5cm tumor - lumpectomy vs. Mastectomy

Walden1

I have two tumors close together in the 3 and 4 o'clock position. Together they cover a 5cm (2cm each) area. I have DD breasts but my surgeon says I need a mastectomy. I don't doubt his recommendation, but some people on this site seem to have lumpectomy with tumors of a similar size. Perhaps they have a more favourable location. I thought maybe if I had a reduction in addition to the lumpectomy I could avoid mastectomy but he said no there won't be enough tissue left for a good cosmetic outcome

Would love to hear from anyone in my similar situation or anyone with a 4-5cm tumor who still achieved a lumpectomy and what factors made it possible.

Ingerp

It might be the location that's the problem. My lumpectomy two years ago was an 8cm x 6cm x 3.3cm chunk. Yes, I have what my BS called a "shark bite" but it's low enough on the breast that I don't notice it unless I look in a mirror (and who at my age does that??). FWIW, my family is known for wearing our scars proudly, whether from surgery or injury. My RO asked me two years ago if I was considering getting the other side worked on to make them more symmetrical and I said, "Heck no." My more recent lumpectomy on the other side is in a different location so I'm kinda mismatched but who cares?

Walden1

Thanks Ingerp! When you say low enough, do you mean the bottom quadrant? Do you mind if I ask what cup size you where before surgery?

Denise-G

I had a 6 cm tumor in 42DD breast. Lumpectomy was never an option because my large tumor was closer to the chest wall. That's why I never felt it.

Walden1

Denise-G: My area of disease is similar but not near the chest wall. The doctor says even with a reduction surgery I won't have enough tissue left to make s proper breast. I think oncoplastic techniques have been used for larger tumors to get good cosmetic results but the data on reoccurrence and OS seems to be limited, from what I've read online. For this reason I'm thinking mastectomy is my best choice even if I had a doctor willing to do an oncoplastic procedure. Did you ever discuss oncoplastic with your medical team

ElaineTherese

Hi!

I had a 5 cm+ tumor and opted for a lumpectomy. However, I did my surgery after chemo, and my tumor had disappeared on the post-chemo MRI and PET scan. My surgeon did end up taking a golf-ball sized ball of tissue around my surgical clip; I do have a scar above my nipple, but you can't really notice the different boob sizes looking at me with my clothes on. Good luck!

Ingerp

Walden—I’d say just barely in the bottom quadrant. I think it would be referred to as 3:00? Or just a little lower—I could see it from the side but not from the top as I look down.As to cup size—I’m honestly not sure. Maybe a C. I generally wear sports bras. My more recent lumpectomy was smaller but there is still plenty of both breasts left.

Reikion

Hi Walden1,

I had oncoplastic surgery - a lumpectomy (left) with a reduction on the right side. My lump was only about 1 cm (just below the nipple) but they took out over 13 cms of DCIS (somewhere between 5 o'clock and 2 o'clock). I went from a DD to a C.

It was one surgery about 5 hours long - breast surgeon for the first 30 min or so and then the plastic surgeon. Plastic surgeon took out additional margins after breast surgeon. The surgery went well with clear margins and I hope the same for you whichever route you choose.

I was considering just a lumpectomy but the oncoplastic reduction was suggested by the breast surgeon on the tumor board (surgeon, oncologist and radiologist).

Best,

Reikion

ruthbru

4 cm, 6 o'clock position. I had a lumpectomy. I am a 36C so if I were running around naked you would see that I'm lopsided and my nipples don't match up.......but I look perfectly fine in a good bra, and even a sports bra.....so who cares? (Not me, and that's all that matters). I would be very, very offended by a doctor who said the word 'deformed' as a reason for a mastectomy. That is very insulting to all women. No one is absolutely symmetrical naturally and you can have surgery after surgery and not be symmetrical either. There are also many women who have a mastectomy and choose, for whatever reason, not to reconstruct.....they are NOT deformed either. Any surgery can have unintended side effects, most people who have reconstruction are going to need multiple procedures, and many who have reconstruction are not overly thrilled with the results. The more invasive surgery you have, the more money the surgeon makes off of you. I'd get a different surgeon. When I was first diagnosed I talked to a friend who was a surgical nurse and who had breast cancer about 30 years before when the only choice was to have a mastectomy. Later, when reconstruction became available, she did that. So, she has seen breast cancer from both side of the operating table. When I asked her advice about what to do, without skipping a beat, she said, "If having a lumpectomy is a choice, TAKE IT!".

