Questions for your Surgeon and Radiation Oncologist:
- Will I need radiation if I have a lumpectomy?
- Will I need radiation if I have a mastectomy?
- How can I avoid radiation for my cancer?
Will I need radiation if I have a lumpectomy?
The answer is most likely, YES. For those diagnosed with a small, Early-Stage breast cancer, a lumpectomy followed by radiation is just as effective at curing your cancer as a mastectomy without radiation. Whenever the term “lumpectomy” is mentioned, it is assumed that “radiation” will follow the surgery in order to keep the chance of a breast cancer local recurrence to an acceptably low rate. There are some instances where a lumpectomy without radiation may be an option for those with very favorable breast cancers. Review our video lesson on “Breast Cancer Recurrence” (here) to learn about the threat to your life from “local and regional recurrence.”
Why is radiation often needed after surgery?
Quite simply, radiation reduces the chance of cancer growing back in the area where the tumor was surgically removed. When a lumpectomy is performed, the surgeon removes a normal layer of breast tissue around the cancer, called margins. Even if the margins are “clear” and uninvolved with cancer, there is still a small chance cancer cells can be left behind in that area of the breast. In the future, these cells can grow to become a “local recurrence” of cancer in the same area of the surgery. Without radiation, the chance of local recurrence after a lumpectomy is about 15 to 25% over a period of 10 years. Radiation reduces this risk to about 5 to 8%.
Will I need radiation after a mastectomy?
The answer is most likely, no. Post Mastectomy Radiation Therapy (PMRT) is the term for applying radiation to the area of the chest wall after a mastectomy, usually performed about 4 weeks after surgery or after both surgery and chemotherapy are completed. PMRT is generally recommended for those with a high risk of local recurrence.
If you or your surgeon. before surgery, think you might need PMRT it is essential to see your radiation oncologist before you have mastectomy surgery. This way, your radiation oncologist will better understand the size, shape, and extent of your breast tumor before it is removed by surgery or has shrunk away with “Neoadjuvant Chemotherapy.” Radiation oncologists have a unique insight into breast cancer treatment options that can assist your surgeon in planning the direction of your cancer care.
The decision to undergo Post Mastectomy Radiation Therapy is complicated. Patients should insist on a multidisciplinary team approach to get the best treatment recommendations for high risk breast cancer situations. When your breast surgeon works closely with your radiation oncologist and medical oncologist, you will be offered the best treatment options. Below is a general outline to help you understand when radiation after a mastectomy is needed.
PMRT for “Early Stage Breast Cancer”
Most patients that have a mastectomy for early stage breast cancer will not need radiation. There are a few important situations that may require Post Mastectomy Radiation Therapy for Early Stage (Stage I or II) breast cancer.
Positive Margins: This is when invasive cancer is found under the microscope on the edges (or margins) of the surgically removed breast tissue from a mastectomy. This means there may be some cancer cells left behind in the surgical area that carry a high chance of growing back. PMRT reduces the chance of local recurrence in patients with positive margins.
Lymph nodes contain cancer: If three or more lymph nodes are involved with cancer, then post mastectomy radiation is usually recommended. This reduces the chance of the cancer recurring in the breast and remaining lymph nodes in the region. Studies have shown that radiation in these situations improve long term survival.
There are a few situations where PMRT is recommended for those with only one or two nodes that are found to have cancer after a mastectomy. This usually involves premenopausal women who carry a higher risk of their cancer recurring. A consultation with a radiation oncologist is essential for you to understand if radiation will be needed in these situations.
PMRT for “Later Stage Breast Cancer”
Post Mastectomy Radiation Therapy is needed for most with Stage III breast cancers because the tumor is larger and/or there may be more extensive involvement of the lymph nodes. In this situation, even if a mastectomy is performed, there is a much higher risk of recurrence in the surgical area, even after the cancer has been removed. Breast cancer recurrence is a threat to your life. Radiation reduces this recurrence risk and may improve survival. Radiation for Stage IV cancer is a more complicated decision process and is beyond the scope of this lesson.
Inflammatory Breast Cancer usually presents as a Stage III cancer. Radiation is always recommended after first undergoing chemotherapy and then a mastectomy. Inflammatory breast cancer carries a very high chance of local and regional recurrence. Radiation dramatically reduces this risk and also may improve survival.
How can I avoid radiation for my cancer?
Your surgical choice…Lumpectomy vs. Mastectomy:
Lumpectomy with radiation is just as effective as a mastectomy without radiation for most early stage breast cancers. This is a choice made with your breast surgeon and is obviously a difficult one. The decision is also a personal one. Usually, you can avoid radiation if a mastectomy is performed for favorable cancers. Review our video lesson on “Lumpectomy vs. Mastectomy“ to learn the questions to ask your surgeon to be better informed about the risk and benefits of each surgical approach.
Advanced age or poor health:
If you are older than 70 and have a favorable, small tumor with no lymph nodes involved, you can consider having a lumpectomy and withholding radiation. This approach is only possible when you take a 5 to 10-year course of hormonal therapy. There are specific criteria for this “lumpectomy only” approach. Make sure to ask your radiation oncologist about the risks and benefits of radiation and no radiation in this situation. The same approach can apply if someone is more advanced in age or those with a fragile health status. In these situations, the risks of radiation can sometime outweigh the benefits of post-lumpectomy radiation.
Chemotherapy administered before surgery for well selected patients can sometimes destroy all of the cancer cells in the breast and the lymph nodes. When surgery reveals that the tissue has no residual cancer cells after completing chemotherapy, this is called a Pathologic Complete Response (pCR). There are specific situations where a pathologic complete response after neoadjuvant chemotherapy can allow you to avoid Post Mastectomy Radiation Therapy. Neoadjuvant chemotherapy is one of the “cutting-edge” treatment options that is being used more often by sophisticated breast cancer teams. Make sure to ask your surgeon about the advantages of neoadjuvant chemotherapy and if it might help you avoid radiation. Review our video lesson (here) on “Neoadjuvant Chemotherapy“ to learn more.
This 10-minute video (here) explains what radiation does, when it is used, and the side effects that can occur. It is provided by the American Society of Radiation Oncologists, the leading radiation therapy organization. It is the best overview available about radiation for breast cancer.
This link (here) by the American Society of Breast Surgeons has an excellent explanation of “Radiotherapy for Breast Cancer.” This site is created for patients by the American Society of Breast Surgeons.
This page (here) “When is radiation appropriate?” outlines when radiation is needed and not needed. This non-profit organization provides excellent patient resources about breast cancer.
This webpage (here) by the American Society of Breast Surgeons has an excellent description of “Post Mastectomy Radiation Therapy.” This site is created for patients by the American Society of Breast Surgeons.
More Detailed References:
This free, interactive document (here) provides expert consensus recommendations for radiation for all stages and types of breast cancer. This webpage has a “dropdown menu” where you can select “Breast Cancer” under “guidelines” and find your clinical situation listed below. It is designed for breast specialists. The “User Guide” (here) shows you how to navigate these treatment recommendations.
If you want to get deep into the details, this free 200-page pdf document (here) has guidelines to help clinicians to make treatment recommendations about nearly all aspects of breast cancer. You can easily register (here) as a non-professional to get access and more information about breast cancer. The National Comprehensive Cancer Network is the leading organization in developing clinical guidelines.