Generally, lumpectomy is the first step in breast-conservation
therapy. Lumpectomy is usually performed in an outpatient setting using
local anesthesia. However, general anesthesia can be used for greater
patient comfort. If cancer cells are present at the margin (the edge of
the biopsied tissue), a re-excision needs to be done to remove the remaining
cancer. If you are large-breasted, most of your breast can be preserved
and you will still have the image you are accustomed to. If you are small-breasted
and need additional surgery, lumpectomy may not result in a good cosmetic
result; mastectomy with reconstruction can be a good option.
Lumpectomy alone is adequate treatment if:
- Only one area of abnormality is found on exam or on
- The area of abnormality is very small.
- The surgeon is able to remove the DCIS completely and
no DCIS is left behind in the breast.
- The mammogram of the breast shows no more suspicious
findings after the lumpectomy.
- The woman is elderly or has other serious illnesses
and would not be able to tolerate more extensive surgery or breast radiation
- The type of DCIS is a less aggressive, or non-comedo,
- The woman consents to close follow-up and surveillance.
Lumpectomy alone carries special concerns and considerations.
Because the remaining breast tissue is not treated with any other intervention,
there is the possibility that if the woman lives many more years, she
can develop cancer either DCIS or invasive cancer in the same breast.
This option is only effective for carefully selected patients with early,
small DCIS lesions with very easily interpreted mammograms. Comedo-type
DCIS tends to be more aggressive and careful judgment needs to be used
in offering lumpectomy alone in women with this cell type of DCIS.
Simple (total) mastectomy
This is a surgical procedure in which the entire breast is removed but
not the lymph nodes under the arm or the muscle tissue from beneath the
breast. The nipple will be removed in this procedure, but much of the
original skin of the breast may be preserved.
Simple mastectomy is used to treat noninvasive breast cancer,
and is one way to remove DCIS that is multifocal (appears in many places
within the breast). The surgeon does not need to remove lymph nodes from
under the arm, because DCIS does not spread to the axiliary lymph nodes.
If the DCIS is high grade and larger, your surgeon may suggest
a sentinel node biopsy at the time of lumpectomy or mastectomy. This is
because of the possibility of invasive cancer. By doing the sentinel node
biopsy at this time, the need for additional surgery may be eliminated.
If invasive cancer is found, the surgeon will remove the
entire breast tissue and some lymph nodes, which is important to determine
spread of the disease. This is called a modified radical mastectomy. When
lymph nodes are removed, there is the risk of lymphedema, or swelling
in the arm.
Simple mastectomy is appropriate management for all kinds
of DCIS. It is the only recommended treatment for multifocal DCIS, extensive
DCIS, or DCIS that has recurred after lumpectomy and radiation therapy.
This procedure is a relatively short surgery, requires general anesthesia,
with a short hospital stay followed by a quick recovery. Reconstructive
surgery to recreate the breast can be done immediately at the time of
mastectomy or at a later date. The recurrence rate and overall chance
of dying from cancer after simple mastectomy is between 0 and 2%.
Women who have the simple mastectomy procedure rarely have
difficulties with shoulder movement or arm swelling after surgery. As
compared to a modified radical mastectomy, the surgery time is shorter
and the recovery period faster.
If a simple mastectomy is chosen as treatment for DCIS,
radiation therapy is not needed following surgery.
Modified radical mastectomy
Modified radical mastectomy is a surgical procedure in which the entire
breast and some or all of the nearby lymph nodes are removed. Underlying
muscles are left intact. This procedure is not usually used for treatment
of DCIS, but may be used if invasive breast cancer is found.
Postoperative radiation therapy
If lumpectomy is chosen as the surgical method, the remainder of the breast
is usually treated with radiation to minimize the chances of having a
recurrence of DCIS in the breast. If, after biopsy, there are cancer cells
present at the margin (the edge of biopsied tissue), an excision can usually
be done again to remove the remaining cancer cells. Radiation treatment
is usually begun three to four weeks after the lumpectomy or when the
wound has healed.
Radiation therapy is used to destroy any cancer cells that
may be left behind in the breast. Radiation treatments are usually given
five days a week for six to seven weeks. The daily sessions take only
a few minutes each.
The side effects of radiation can include swelling and heaviness
in the breast, sunburn-like skin changes in the treated area, fatigue
and loss of appetite. For some women, the breast may become smaller, firmer
and more tender after the radiation therapy.
These common side effects generally begin toward the middle
of the treatment and continue for a short time after completion of radiation.
The side effects are usually gone within six months to a year. Radiation
can only be used once for primary treatment, because the breast does not
tolerate repeated radiation therapy at the doses required to eradicate
Radiation therapy after lumpectomy is considered adequate
treatment in the following situations:
- When there is only one area of abnormality in the breast,
either on physical exam or mammogram.
- When the surgeon is able to remove all of the DCIS cleanly,
and this is verified by mammogram after the surgery. When additional
DCIS is found, re-excision (additional surgery) is necessary.
