Women who have only the lump removed in early-stage breast cancer may have better survival rates than women who get a mastectomy, a study suggests. Researchers looked at records for more than 112,000 women. All of them had early breast cancer, Stage I or II. Most women with early breast cancer can have the lump removed (lumpectomy) instead of the whole breast (mastectomy). In the study, 55% chose lumpectomy, followed by radiation. The others had mastectomies. Researchers kept track of the women for a median of 9 years. Half were followed for a longer time, and half for less time. More than 31,000 women died during follow-up. About 40% of the deaths were from breast cancer. Women who had a lumpectomy and radiation were more likely to survive than those who had mastectomies. The difference was greatest for women over 50 with a type of cancer that grows in response to hormones. Women in this group were 13% less likely to die of breast cancer than women who had mammograms. They were 19% less likely to die of any cause. The journal Cancer published the study online. HealthDay News wrote about it January 28.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Lumpectomy followed by radiation first made headlines more than 20 years ago. Today, it's an alternative to mastectomy for most women with early-stage breast cancer. It's also known as breast-conserving surgery. But many women who could have this procedure still opt for mastectomy. There's a lingering belief that removing more tissue improves the cure rate and survival.

Early breast cancers that might be treatable with lumpectomy and radiation include cancers with the following features:

• The breast cancer is 2 centimeters or smaller, and it has not spread to lymph nodes (Stage I).
• The breast cancer is between 2 and 5 centimeters but has not spread to lymph nodes, or the cancer is no larger than 2 centimeters and has spread to one or more lymph nodes (Stage II).

Past studies have shown that breast-conserving surgery has outcomes just as good as those with mastectomy. And some study results suggested that women treated with lumpectomy and radiation fared better than those who had a mastectomy.

The results of this new study once again lean toward better outcomes with lumpectomy and radiation.

The researchers gathered information on 112,154 women with Stage I or Stage II breast cancer. Slightly more than one-half (55%) of the women had lumpectomy and radiation. The others (45%) had mastectomy without radiation. The follow-up had a median time of more than 9 years.

In all age groups, women who had the breast-conserving surgery did at least as well as those who had a mastectomy. This was true for women with both hormone-receptor positive and hormone-receptor negative breast cancers.

Women who showed the clearest advantage with breast-conserving surgery were those older than 50 with hormone-receptor positive cancer. They had a 19% lower death rate from all causes than similar women who had a mastectomy. And they had a 13% lower rate of death directly caused by breast cancer.

This was an observational study. Women were not randomly assigned to have one treatment or another. Observational studies show links between factors. They cannot prove a cause and effect.

We don't know why women treated with lumpectomy and radiation had better outcomes. It may be that doctors and their patients tended to choose mastectomy in women who were at higher risk of a bad outcome when the diagnosis was made.

What Changes Can I Make Now?

If you are diagnosed with early-stage breast cancer and have only one tumor, you can confidently consider lumpectomy followed by radiation. That does not mean you would be wrong to choose mastectomy. You and your doctors will decide what is best for you.

Reasons you might opt for mastectomy include:

• A cancer that is between 4 and 5 centimeters. This is close to the upper size limit for an early-stage cancer.
• Higher than average risk from radiation or reasons you cannot have radiation.
• A strong family history of breast cancer or a known genetic mutation that puts you at very high risk of having another breast cancer. (In that case, you would probably consider a double mastectomy.)

Breast-conserving surgery is just one of the advances that have made treatment of breast cancer less toxic and disfiguring. There are more options, especially for early-stage disease. And these options provide better chances than ever of wiping out breast cancer and preventing it from coming back.

For example, surgeons used to routinely remove many lymph nodes that surround the breast. This often led to arm swelling and pain from a condition called lymphedema. Today, surgeons do what is called a sentinel node biopsy. They remove the one to three lymph nodes closest to the tumor. If they are free from cancer, no more nodes need to be taken out.

Radiation techniques continue to improve. This means there is now much less risk of damage to tissue around the tumor. For some women, radiation also can be given over a shorter time. Results are just as good as with the standard longer course.

Women who choose mastectomy have better options for reconstructing the breasts than ever before. With today's surgical techniques and implants, you'll probably like how the results look.

What Can I Expect Looking to the Future?

Having more treatment choices for early breast cancer is wonderful. More advances are sure to come.

But having options can be stressful when one choice does not offer a clear advantage. If you can't decide right away, talk with your doctor about taking a week or two to think it over.