A Breast Surgeon Explains Lumpectomy, Mastectomy and Recovery

For many people with breast cancer, the first meeting with a surgeon comes quickly after a diagnosis, often before there has been time to take in the news. As Breast Cancer Awareness Month begins, CURE spoke with Dr. Maureen P. McEvoy, a breast surgeon and associate professor at Montefiore Medical Center, about what to expect from that conversation, how surgical decisions are made and what recovery looks like beyond the operating room.

What should someone newly diagnosed with breast cancer know before meeting with a surgeon?

Dr. McEvoy: That initial phone call that you get, either from the radiologist or from your primary care doctor, can be extremely overwhelming. The first person that you typically meet and have the discussion with is me as a breast surgeon, and my main goal during that meeting is to help educate you and give you all of your options so that you end up walking away feeling a sense of control and having a plan forward. A lot of times, just having a plan makes you feel a lot better.

How do doctors decide between a lumpectomy and a mastectomy?

Dr. McEvoy: There has been a tremendous amount of de-escalation in terms of surgery and even systemic treatment. Because of breast cancer screenings such as mammograms and ultrasounds, we're catching cancers earlier. And typically, an earlier cancer means that it's less extensive. It's not as big. So as long as the tumor is small relative to the breast size, we are able to safely do what's called a lumpectomy, which means we're just removing the tumor and we're not removing the entire breast.

There's plenty of data, with over 20 years of follow-up from randomized trials, showing that these two options are equivalent. Just removing the tumor compared with removing the entire breast, the outcomes are the same — and those outcomes are the chance of it coming back in the breast and also long-term survival.

Patients who are unable to have a lumpectomy and need a mastectomy are those who have a larger tumor compared with their breast size or have multiple tumors throughout the breast. And the last thing is that it truly is the patient's choice. If you're able to have a lumpectomy, you certainly can choose a mastectomy. We would walk you through the risks and benefits, and if it is your personal choice, that's something that we definitely support.

What advances in breast surgery are changing outcomes and quality of life?

Dr. McEvoy: I think the idea of saving the breast — breast conservation — is really important, and there's been much more of a push toward that. In the past, we used to have a size cutoff for the tumor. Now, for someone with a larger tumor who still wants breast conservation, I can go in and remove the cancer, and a plastic surgeon would be there during the same surgery to help rearrange your own tissue to rebuild the breast, sort of like doing a breast reduction or a breast lift.

We conducted a study at Montefiore comparing this procedure, where we save the breast and rearrange the tissue, with patients who had the breast removed and had reconstruction, such as with an implant. We have a patient-reported outcomes database where we track patients, and we were able to see that the patients whose breast we saved and rebuilt with their own tissue were much happier. Their patient satisfaction scores were higher. Listening to our patients has allowed us to change the way we approach these conversations, and I continue to see advances in the field that are focused on what patients want and what gives them a better cosmetic outcome, as long as it's oncologically safe.

There are also many tools being developed to help us do the right surgery the first time. There's about a 20% to 30% risk of needing to come back to the operating room after your initial surgery if the margins are positive, meaning the first surgery did not clear everything. There's a device called Lumicell that we're going to be using at Montefiore, where the cancer cells actually light up, and we have an instrument in the operating room so we can detect them. This will decrease the risk of having to come back for additional surgery and greatly increases the chances of getting the tumor out the first time.

How do surgeons talk with patients about body image and reconstruction?

Dr. McEvoy: Cosmetic outcome is really important. Patients are being diagnosed earlier, so they're living longer, and it's really important to take that into account when planning for breast surgery. Our patient-reported outcomes database gives patients an opportunity to rate many factors, including how they felt about their body and their breasts before surgery, and then they have follow-up after surgery as well.

Patients who undergo a mastectomy can choose to go completely flat, and there are options to use a prosthetic bra. Another option is immediate reconstruction, and there are a lot of advances there. We're able to do same-day implant-based reconstruction, so it's not a staged procedure. There are also advances toward saving the skin, the nipple and the areola, and in preserving the nerves so that you still have sensation in the nipple.

I think it's about having an open conversation with the patient: How do you feel about your breasts? How important are they to you in terms of who you are and your appearance? Some patients say not at all — they have no relationship with them — and a lot of patients feel really strongly about it, so we do what we can to preserve that. Survival rates are increasing, and five or 10 years from now, I want them to be happy with their outcome.

What are common misconceptions or fears about breast cancer surgery?

Dr. McEvoy: One of the most common things I see is patients who have heard from a neighbor or a friend who went through this themselves that if you don't remove everything, it's just going to come right back. They come in wanting to be super aggressive — removing both breasts, perhaps not even having reconstruction — and that is based on fear, which is completely understandable.

But I feel my job is to give them the data. Not one case, such as your neighbor's, but thousands of women who were brave enough to enroll in randomized trials that give us the ability to say that saving the breast is just as safe as removing it. Once I've educated them, I leave it up to the patient, so they can make that decision knowing the data.

What should patients expect during recovery from breast cancer surgery?

Dr. McEvoy: There are a few steps to recovery. Immediately after surgery, you're recovering from the physical change that's happened to your body. A smaller lumpectomy is a same-day procedure. You go home the same day, and usually within a couple of days you feel OK — you're up and around and able to do things. You may have soreness here and there, and that's totally expected. I usually say give yourself about two weeks, and the healing is mostly complete at about six weeks.

A mastectomy, or a mastectomy with reconstruction, is a much bigger surgery. Those patients typically spend one night in the hospital, and recovery is longer. You can expect pain, you'll have drains that need to come out and you need a bit more care and attention. I usually say at least six weeks of initial recovery.

Once you're through that, I follow my patients for several years, and usually at the six-month or one-year visit, recovery becomes: What does life look like for you with this diagnosis as a survivor? When you're first diagnosed, you're going through all the motions and getting everything done. Later, some patients have side effects, and some need to adapt emotionally and psychologically to what they went through and any long-term effects it has had on them.

What are the biggest disparities in access to breast cancer surgical care?

Dr. McEvoy: At Montefiore, we do a lot of research looking at disparities. Part of it is patient education and understanding your risk. Breast cancer can be diagnosed early, and when it's diagnosed early, survival rates are excellent. However, some patients don't understand that screening is something they should be doing every year, perhaps because of their level of medical education or access to care. Sometimes it's not convenient to come every year for a mammogram, and that's a big barrier.

When someone presents with a palpable cancer — something they felt themselves — that's typically a more advanced stage. There's a huge difference between catching something at stage 1 versus stage 3, whether that's because you couldn't get to your mammogram or didn't know to get one. That's an opportunity to intervene, because it really can change survival.

What could help close those gaps?

Dr. McEvoy: Some of it is understanding what the barrier is. If it's access to care, that could mean making mammograms available on weekends or holding screening events. We host them at Montefiore — free events on a Saturday where anybody can come in and get screened. Opening up that kind of access can help with that piece of the disparity we see.

What message do you have for people with breast cancer during Breast Cancer Awareness Month?

Dr. McEvoy: One of the things I love about treating patients with breast cancer is that it is often screen-detected, so patients do well. Getting your mammogram every year allows the radiologist to compare back each year and see when there's a slight difference, and that's when we find very early-stage, curable breast cancers.

To all of the patients who have gone through this and are survivors: I value everything you've taught me and how you've helped move the field along. Many patients sign up for trials, and all of these experiences are helping everybody who comes after them.

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