*There are situations when a mastectomy is the only, and/or the reasonable choice, but saying to a patient that they'll be deformed if they don't have one is not one of them!!!!!

ruthbru

Here's a more impartial look at the issue. Beesie is one of the resident experts on the boards. I am copying a very well thought out post she did on this topic.

"Some time ago I put together a list of considerations for someone who was making the surgical choice between a lumpectomy, mastectomy and bilateral mastectomy. I've posted this many times now and have continued to refine it and add to it, thanks to great input from many others. Some women have gone through the list and decided to have a lumpectomy, others have chosen a single mastectomy and others have opted for a bilateral mastectomy. So the purpose is simply to help women figure out what's right for them - both in the short term but more importantly, over the long term.

Before getting to that list, here is some research that compares long-term recurrence and survival results. I'm including this because sometimes women choose to have a MX because they believe that it's a more aggressive approach. If that's a big part of someone's rationale for having an MX or BMX, it's important to look at the research to see if it's really true. What the research has consistently shown is that long-term survival is the same regardless of the type of surgery one has. This is largely because it's not the breast cancer in the breast that affects survival, but it's the breast cancer that's left the breast that is the concern. The risk is that some BC might have moved beyond the breast prior to surgery. So the type of surgery one has, whether it's a lumpectomy or a MX or a BMX, doesn't affect survival rates. Here are a few studies that compare the different surgical approaches:

Lumpectomy May Have Better Survival Than Mastectomy

Twenty-Year Follow-up of a Randomized Trial Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus Irradiation for the Treatment of Invasive Breast Cancer

Twenty-Year Follow-up of a Randomized Study Comparing Breast-Conserving Surgery with Radical Mastectomy for Early Breast Cancer

Now, on to my list of the considerations:

• Do you want to avoid radiation? If your cancer isn't near the chest wall and if your nodes are clear, then it may be possible to avoid radiation if you have a mastectomy. This is a big selling point for many women who choose to have mastectomies. However you should be aware that there is no guarantee that radiation may not be necessary even if you have a mastectomy, if some cancer cells are found near the chest wall, or if the area of invasive cancer is very large and/or if it turns out that you are node positive (particularly several nodes).
• Do you want to avoid hormone therapy (Tamoxifen or an AI) or Herceptin or chemo? It is very important to understand that if it's believed necessary or beneficial for you to have chemo or take hormone therapy, it won't make any difference if you have a lumpectomy or a mastectomy or a bilateral mastectomy. (Note that the exception is women with DCIS or possibly very early Stage I invasive cancer, who may be able to avoid Tamoxifen by having a mastectomy or a BMX.)
• Does the length of the surgery and the length of the recovery period matter to you? For most women, a lumpectomy is a relatively easy surgery and recovery. After a lumpectomy, radiation usually is given for 6 weeks. A mastectomy is a longer, more complex surgery and the recovery period is longer.
• How will you deal with the side effects from Rads? For most patients the side effects of rads are not as difficult as they expected, but most women do experience some side effects. You should be prepared for some temporary discomfort, fatigue and skin irritation, particularly towards the end of your rads cycle. Most side effects go away a few weeks after treatment ends but if you have other health problems, particularly heart or lung problems, you may be at risk for more serious side effects. This can be an important consideration and should be discussed with your doctor.
• Do you plan to have reconstruction if you have a MX or BMX? If so, be aware that reconstruction, even "immediate" reconstruction, is usually a long process - many months - and most often requires more than one surgery. Some women have little discomfort during the reconstruction process but other women find the process to be very difficult - there is no way to know until you are going through it.
• If you have a MX or BMX, how will you deal with possible complications with reconstruction? Some lucky women breeze through reconstruction but unfortunately, many have complications. These may be short-term and/or fixable or they may be long-term and difficult to fix. Common problems include ripples and indentations and unevenness. You may have lingering side effects (muscle pain, spasms, itching, etc.) on one side or both (if you have a BMX). If you don't end up with symmetry (symmetry is not a sure thing by any means, even if you have a bilateral mastectomy with reconstruction done on both sides at the same time), will you regret the decision to remove your breasts or your healthy breast? Are you prepared for the possibility of revision surgery?
• How you do feel about your body image and how will this be affected by a mastectomy or BMX? A reconstructed breast is not the same as a real breast. Some women love their reconstructed breasts while some women hate them. Most probably fall in-between. Reconstructed breasts usually looks fine in clothing but may not appear natural when naked. They may not feel natural or move naturally, particularly if you have implant reconstruction. If you do choose to have a MX or BMX, one option that will help you get a more natural appearance is a nipple sparing mastectomy (NSM). Not all breast surgeons are trained to do NSMs so your surgeon might not present this option to you. Ask your surgeon about it if you are interested and if he/she doesn't do nipple sparing mastectomies, it may be worth the effort to find a surgeon who does do NSMs in order to see if this option is available for you (your area of cancer can't be right up near the nipple).
• If you have a MX or BMX, how do you feel about losing the natural feeling in your breast(s) and your nipple(s)? Are your nipples important to you sexually? A MX or BMX will change your body for the rest of your life and you have to be prepared for that. Keep in mind as well that even if you have a nipple sparing mastectomy, except in rare cases (and except with a new untested reconstruction procedure) the most feeling that can be retained in your nipples is about 20% - the nerves that affect 80% of nipple sensation are by necessity cut during the surgery and cannot be reconnected. Any breast/nipple feeling you regain will be surface feeling only (or phantom sensations, which are actually quite common and feel very real); there will be no feeling inside your breast, instead your breast will feel numb. For some, loss of breast/nipple sensation is a small price to pay; for others, it has a huge impact on their lives.
• If you have a MX or BMX, how will you deal emotionally with the loss of your breast(s)? Some women are glad that their breast(s) is gone because it was the source of the cancer, but others become angry that cancer forced them to lose their breast(s). How do you think you will feel? Don't just consider how you feel now, as you are facing the breast cancer diagnosis, but try to think about how you will feel in a year and in a few years, once this diagnosis, and the fear, is well behind you.
• If you have a lumpectomy, how will you deal emotionally with your 6 month or annual mammos and/or MRIs? For the first year or two after diagnosis, most women get very stressed when they have to go for their screenings. The good news is that usually this fear fades over time. However some women choose to have a BMX in order to avoid the anxiety of these checks.
• Will removal of your breast(s) help you move on from having had cancer or will it hamper your ability to move on? Will you feel that the cancer is gone because your breast(s) is gone? Or will the loss of your breast(s) be a constant reminder that you had breast cancer?
• Appearance issues aside, before making this decision you should find out what your doctors estimate your recurrence risk will be if you have a lumpectomy and radiation. Is this risk level one that you can live with or one that scares you? Will you live in constant fear or will you be comfortable that you've reduced your risk sufficiently and not worry except when you have your 6 month or annual screenings? If you'll always worry, then having a mastectomy might be a better option; many women get peace of mind by having a mastectomy. But keep in mind that over time the fear will fade, and that a MX or BMX does not mean that you no longer need checks - although the risk is low, you can still be diagnosed with BC or a recurrence even after a MX or BMX. Be aware too that while a mastectomy may significantly reduce your local (in the breast area) recurrence risk, it has no impact whatsoever on your risk of distant recurrence (i.e. mets).
• Do you know your risk to get BC in your other (the non-cancer) breast? Is this a risk level that scares you? Or is this a risk level that you can live with? Keep in mind that breast cancer very rarely recurs in the contralateral breast so your current diagnosis doesn't impact your other breast. However, anyone who's been diagnosed with BC one time is at higher risk to be diagnosed again with a new primary breast cancer (i.e. a cancer unrelated to the original diagnosis) and this may be compounded if you have other risk factors. Find out your risk level from your oncologist. When you talk to your oncologist, determine if BRCA genetic testing might be appropriate for you based on your family history of cancer and/or your age and/or your ethnicity (those of Ashkenazi Jewish descent are at higher risk). Those who are BRCA positive are very high risk to get BC and for many women, a positive BRCA test result is a compelling reason to have a bilateral mastectomy. On the other hand, for many women a negative BRCA test result helps with the decision to have a lumpectomy or single mastectomy rather than a bilateral. Talk to your oncologist. Don't assume that you know what your risk is; you may be surprised to find that it's much higher than you think, or much lower than you think (my risk was much less than I would ever have thought).
• How will you feel if you have a lumpectomy or UMX and at some point in the future (maybe in 2 years or maybe in 30 years) you get BC again, either a recurrence in the same breast or a new BC in either breast?Will you regret your decision and wish that you'd had a bilateral mastectomy? Or will you be grateful for the extra time that you had with your breasts, knowing that you made the best decision at the time with the information that you had?
• How will you feel if you have a bilateral mastectomy and no cancer or high risk conditions are found in the other breast? Will you question (either immediately or years in the future) why you made the decision to have the bilateral? Or will you be satisfied that you made the best decision with the information you had?

