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Interviewer: What's the better option for breast cancer treatment? Is it a mastectomy or a lumpectomy? Turns out it is a very personal and it can be a very difficult decision to make. We'll look at some of the reasons why on The Scope.

Announcer: Medical news and research from University of Utah physicians you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: By the time you have to make a decision whether you should have a mastectomy or a lumpectomy to treat your breast cancer, you've likely to have already been on quite an emotional journey, so things can be pretty scary and confusing. I'm going to try to add some facts to the equation. I'm going to try to help you make the decision that's right for you. We're with Dr. Cindy Matsen. She's a breast cancer surgeon at Huntsman Cancer Institute. So when it comes to breast cancer, is it always a surgical procedure. Is it going to be the mastectomy or lumpectomy or is there something else somebody needs to consider?

Dr. Matsen: So for the majority of breast cancer patients who have been diagnosed with cancer that has not spread to other parts of their body, surgery will definitely be a part of their treatment.

Interviewer: Okay, so that's just going to be a part of it. No way around it at that point. What's the biggest struggle a woman faces when making this decision between the two procedures?

Dr. Matsen: So there's a lot of different things women take into consideration when they're thinking about what type of surgery they would like to have for their breast cancer. One of the first things to emphasize is that there are certain women who will not have a choice. The majority of women do, but about 20% of women will require a mastectomy just based on how big their tumor is or based on other factors related to their disease. So for those women, we tell them upfront, "The option for you is very limited." But for that 80% of women, there is a choice.

Interviewer: Okay, is it usually a difficult choice for most women or is it pretty simple? What's your experience been with that?

Dr. Matsen: My experience with it is that most women struggle with that.

Interviewer: Why is that?

Dr. Matsen: I think it's because they get a lot of different information from a lot of different resources and it's a hard time processing what's going to be valuable for them. And it's very difficult when you're given a cancer diagnosis, "Okay, well what's going to happen 5, and 10 and 15 years from now?" And how do I make a decision that I'm going to be happy with at that time because right now the only thing that most women are thinking about is that they want to be cured. The good thing about the options for surgery are whether you have a mastectomy or a lumpectomy which is also called Breast Conservation Surgery, the outcomes, meaning that the likelihood you are going to survive your cancer, is the same regardless of which procedure you cho0se.

Interviewer: So neither one is going to offer a benefit in outcomes?

Dr. Matsen: Right, in terms of survival.

Interviewer: So I scratch my head, why would a woman want a mastectomy? Why would a woman want to go to that extreme at that point is both of them are the same.

Dr. Matsen: Well, let's first just describe what the procedures are so we have a good understanding of what it is that it means to have a mastectomy or a lumpectomy. A mastectomy removes all of the breast tissue, and if you don't get reconstruction, it leaves you with just a flat chest wall. Now women who get a mastectomy obviously have reconstructive options, but it is important to understand with breast reconstruction, that simply creates a breast shape. It doesn't recreate a breast. So it doesn't function like a breast. It doesn't feel like a breast. But it does help with body image, and it does help with how your clothes fit and how you feel with losing a body organ.
A lumpectomy on the other hand retains most of the breast tissue, but removes the tumor and a rim of normal tissue around it. Even with a lumpectomy there will be some changes with what your breast looks like, so there will be a scar. There will be some changes in the contour of the breast and almost always for breast cancer, lumpectomy is followed by radiation, and radiation can also have a significant impact on what your breast looks like afterwards.

Now the reason why women may chose to have a mastectomy versus a lumpectomy is that there is a slight difference in what we call the risk of recurrence and that means cancer coming back within the chest wall or the breast. Even with a mastectomy, it's not perfect. So even if you get a mastectomy there is still a chance that cancer can come back in the chest wall. That chance is low. It's around 1 to 3%. That's what I typically quote patients.

Interviewer: Do you feel that is statistically low.

Dr. Matsen: Yes it is. The ranges can vary depending on what study you are looking at. In general, it's around 1 to 3% and that's at 10 to 15 years out from your surgery.

Interviewer: Oh okay.

