For decades, having breast cancer meant undergoing a dreaded radical mastectomy, the highly disfiguring removal of the breast, lymph nodes and chest muscles. But "bigger is better" got a successful challenge from Dr. Bernard Fisher, who led the landmark National Surgical Adjuvant Breast Project trial demonstrating lumpectomy was "as good as mastectomy."
Doctors improved lumpectomy by pairing it with radiation. They developed nipple-sparing mastectomies that particularly allowed younger women, smaller-breasted women, and those undergoing prophylactic surgery to undergo breast reconstruction using their own nipples and areolas.
Most recently, as digital mammography, MRI, and 3-D tomosynthesis have picked up tiny cancers that often went undetected in the past, some women are taking no chances "and we've kind of seen the pendulum shift back to more mastectomy," Golshan said.
So what's a newly diagnosed patient to make of all this?
Nurse-advocate Lillie Shockney, a two-time breast cancer survivor and administrative director of the Johns Hopkins Breast Center, says the key is bringing the patient into discussions balancing aesthetic concerns with her physical and mental wellbeing.
"I am a believer in the 2 mm margin," Shockney said. With the average woman's breast size a 34C, taking away 10 mm in every direction means "she's not going to have a lot of breast left," and could make her fear lumpectomy.
Low-grade DCIS cells closely resembling normal cells can elude sophisticated imaging, especially if diffusely spread along the milk ducts, leading to re-excision, she said. "You can get a clear margin and not know that there is more DCIS further up the duct, or further below the duct, and later on, doctors find more cancer."
That makes her adamant that patients clearly understand what's ahead. Surgeons must explain "the possibility that you may need a re-excision." If a woman insists she's "only going to go into the OR once," the surgeon must address the chances of an extensive lumpectomy or mastectomy and bring in a plastic surgeon to discuss reconstruction.
Shockney frequently talks petrified patients "off the cliff" by telling them their cancer likely has been around for years and there's time to think ahead. "I can say, 'you now know it's there, so your hair is on fire. I'm here with the fire hydrants to put the fire out, so we together can make good decisions, whether that be to take a little tissue out of (the breast) or rebuild you a new one."