Should I just jump straight to the mastectomy/ies?

kuriatas

I have recently had a lumpectomy and sentinal node biopsies which were negative.  I am a stage 2a for the size, which is 2.2cm.  While my margins were clear, one side had only a 1mm clearance and my surgeon states that he would rather not re excise that area because it is very close to the skin and would likely cause a nipple defect if he takes more tissue.  He feels radiation should cover it ok.  I haven't seen the radiation oncologist yet, but I keep wondering if I should just go for the whole mastectomy, perhaps trying for a nipple sparing or skin sparing procedure, and perhaps doing the other side prophylactically as well.  I am concerned about irradiating my breast, then having a recurrence because of the narrow margin and then having a less than good reconstruction because of the changes the radiation will make to my breast.  I keep feeling like just going for it right away might give me a better result, and allow me to not have radiation at all.  Another concern is that my breast MRI states that I have a moderate amount of "foci" which may make diagnosing smaller cancers more difficult in the future.  I am still gathering data and going for a second opinion at Mayo Clinic before I decide.  Just wondering if any of you were faced with a similar situation and what choices you made.

momand2kids

Hi

Not in your exact situation but had the same size and grade.  I think you do need to talk to the radiation oncologist.... he/she can really give you some guidance here.... 

If you read some of Beesie's posts about mastectomy vs lumpectomy, that could be of some help.  Remember that some people still have radiation with an MX and recurrence is also possible with an mx.  So, it is not an automatic out..... 

I did not have an mx, so I cannot speak to it--but I will say, whatever decision you make has to be one that you can live with-- and if you talk to the radiation onc and still have concerns, I would suggest that you listen to your instincts..... 

Good luck....

Lojo

Hi - 

I didn't have the option for a lumpectomy as my tumor was larger and multifocal. I had hoped to avoid rads after the mastectomy, but my margins were very close and I ended up needing radiation anyway, so the mastectomy is no guarantee you won't need rads. 

No easy decisions - from every thing I've read, though, lumpectomy + rads provides equivalent reduction in local recurrence risk to mastectomy + rads - the problem is that sometimes rads are omitted after mastectomy  - and there is still some controversy over when to do rads post-mastectomy. As for the prophylactic mx - there are many things to consider before you go that route. 1) Do you have a significant family history? 2) Have you already had lots of biopsies to the healthy breast? 3) Did mammograms pick up this cancer? 4) Are you ER+? (if so, then tamoxifen or AI's will reduce contralateral recurrence rate) 5) How old are you? (younger = longer timeline for contralateral recurrence) 

I went with the prophy mx because 1) I have a significant family history - mom was dx pre-menopausal and died from BC in her 50s,  (even though I'm BRCA neg), 2) I'm relatively young (41), 3) I have ILC (somewhat higher chance of contralateral recurrence than IDC), 4)mammograms and ultrasounds didn't pick up the 4cm tumor and it wasn't detected until it was palpable, 5) I have (had!) dense breast tissue (though tamoxifen would have possibly helped this if I'd kept the other breast).

If I'd had fewer of  these risk factors (most importantly a negative family history) I wouldn't have done the prophy. I'm happy with my decision, though I occasionally mourn the loss of my healthy side (more so than the cancer side, which I know had to go). It's a big decision - and although I've not had reconstruction, reconstruction from what I've read has its own significant challenges.

Good luck!

kuriatas

Thank you for your posts.  I have a niece who was diagnosed with BC at 36, and her mother, my sister, died from ovarian/colon cancer (it was never definitively identified which type due to late diagnosis.)  We also all grew up in a rural area where there was a lot of crop dusting right across the street from us.  My niece is BRCA negative and I don't have my genetic results back yet.  My tumor was not seen on mammogram even though I've been diligent since turning 40 about getting them every year (I'm 47.)  I noticed a very subtle change in my breast appearance and my gyn couldn't tell what she was feeling as I have dense, lumpy breasts.  Fortunately the radiologist who read the mammogram decided to do an ultrasound even though it came back negative, and the tumor was clearly seen.  I feel like I'm in the exact middle regarding my future risks and it's so hard to know what the "right" choice is.  I'm looking forward to some more appointments this week and hopefully things will start to fall into place and tip me one way or the other.  I appreciate hearing all your stories!