Wide area excision or mastectomy?

Hi CER

Thank you for contacting us. My name is Lynsay and I am one of the information nurses with Macmillan Cancer Support.

Making treatment decisions can be really challenging, so I am glad you have got in touch and I will try and help answer the questions you have.

You are correct in thinking the risk of the cancer having spread is the same regardless of the surgery you choose.

The further investigation of having a sentinel lymph node biopsy (SLNB) when having a mastectomy for DCIS relates to the recommendation within the national guidance that is followed within the UK. The information is in section 1.4.4 of the guidance.

The rationale for this recommendations is that when there is more extensive DCIS (extensive DCIS refers to an area great than 50mm) there can be an anticipated risk that an area of this may be upstaged to invasive breast cancer when this is examined by pathology after surgery.

If a SLNB is not done at the time of mastectomy and an invasive area was then discovered this would then require further surgery to assess the lymph nodes. However, it could be argued that the pathology assessment after surgery would confirm whether a SLNB was required. This is discussed more fully in a recent systematic review, I have attached this here.

As you have already had surgery it may be beneficial to have a further discussion about the pathology findings from the first surgery. However as there is this 50% chance that all the DCIS cannot be removed with a further lumpectomy, this could mean that not all the DCIS could go through pathological assessment, this being the case we would not know if any of the potentially remaining DCIS had become invasive as if it had, this would indicate the need for a SLNB

Lumpectomy followed by radiotherapy is deemed to be as effective and have the same overall survival as mastectomy. However, due to the size of the area of DCIS, radiotherapy treatment would have been indicated as part of your treatment even if you had clear margins after surgery. This being the case, are they proposing a mastectomy following a further lumpectomy if again clear margins are not achieved? It may help to ask about this if this has not been clarified as it may help in your decision making.

In terms of the risk of lymphoedema following a SLNB, this is low and generally seems to be estimated as less than 5%. This risk of lymphoedema increases with the number of lymph nodes removed. SLNB often only results in the removal of up to three lymph nodes so the risk of lymphedema is minimal. If you have found information suggesting the risk to be higher, then it can be helpful to discuss this with your consultant as they can explain the information they base their estimated risk on.

In relation to the hard and lumpy changes you feel in the breast following surgery,, this is normal. This can potentially soften over time and the sensation may return to your skin, however often the skin along the scar line will remain numb.

It may help to have a discussion with your breast care nurse as this way you can explore your feeling regarding each option. You are also welcome to call us on the support line, we would be more than happy to talk with you and answer any further question you may have, this may help to clarify things a bit.

I hope this is helpful.

Please don’t hesitate to get back in touch if you have any further questions.

Best wishes, 

Lynsay, Cancer Information Nurse Specialist  

You can also speak with the Macmillan Support Line team of experts. Phone free on 0808 808 0000 (7 days a week, 8am-8pm) or send us an email. 

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