Dr. Matsen: And that's based on data that is about 30 years old now, so that's very mature data that we feel very confident about. For breast conservation surgery, we know that in modern data, meaning that in the last 10 years or so, with the kind of radiation we give, with the kind of medications that we use for treating breast cancer now, that the risk of recurrence after 10 to 15 years is probably somewhere in the 5 to 7% range, and that's much lower than what it was with older data. So there is a difference, but it is very small. So you're look on the order of 4%.

Interviewer: Is that a factor that should be considered into a woman's choice at that point? It is a small difference. Are they essentially equal in your mid?

Dr. Matsen: In my mind, they are essentially equal.

Interviewer: Okay.

Dr. Matsen: However, there is sometimes a psychology benefit that women feel to getting a mastectomy because it reduces the risk maximally.

Interviewer: Sure.

Dr. Matsen: One of the interesting things when you look at surgical choice, is that what happens in America is quite different than what happens in other parts of the world. America seems to be more driven to bigger surgery and this belief that bigger may be better. We don't necessarily feel that, as breast cancer providers, feel that's true. But there is a misconception, that by having a mastectomy, you're doing more to treat your cancer.

Interviewer: So, I'm finding myself confused. I can only imagine at this point, a woman who has to face this decision, what she is going through. Because still there is that slight chance, and what's the impact on the mental, and then there's the visual and the appearance. How do you help a woman make the right decision for her?

Dr. Matsen: That is one of the most difficult challenges we face. When a woman comes in to see me, one of things I tell them is that every woman feels differently about their breasts. And every woman approaches their decision making and breast cancer differently. I can't be the one who tells them the right or wrong thing to do. And like I said from a medical point of view, these things are equivalent in my mind. So it has to come down to other factors that are important to them.
We haven't mentioned this yet, but a lot of women are concerned with the other breast. What we are typically seeing nowadays is that people are not necessarily choosing between just having the cancer side taken off, but they are actually making a decision between having both breasts taken off versus just having a lumpectomy. The conversation gets very complicated because we have to talk about things that are outside of what we are concerned about medically.

What we are really talking about is, what are the concerns psychologically. What are the sexual, physical, psychological implications of having your breasts removed? How are you going to feel 10 or 15 years from now? If the cancer does come back, are you going to feel responsible because you feel like you maybe should have had more surgery even though we are telling you that's not the case.

So, it's a really difficult decision for women to make. We try to provide them with the best information possible to help with that, and help identify the values that are most important to them in deciding. But in the end, the woman really has to go home and contemplate on her own what information we've given her and what's important to her. It's a very difficult decision, and I think there are a lot of good resources out there, but you do have to be a little bit choosey about which ones you look at.

The Komen Foundation tends to have some very good resources. The American Cancer Society has some very good resources. There are a lot of support groups out there for women with breast cancer. And some of these decisions are very different based on a woman's age, too. If you are a younger woman, the decision might be very different if you're a younger woman.

There are support groups that are age specific, and some of those can be found through social media. Every woman, like I said, approaches this differently. A lot of women talk to a lot of other patients and people who are around them because breast cancer is a very common disease. There are a lot of people, when a woman is diagnosed, who come out of the woodwork that tell them their story.

Interviewer: Do you have a team approach Huntsman Cancer Institute? Do you have someone to help with that mental aspect of it?

Dr. Matsen: Absolutely. We actually have a social worker in all of our clinics who is incredibly helpful with helping to identify the other concerns that patients have outside of just the medical concerns, and helping to address those and give them resources to help with some of those decisions.

Interviewer: So it sounds like what we've learned is nobody else can make the decision. Each woman has to make her own decision. It's probably going to be a difficult decision. Best thing to do is talk to other survivors. Get out there. Read some reputable resources. Use a social worker at a place like Huntsman Cancer Institute to help gather all that information to figure out what's important to you. And it's not going to be easy.

Dr. Matsen: It's not easy.

Interviewer: But all the other things aside, I think the important thing too, from what I'm hearing from you, that regardless of if it is a mastectomy or a lumpectomy, they are going to provide the similar outcomes. So at least that's one thing you can kind of push aside and not worry about as much.

Dr. Matsen: Right. In terms of the cancer, similar outcomes. I wish hat I could make it easy, but it's just not. And it's a very vulnerable time period. It's a new diagnosis, and women are scared. It's a very hard time to make a decision like that, and we try to give them the most support possible, so that they can make a decision they are going to be comfortable with in the long term.

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