.I hope that this helps. And remember.... this is your decision. How someone else feels about it and the experience that someone else had might be very different than how you will feel about it and the experience that you will have. So try to figure out what's best for you, or at least, the option that you think you can live with most easily, given all the risks associated with all of the options. Good luck with your decision!"

Walden1

ruthbru- thanks for this great information.

One thing I notice about these studies is they focus on overall survival and it’s harder to understand local reoccurrence risk comparing lumpectomy and mastectomy. Also, When you read the fine print for many of these studies it is based on research for tumors less than 2cm, or less then 4cm. Being multifocal with suspected additional non mass DCIS extending to 6cm around the two tumors, I don’t know that these well documented findings truly apply to my case. In addition I am 44, strong family history but not BRACA positive, dense breasts making mammograms so useless they can’t even see my current cancer. Local reoccurrence would possibly mean more chemo etc. so it’s a significant concern to me. Not to mention the possibility that there is more not yet seen on imaging.

Anyone here had their doctor advise that there is slightly more risk for lumpectomy reoccurrence when you are young or have, more disease than 2-4 cm?

Wildplaces

Walden 😊

Lumpectomy plus radiation has a slighter higher risk of local recurrence than Mastectomy. Both treatments have the same overall risk of distant metastasis or survival.

Bessie's post via Ruthbru is brilliant.

In the end for ME the decision was about how much I valued my breast, my piece of mind be that based on fact or fiction, my assessment of what I thought getting through surgery would be like, my hope to avoid radiation ( although I ended up doing rads ...). I am 50 and not wild about having my breasts - that is hugely personal - please don't assume that I do not take pride in my appearance - I do. I also had small but to me great breasts and knew deep down that I would not be happy with recon. To me it would feel odd. I don't like that I do not have breasts but I am ok with that. Do I look in the mirror and I am ok with it? Yes - sometimes I forget they are gone and I am out the door without my trusty socks ( I hate prosthesis again personal) mercifully most of the gym bras I wear have padding ...and that is only because I am not one for attracting attention to myself - otherwise I would go flat. I have feeling in both scars and breast area but I had a very smooth surgical course. For fun times I wear a silk camisole or nothing depending on how much humour is injected into the situation and how the mood strikes. It's fine - really it's all fine as long as we stay healthy

I think if you ask a room of a thousand women on this you will get a thousand different answers. And I think it is hard for surgeons to advise you because the risk difference is not that great and each treatment option has its benefits and downfalls.

My only words to you would be to read all the info, make the best decision you can for YOU and then DO NOT second guess yourself - you have done your best, move to something that brings you joy.

Good luck with it

😊🌷

AliceKo

How about a second surgical opinion? I made a decision to have a mastectomy d/t to the location, multiple tumors and size. I wish I had a lumpectomy instead. Whatever the plastic surgeon calls a good outcome is not that good as a real thing. Nerve damage on your body above and below the chest, your side, maybe even your back - depends how they cut your nerves. My take now, the less is better. And there is reconstruction after lumpectomy (with your own tissue) - it's more complicated for PS.

Walden1

AliceKo,

What was your diagnosis

Reikion

Walden1,

I was diagnosed just before I turned 43. Doctors want to be aggressive with younger patients. As wildplaces said, "Make the best decision you can for YOU." My initial diagnosis was DCIS but the doctors thought there might be IDC in the lump and there was 0.9 cms of IDC found after surgery.

Best,

Reikion

Jwb44

well i was 72 when I got diagnosised and I weighed everything and at that age i felt mastectomy was the only way to go. I believed this because I am pretty healthy but if I did lumpectomy and the cancer came back i might not be healthy enough to do the chemo. Does anyone have pain in the arm after mastectomy since they took some lump nodes?. They could not see my tumor because it was in between the ducts. I am the first in my family of sisters cousins and niece aunt's to have breast cancer.