- When the size of the DCIS is small enough in relation
to the size of the breast so that the woman is left with a cosmetically
Some of the problems with having lumpectomy and radiation
- Radiation therapy is time-consuming, with treatments
lasting five to seven weeks.
- While risk of recurrence is reduced by adding the radiation
therapy to lumpectomy, about 8% to 10% of women with this treatment
will have a recurrence in the treated breast. Half of the women who
have recurrence will have invasive cancer when the cancer returns. Women
with comedo DCIS have the highest risk of developing invasive recurrences.
Cosmetic results may be of concern. While lumpectomy and radiation therapy
may preserve the breast and breast sensation and "feel," radiation
and surgery sometimes result in a change in the texture of the breast,
a poor cosmetic result and deformity.
Lumpectomy with postoperative radiation therapy may not
be appropriate for:
- Women with a local recurrence or new primary DCIS or
breast cancer who have already had radiation therapy to the affected
breast or chest.
- Women with two or more areas of DCIS in the same breast,
too far apart to be removed by one incision.
- Women whose first excision biopsy or when needed,
their re-excision has not completely removed the DCIS, or whose
re-excision may result in an unsatisfactory appearance of the breast.
- Women with certain autoimmune diseases that make body
tissues especially sensitive to the side effects of radiation therapy.
Ask your doctor if you have one of these conditions.
If a woman is pregnant when diagnosed with DCIS, radiation
therapy may be delayed until after completion of her pregnancy because
DCIS is not an emergency. Although radiation is often delayed, surgery
can be safely performed during her pregnancy or can be done after the
birth of her child with no compromise to the mother.
Choosing your DCIS treatment
If you are choosing which kind of surgery to have, here are some facts
that will assist you in your decision-making:
- For anyone choosing mastectomy it is important
to know that it is almost impossible to remove all of the breast tissue,
and therefore a recurrence is still possible in the remaining tissue.
- Possible short-term side effects of both lumpectomy and
mastectomy include wound infection, hematoma (accumulation of blood
in the wound), and seroma (accumulation of clear fluid in the wound).
- About 95% of women with DCIS do not require a mastectomy.
- The survival rates for a combination of lumpectomy with
radiation therapy have shown that is it just as effective as mastectomy.
- Local recurrence with total mastectomy is rare.
- Women who opt to preserve their breast with a combination
of lumpectomy and radiation therapy have a higher rate of recurrence
than women who have a mastectomy, but there is no proven impact on survival.
- Following lumpectomy or mastectomy, some women
experience discomfort or pain that comes and goes. It is not uncommon
to feel discomfort at the site of the incision when there are significant
climate changes. Women may also experience breast tenderness after radiation
discussing treatment options, the doctor needs to conduct a physical examination
and ask your medical history. This will include questions about your family
history, such as the following:
- Relatives who have had breast cancer
- Their age at diagnosis and whether one or both breasts
- Whether any relatives had ovarian cancer or other cancers
- Any history of radiation to the breast area
- Any history of vascular disease
- Whether you have breast implants
- The date of your first menstrual period
- The date of your last menstrual period
- The possibility of present or future pregnancy
- Your use of hormone replacement therapy
- Your use of oral contraceptives
- Whether you have had fertility or gynecologic surgeries
- Whether you have nipple discharge
The doctor will use this information and the pathology results
to determine which therapies are most suitable for you, and will then
discuss treatment options with you. To summarize: Most women and their
doctors prefer lumpectomy and radiation therapy rather than mastectomy.
The advantage of lumpectomy is that it may save the appearance of your
breast. The disadvantage of a lumpectomy is that it is followed by several
weeks of radiation therapy. Unfortunately, for some small-breasted women,
a lumpectomy may be very disfiguring, and a simple mastectomy with reconstruction
may be a better cosmetic option.
Your individual feelings, attitudes and values may
be just as important as the scientific facts in weighing your options.
As you consider your choices, think about the following questions:
- How do you feel about losing your breast?
- How much breast tissue will need to be removed?
- How far will you have to travel for radiation therapy?
- Do you want or are you willing to have reconstructive
surgery after mastectomy?
- Are you thinking of mastectomy as a way to rid
yourself of your cancer as quickly as possible? Or is it because it
represents the least chance that cancer will reappear?
- How important is it to have a normal-appearing
breast when all treatment is complete? If your breast is small or the
amount of tissue that must be removed is large, a mastectomy with or
without reconstruction may yield a more pleasing appearance.
Remember, lumpectomy and radiation for the treatment
of DCIS are not appropriate if:
- You have had previous radiation to the breast or
- You are pregnant (although radiation can be performed
- The disease is in several areas of your breast.
- There are suspicious areas of calcium throughout
your breast on a mammogram or breast MRI.
Furthermore, lumpectomy and radiation as treatment
for DCIS may not be appropriate if:
- Two separate incisions are needed to remove the
- You have an autoimmune disease such as scleroderma
or systemic lupus.