Mario…. I’m really sorry.
The disembodied voice came over the phone at 2 pm in the middle of a busy ER where, just moments before, I was the doctor. And now, suddenly, I’m the patient.
I’m sure the disembodied voice of my doctor said the word cancer. I’m sure we discussed hormone sensitivity, grade, and the other markers of a breast cancer diagnosis, but all I remember is standing at my charting computer, outside of room #8 in the Emergency Department, crying. I’m sure that somehow, I finished my shift taking care of patients and went home to prepare for becoming a full-time patient myself.
The first days of any cancer diagnosis are frightening, confusing, and full of urgent, bewildering decisions. They are truly emotionally worse than any other time during cancer treatment. One of the decisions many women face when hearing the words, “breast cancer,” is what type of surgery to have as breast cancer treatment begins- lumpectomy versus mastectomy.
For some women, mastectomy is the only option given the tumor size or type. Genetic testing for a woman’s susceptibility to cancer may also influence the decision. However, for many, many, many more, they are given a choice between mastectomy (one breast or both breasts being surgically removed, with or without reconstruction (multiple options there too)) OR lumpectomy (when a tumor and some healthy tissue is removed.) and radiation.
Decisions about breast cancer treatment have to be made during a time of intense fear and emotional reactivity. Our immediate response is often “Just cut ‘em off”. Women may feel safer with no breasts. We may want them both gone just in case the other one tries to turn on us. We feel death breathing down our neck, and if the sacrifice we have to make is our breasts, then so be it.
For those of us who DO have a choice about what surgical treatment to pursue, I want to examine some of the issues that surround the decision to have a lumpectomy or a mastectomy.
Each individual needs to weigh the risks and benefits of their choice, given their individual circumstances, and in the end, they are the only one who has to live and die with the decision. Each individual is the ONLY person who can make the right breast cancer treatment decision for themselves. However, making the right decision involves knowing the facts. It involved challenging your irrational fears, and magical thinking. And THAT is scary too. Magical thinking is, at this point, the only thing that allows anyone with a new breast cancer diagnosis to get any rest.
The first issue I want to talk about is women’s emotional relationship with our breasts. In Western culture, breasts are a sex symbol. Breast cancer is more common in women as we age, as are saggy boobs. We, as a culture, hate our saggy boobs. Cosmetic boob jobs are big business. The idea that you can get a “free boob job” and get “perkier boobs” due to your breast cancer is rampant and unfortunately suggested to many breast cancer patients by well-meaning but insensitive people. It is true that many breast cancer survivors are wandering around with gravity-defying roboboobs after breast surgery. But make no mistake- breast cancer treatment is NOT a free boob job.
The second issue I want to discuss is the scope of the two surgeries. Mastectomy is a huge surgery. The recovery is prolonged. There are drains in place for days to weeks. There is general anesthesia, an inpatient hospital stay, significant pain, and opportunity for infection and skin breakdown. If you decide to remove both breasts (for symmetry or out of fear your other breast will become murderous), double the wound-related risks. Then add more surgery, with its associated risks, for reconstruction, if you decide to do that (we won’t even go into all the options here as it is beyond the scope of this blog). Suffice it to say that the decision to do a mastectomy is a giant life-changer both in the short term and the long term. Additionally, insurance companies are starting to refuse payment for the nonaffected breast surgery in the case of people who want both breasts removed.
In contrast, lumpectomy is a tiny, same-day surgery, and, depending on your job, you can be back at work in the next day or two with a slightly sore and beat up looking boob. Of course, there are infection risks, but they are smaller than the risks when drains are in place, like during a mastectomy. The recovery from a lumpectomy is a snap. Honestly, having my port for chemo inserted, was WAY more of a big deal than my lumpectomy as far as pain and recovery go.
But hey, if a mastectomy is gonna save my life, it’s totally worth it, right?
Well here’s the kicker. If you are given a choice of mastectomy vs lumpectomy and radiation, THERE IS NO DIFFERENCE IN MORTALITY (death,) and for most people, only a tiny difference in local cancer recurrence rate between the two procedures (for me a 1% difference.)
So, the benefit of feeling safer with no breasts is really an illusion. There is NO difference in your chance of dying and minimal difference in your chance of getting cancer again whether you get a lumpectomy with radiation or a mastectomy.
So, why would anyone have the bigger surgery (a mastectomy) when the smaller surgery (a lumpectomy) is just as good?
- People feel safer. It’s an illusion, but that doesn’t make it not important. Mental health and comfort with your decisions around your cancer treatment are incredibly important. We know that both depression and anxiety are increased in breast cancer survivors. Anything breast cancer survivors can do to take back control, to make choices that feel right to us, is important.
- If you have a bilateral mastectomy, there is no more breast screening done and no twice-yearly scanxiety. (Anxiety related to scans and tests)
- You OFTEN don’t need radiation if you choose to have a mastectomy. If there is one intellectually reasonable argument for the bigger surgery, this is it.
- You have the opportunity to have gravity-defying roboboobs- or no boobs or one boob. Whatever you want. Sometimes you can even get a side order of tummy tuck (with a DIEP Flap).
Why have the smaller surgery (a lumpectomy)?
- Smaller surgery and fewer surgical risks
- Improved healing time
- More natural feel to your boobs and the possibility of retaining sensation in your nipple.
- No change in mortality and minimal change in recurrence.
- No insurance hassles.
Having a lumpectomy over a mastectomy however calls on you to really examine your relationship with your breasts, your fear of recurrence, and your belief in statistics and data over emotion. It is a leap of faith to live with your breasts, to build a relationship with them, to continue to love and honor them, to not curse them, and to trust them.
These decisions have to be made in the heat of one of the most emotional times in many women’s lives. For me, the data supported getting the smaller surgery. My challenge was to then come to terms with living, unafraid, with my breasts. I have accepted that challenge. Despite the mammograms and ultrasounds and repeat surgery to check out weird calcifications, I am happy with my decision. When I stand naked and look at myself in the mirror, I thank my breasts for their service and admire them more now than I did 30 years ago.
My advice to all women facing this decision about breast cancer treatment is to look at the DATA on mortality and local recurrence for your specific case, understand the difference in the extent of the surgical options, then have a difficult talk with yourself, knowing who you are, and how you handle anxiety, and make the right breast surgery treatment decision for YOU.
