Grade 3, ER+/PR+ Lumpectomy vs Mastectomy

I have the same and my surgeon said lumpectomy with a very low risk of it coming back . Are you having chemo first or after ? I had it before down to my last on June 13 then six weeks after that I'm having a lumpectomy not sure if it's the right thing having doubts as of now I don't ever want to go through this again good luck

Kayaknana -

My diagnosis is similar to yours - I had a smallish tumor, grade 3, with 10+ positive lymph nodes on imaging. I had neoadjuvant chemo, so I had time to think about surgery options. From the beginning, my surgeon was advocating for lumpectomy, as she thought the chemo would shrink the tumor, and therefore allow me to keep my breast. I, too, thought bilateral mastectomy was in my future. In the beginning, I just wanted to remove both breasts, thinking that would ensure that the cancer would never come back, and I would be done.

Over the weeks - and months! - of chemo that followed, my thinking changed. While I didn't have a complete response to chemo, it did shrink the tumor by 92%, and the surgeons' group was very pleased. I was going to get radiation regardless of the surgery I had, because of the lymph nodes. She was confident about the lumpectomy, and reminded me that I could have a mastectomy later, but once the breast was gone, it was gone. With that said, she also said that she would do the mastectomy if I wanted it. I chose the lumpectomy, and I'm very happy with my decision.

Do you know if you will have chemo first, and if you will have radiation? There are so many factors to consider, I know. You are at the most overwhelming stage of this rotten game. There are many women on the boards who have had to make this decision!

I wish you the best, and please feel free to ask me any other questions!

Hello, I too am sorry that you have to join us. I opted for lumpectomy because my tumor, although aggressive, was small. I was remarried in 2014, and my new husband loves my breasts. Having a couple of scars and both breasts makes me happy, and well as him. I also had oophorectomy two years ago when I had my hysterectomy, so that also swayed me to lumpectomy. If I had had a larger lump, hadn't been 100 percent ER+ and 100 percent PR+, I might have opted for the mastectomy. There are a lot of considerations. I feel like radiation and AI drugs for maybe forever will keep the cancer cells at bay. With a OncoDX score of 12, I think I did the right thing.

When I was diagnosed, I thought I had 2 tumors (both around 1 cm)....I chose bmx because of 2 spots. I am very glad I did as after mx, I learned I had 3 tumors, one much larger than expected and a new, very small spot that no form of imaging picked up because it was so small. It would have been missed completely and left for radiation to zap...which may or may not have been successful. I also learned that all 3 tumors were grade 3 (not 2). No regrets. My 34B breasts were very dense and imaging was not very helpful. I would have worried all the time and demanded imaging on a regular basis.

Beesie is one of the resident experts on the boards. I am copying a very well thought out post she did on this topic. Hope it helps:

"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!"

I had a tumor less than .5cm and chose to get a BMX mostly because of family history and I had always wanted a breast reduction and figured this was my chance!! I lived with DD most of my life and while impressive, they have their own set of issues lol.

My BS recommended a lumpectomy but was happy to do what I decided. She was more concerned with my self esteem and didn't want me to have any regrets. After assuring her that I would be totally fine without them we proceeded! I have absolutely no regrets. I love my smaller breasts and am loving that I never have to wear a bra again!! I know the statistics on recurrence rates and they are great to refer to when making your decision. What I've learned during this process is that NO ONE not even the doctors know what they will find and what is lurking that hasn't been revealed until surgery and the final pathology report. Only you know what your gut/heart is telling you and ultimately you need to make a decision that will leave you with the most peace.

Grade 3 is a tricky one... Even though mine was very small, it was already in the nodes, which all of my doctors told me theywould have bet money was not the case before surgery.

Get all the information you can and trust that you are doing what's right for you!

Best of luck!!

-Keely

Dear Kayaknana,

Your post made me laugh (I can so visualize your relative and the bra struggle, that is SO funny and I can totally relate) and also made me cry. I remember how raw and emotional everything is in those first days and that on top of what you've already been through, losing your parents...I can't imagine and I'm so sorry and now this? Really? Honestly, the best advice I was given and that I would share with you is "just show up" and let the experts work for you. I don't know if I just got lucky, or if I was simply naive but I had the best, most caring team of doctors along the way and I seriously just buckled in and took everything one moment, one day, one procedure at a time and tried not to think too far down the road to the next big decision. I had delayed reconstruction and actually lived "flat" for six months and with my beautiful set of foobs and super supportive husband (just like you), it was tolerable. I had three surgeries and although I did have to take some time off work, it was manageable. Thankfully I didn't have to go through chemo (but it was on the table for a while due to the grade 3 tumor) or rads (because I opted for BMX) but even if I would have, I know now that I could have and whatever you have to do, you will just meet it head on and do what you have to do. Just do your research, listen to your doctors, listen to YOURSELF, ask lots of questions and make the decision that feels right for you and then set your mind and never look back. I promise, in the not too distant future, this will all be behind you. I remember when my surgeon said righty had to go. I admit, I was sad, but I immediately said "ok, both are going because I don't ever want to go through this again" and honestly, it was kind of a relief. I remember the silence in the room as both he and my husband stared at me and said "are you sure?" but I just knew. I will say one silver lining for me is that I didn't go big with my reconstruction, maybe a B cup, and I don't think I'll ever have to wear a bra again. That is wonderful. On the flip side of that, one of my good friends had a lumpectomy and rads and is 5 years out and doing awesome with her own boobs! None of this is fun but you're going to do great, just hang in there! ((hugs)).

Kayaknana - I'm so glad you are relieved with your choice and you can proceed with the plan!