten patient in all of these neat discussions of (BCS + RT) VS (Mastectomy) are the patients who endure RT unnecessarily and then develop breast and truncal lymphedema, arm lymphedema or both -- conditions which require lifelong daily treatment and are major detriments to the patient's quality of life.

So it behooves our medical community to include this additional dimension in their discussions, reflecting the effect of hormonal therapies on the traditional recurrence rate/mortality discussions and recognizing and discussing with their patients the long-term sequela of the proposed treatments.

Take the population of patients with "relatively small breast cancers":

What is the mortality of those who undergo (BCS) alone VS (BCS + RT) VS (BCS + HT) VS (BCS + RT + HT)?

My real concern is that many of the patients with "relatively small breast cancers" might do quite well with breast conserving surgery (lumpectomy) and hormonal therapy without radiotherapy. And the real forgotten patient in all of these neat discussions of (BCS + RT) VS (Mastectomy) are the patients who endure RT unnecessarily and then develop breast and truncal lymphedema, arm lymphedema or both -- conditions which require lifelong daily treatment and are major detriments to the patient's quality of life.

So it behooves our medical community to include this additional dimension in their discussions, reflecting the effect of hormonal therapies on the traditional recurrence rate/mortality discussions and recognizing and discussing with their patients the long-term sequela of the proposed treatments.

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member1136
- 01/25/2012

Unfortunately, a lot of the studies are either looking at either DCIS or invasive cancer; many of the studies looking at invasive cancer do not necessarily differentiate between size of the cancer (except for T1 tumors <2cm or T2 tumors 2-5cm) and many of the older studies did not stratify for the biologic behavior of a cancer, such as ER/PR and Her2/neu status. In addition, you are correct that modern use of anti-estrogen medications such as tamoxifen and aromatase inhibitors will further reduce the risk of recurrence.

The NSABP B-06 trial, published in 1984, demonstrated no difference in survival in women who underwent modified radical mastectomy (removal of the breast and underarm lymph nodes but not the pectoralis muscle), lumpectomy, axillary dissection, and postoperative radiation, or lumpectomy without radiation therapy. However, the lumpectomy alone group did have a higher rate of local recurrence (39% compared to 14%), which gives the rational for our current practice of post-lumpectomy radiation (http://www.clinmedres.org/content/1/4/309.full). Some overview analyses have demonstrated that local recurrence does result in an increased mortality over a long period of follow up (http://www.ncbi.nlm.nih.gov/sites/entrez/16360786?dopt=Abstract&holding=f1000,f1000m,isrctn). The NCCN guidelines do discuss certain subsets of women that may be able to avoid radiation therapy (http://www.nccn.com/files/cancer-guidelines/breast/index.html#/68/).

There is no doubt that radiation therapy, surgery, and our other treatments cause harm and unfortunately, we are not always able to predict (in terms of radiation-related complications) who will develop a firm fibrotic painful breast, who will develop lymphedema as a result of the therapy, and other potential complications. As we learn more about the biology of an individual woman's specific cancer, we should be able to provide more detailed counseling to a woman regarding HER specific tumor, HER risk of recurrence, and then make decisions about what treatment will provide the best option for long-term disease free and overall survival with a minimal or acceptable risk of complications.

The NSABP B-06 trial, published in 1984, demonstrated no difference in survival in women who underwent modified radical mastectomy (removal of the breast and underarm lymph nodes but not the pectoralis muscle), lumpectomy, axillary dissection, and postoperative radiation, or lumpectomy without radiation therapy. However, the lumpectomy alone group did have a higher rate of local recurrence (39% compared to 14%), which gives the rational for our current practice of post-lumpectomy radiation (http://www.clinmedres.org/content/1/4/309.full). Some overview analyses have demonstrated that local recurrence does result in an increased mortality over a long period of follow up (http://www.ncbi.nlm.nih.gov/sites/entrez/16360786?dopt=Abstract&holding=f1000,f1000m,isrctn). The NCCN guidelines do discuss certain subsets of women that may be able to avoid radiation therapy (http://www.nccn.com/files/cancer-guidelines/breast/index.html#/68/).

There is no doubt that radiation therapy, surgery, and our other treatments cause harm and unfortunately, we are not always able to predict (in terms of radiation-related complications) who will develop a firm fibrotic painful breast, who will develop lymphedema as a result of the therapy, and other potential complications. As we learn more about the biology of an individual woman's specific cancer, we should be able to provide more detailed counseling to a woman regarding HER specific tumor, HER risk of recurrence, and then make decisions about what treatment will provide the best option for long-term disease free and overall survival with a minimal or acceptable risk of complications.

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DrAttai
- 01/28/2012

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Latest Activity: 01 / 28 / 2012
Views: 232
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