Lumpectomy vs Mastectomy: How to Compare

Breast-conserving surgery is usually called a lumpectomy. It removes the cancer plus a rim of healthy tissue around it. The rest of the breast stays. A mastectomy removes the whole breast. For most people with early-stage breast cancer or ductal carcinoma in situ (DCIS), both are reasonable. The National Cancer Institute (NCI) says it plainly. Women who have breast-conserving surgery live as long as women who have a mastectomy.

Survival is the same. So what is left to weigh is what each operation asks of you.

The surgeon removes the DCIS or cancer along with some healthy tissue around it. The name depends on how much tissue is taken. It may also be called a partial mastectomy, a segmental mastectomy, or a quadrantectomy.

A pathologist then checks the edges of the removed tissue. Those edges are called margins. If cancer cells reach an edge, more surgery is needed. Sometimes that ends in a mastectomy after all. For DCIS, the American Cancer Society (ACS) notes that surgeons generally want at least 2 mm of normal tissue at the margin.

Most people go home the same day. Most return to usual activities within about two weeks. Risks include bleeding, pain, infection, and fluid collecting at the surgical site. The shape of the breast can change. Lymphedema, a swelling caused by fluid buildup, can follow if lymph nodes were removed.

A mastectomy removes the whole breast: nipple, areola, breast tissue, and skin. A total or simple mastectomy removes the breast. A modified radical mastectomy also removes lymph nodes under the arm. Skin-sparing and nipple-sparing versions keep more skin, or the nipple and areola. That allows a more natural reconstruction. But they do not suit every tumor.

Recovery takes longer. NCI says most people are back to usual activities in 3 to 4 weeks, and reconstruction can stretch recovery to 6 to 8 weeks or more. Side effects can include infection, stiffness in the arm and shoulder, numbness, and lymphedema. Another is post-mastectomy pain syndrome. ACS describes it as burning or shooting pain in the chest wall, armpit or arm. NCI says pain or discomfort after a mastectomy may or may not get better over time.

Survival is the same. What differs is how often cancer comes back in the same place. NCI reports that about 5% to 10% of women, or 1 out of every 10 to 20, who have a lumpectomy followed by radiation therapy get cancer in the same breast within 12 years. About 1 out of every 20 women who have a mastectomy get cancer on the same side of the chest within 12 years.

So a local return is somewhat less likely after mastectomy. That does not translate into living longer. Cancer that returns in a conserved breast can be treated, often with a mastectomy at that point. NCI also reports that women who have breast-conserving surgery have a better long-term quality of life than those who have a mastectomy.

Most people with DCIS or breast cancer that surgery can remove may consider a lumpectomy. NCI lists situations where a mastectomy may be the better choice:

• you have small breasts and a large area of DCIS or cancer
• you have DCIS or cancer in more than one part of the breast
• the DCIS or cancer is under the nipple
• you are not able to have radiation therapy, or prefer not to

ACS adds other reasons breast-conserving surgery may not suit. They include previous radiation or a lumpectomy on that breast. They include a tumor larger than 5 cm. They also include inflammatory breast cancer, and margins that stay positive after repeat surgery. In most cases pregnancy rules it out too. So can some connective tissue diseases, such as scleroderma or lupus.

Most people who have a lumpectomy have radiation therapy afterward. It lowers the chance the cancer returns in that breast. NCI describes radiation as often given 5 days a week for up to 6 weeks. That is a real commitment of time, travel, and energy.

NCI says that after a mastectomy you may not need radiation. That is not a promise, because your own results decide it. Ask your team how likely radiation is under each plan. Avoiding it is only a reason to choose mastectomy if that turns out to be true in your case.

After a mastectomy you can rebuild a breast shape, or not. Reconstruction can use implants. It can also use your own tissue, taken from the abdomen, back, thigh, or buttock. Implant reconstruction is often done in two stages. A tissue expander goes in first. A permanent implant follows 2 to 6 months later. Tissue flap surgery is a bigger operation. Reconstruction can be done at the time of the mastectomy, or months to years later. Ask how many operations to expect and how long recovery will take.

Radiation affects the plan. Implant reconstruction is usually still possible. NCI says tissue flap reconstruction is usually saved for after radiation finishes.

Having no reconstruction is a full option in its own right. In an aesthetic flat closure, the surgeon removes extra fat, skin, and other tissue. The chest wall is then smoothed so it lies flat. Some people then wear a prosthesis and some do not. In the United States, the Women's Health and Cancer Rights Act requires plans it covers to pay for all stages of reconstruction after a mastectomy, plus a prosthesis. CMS says it applies to employer and union group plans and individual policies. NCI notes that some religious and government plans are exempt, so check yours.

Two people with the same scan and the same pathology report can reasonably choose differently. One wants to keep her breast and does not mind six weeks of radiation. Another lives two hours from the nearest radiation center and cannot make that trip daily.

What helps is the specifics of your own case, not the averages. How large is the cancer relative to your breast? Is it in one place or several? How likely is radiation either way? What would reconstruction or flat closure involve? And how much time do you safely have to think? A second opinion is reasonable when both operations are genuinely on the table.

• Call 911 or go to an emergency department if breathing becomes hard after either operation, or your chest hurts. Do not drive yourself.
• Call your surgical team the same day if your temperature reaches 101.5°F (38.6°C) or higher, the wound bleeds, is red or warm to the touch, or the drainage from it is thick and yellow, green or pus-like. If you are also having chemotherapy, call right away for 100.4°F (38°C) or higher, day or night.
• Call your care team the same day if the arm or the breast on the treated side swells, pain is no longer eased by the medicine you were sent home with, you have a cough that does not go away, or you cannot eat or drink.

These come from MedlinePlus discharge advice after breast surgery.

• Choosing Between a Lumpectomy and Mastectomy — NCI
• Breast Reconstruction After Mastectomy — NCI
• Breast-Conserving Surgery (Lumpectomy) — American Cancer Society
• Mastectomy — American Cancer Society
• Mastectomy — discharge — MedlinePlus