When is mastectomy advised for breast cancer treatment?

From the Guidelines

Mastectomy is advised for breast cancer when breast-conserving surgery (lumpectomy) is not appropriate or when it's the patient's preference after understanding all options, particularly in situations such as large tumors, multiple tumors, inflammatory breast cancer, previous radiation, genetic mutations like BRCA1/2, or positive margins after lumpectomy. Specific situations that typically warrant mastectomy include:

• Large tumors relative to breast size
• Multiple tumors in different areas of the breast
• Inflammatory breast cancer
• Previous radiation to the affected breast
• Genetic mutations like BRCA1/2 that increase recurrence risk
• When radiation therapy cannot be given after lumpectomy
• Positive margins after multiple attempts at lumpectomy, meaning cancer cells remain at the edge of removed tissue 1. Some patients choose mastectomy over lumpectomy plus radiation for personal reasons, including anxiety about future screenings or recurrence. The decision between mastectomy and breast conservation should be made through shared decision-making between the patient and healthcare team, considering both the medical aspects and the patient's values and preferences regarding body image, recovery time, and need for additional treatments 1. Key factors influencing this decision include the stage of the cancer, the size and location of the tumor, the patient's overall health, and their personal preferences. It's also important to consider the potential benefits and risks of each option, including the risk of recurrence, the need for additional treatments, and the potential impact on quality of life. Ultimately, the decision to undergo mastectomy or breast-conserving surgery should be based on a thorough discussion of the available options and the patient's individual needs and preferences.

From the Research

Indications for Mastectomy

Mastectomy is advised for breast cancer treatment in certain situations, including:

• Factors that increase the risk of local recurrence, such as extensive malignant-type calcifications visible on the mammogram, multiple primary tumours, or failure to obtain tumour-free margins 2
• Physical disabilities that preclude lying flat or abducting the arm, preventing the use of radiotherapy 2
• Absolute contraindications for radiotherapy, such as pregnancy or previous irradiation of the breast, or relative contraindications, such as systemic lupus erythematosus or scleroderma 2
• Large tumour size in proportion to breast size 2, 3
• The patient's clear preference for mastectomy 2
• BRCA1 or BRCA2 germline mutation carriers, where prophylactic mastectomy can reduce the risk of breast cancer development by 90 percent or more 4, 5

Contraindications for Breast-Conserving Surgery

The following factors are not contraindications for breast-conserving surgery:

• The presence of a centrally located tumour mass 2
• Axillary lymph-node involvement 2
• The presence of breast implants 2

Surgical Techniques

Different surgical techniques can be used for mastectomy, including:

• Nipple-sparing mastectomy (NSM), which provides superior cosmetic results and is considered the gold standard for prophylactic mastectomy 4, 5
• Skin-sparing mastectomy, which preserves the skin envelope and can be used for immediate breast reconstruction 5

Patient Considerations

When considering mastectomy, patients should be informed about:

• The potential benefits and risks of the procedure, including the risk of local recurrence and surgical morbidity 2, 5
• The availability of breast reconstruction options, including immediate reconstruction with tissue expander/implant based procedures or autologous tissues 4, 5
• The importance of genetic counseling and testing for BRCA1/2 mutations, which can inform surgical decision-making and risk management strategies 5, 6