Joe i wish I had both removed cause as we all know if could come back on the other side. Had anyone been told that once you have breast cancer that you will cancer somewhere else in your body?

ruthbru

Having chemotherapy has nothing to do with the choice between having a lumpectomy or a mastectomy. They are two totally different issues. Chemo is advised if there is a higher chance that cancer cells have already escaped into the blood stream, so your choice of surgery won't make any difference in going after them. Some (but not all) people are able to avoid radiation by having a mastectomy. Family history or certain genetic factors can make you prone to a totally different cancer, unrelated to BC, showing up down the line.

ctmbsikia

Walden,  this may not help, but you are lucky to at least have the choice.  I was advised that at 5cm  you're no longer a candidate for lumpectomy.  I did seriously consider mastectomy but since I'm only 56 and a 4cm tumor I opted for the lump.  Good luck to you in your decision.

When they are taking 30% of your breast I think either way, it's never going to look good.

Walden1

Ctmbsikia,

Actually it is a big help. It sounds like my surgeon agrees with yours, as he has always been clear that my size of disease and the location means I need a mastectomy. It would certainly be 30 percent of the breast. He said ultimately he could do a lumpectomy so I could see what the cosmetic result would be if I really wanted, but there won't be much of a breast left. I'm just trying to understand if the result would be "not perfect but preferable to mastectomy" as some have described, or so poor it would be preferable to manage with a prosthetic. I've read oncoplastic techniques could help but don't know if they apply in my case.

There are many other reasons to choose mastectomy as many have mentioned here. It just helps me to hear what path others choose. Did your surgeon or you have concerns with your lumpectomy from a cosmetic point of view

Sophiemara

Hey Walden, my surgeon initially gave me the option of a lumpectomy because they thought my tumour was <5cm on ultrasound, but said if it turns out larger during surgery do I give permission for mastectomy. I actually decided prior to the surgery to just get rid and have a mastectomy. I had a C cup and at dx knew it had taken up most of my breast. I felt like my breast hadn't been my breast for a long time. It was 8cm total (1 x 5cm and the other satellite 3cm).

I had grade 3, which meant poorly defined cells inbetween those tumours and tumour edges so I was keen for my surgeon to take as much breast as they could really to ensure clear margins. Being dx young I didn't want the slightest rogue cell to potentially escape and metastasize locally within the remaining breast.

At that time I also had a lumpectomy on my good side because they found calcifications, which later turned out to be benign. I have since had reconstruction on both sides and am happy with my decision, as the lumpectomy ended up very saggy and flat. Good luck with your decision

Redjuliet1229

Hello,

I’m posting for my best friend..... she had a biopsy a week ago that showed cancer... she goes for her first appointment tomorrow...... they originally said it was quarter sized and now saying egg size..... what would you consider yours to be equivalent tin size of a walnut?? She says her doctor said egg size and then she said it measures “2” that can’t be 2 cm if it’s egg size could they be talking inches? I’ve never seen where anyone has discribed in inches before

Thank you

Walden1

Hi Redjuliet12,

I was always told the size in centimeters. Perhaps they meant egg shaped, not egg sized? I often found it difficult to remember all the details from my appointments, so I had someone with me taking notes. Also i got copies of all my lab, and imaging reports. Best wishes to your friend.

movingsoccermom

Hi Walden1. I opted for a lumpectomy. At the time I was an E cup, and they did take 25-30% of the breast, with 2 tumors; one at the outside midline, the other on the chest wall. I was adamant they take only what they needed, since that was important to me. This despite a huge family history (3 Aunts, Mom and sister). Even with my recurrence and Stage 4 I would not change my initial surgical choice. As folks have mentioned, naked you can see a big difference. Under clothes, its harder to tell. I am even able to wear my old bras without modification. I have been very satisfied with my choices and happy with where my body is now. It's such a personal choice and I wish you the very best as you decide.

All the best.

GiddyupGirl

At 5cm I opted for a lumpectomy, I was a 38D ( my surgeon was good with it). I am happy with my decision whatever lies ahead. One of the ladies on the board made the point that once you take off the breast you can't get it back so just make sure you are really sure of what you want. Wishing you the best of luck and good health.

Walden1

Sophiemara,

Thanks for sharing your surgery journey with me. I’ve been living with the mastectomy for over a year now and feeling very thankful mother have the majority of my treatment and all those difficult decisions behind me. Like you, I felt that at 44 I wanted to minimize all risk of reoccurrence in my future so I ultimately felt the mastectomy was my best option too. How are you feeling on OS and AI?