Should I Consider Surgery for My Remaining Breast After Cancer?

The left breast has undergone a total mastectomy for breast cancer, and there are multiple calcifications and a suspected cyst in the right breast. Should these be excised?

Hello, Doctor.
I am currently 45 years old.
Around the age of 35, I discovered a hard lump in my right breast, which I monitored regularly for about five years.
Then, three and a half years ago, I was diagnosed with stage II breast cancer in my left breast, which had invaded one lymph node.
I underwent a total mastectomy of the right breast and partial lymphadenectomy, and I have been taking Tamoxifen since the surgery.
Two years ago, I also had an ovarian cyst that had been monitored for many years surgically removed.
Therefore, I have been completely menopausal for the past two years and have no estrogen.
I continue to take Tamoxifen.

What puzzles me is that despite being menopausal, having no estrogen, and taking Tamoxifen, during regular follow-ups, multiple calcifications and a lump have been found in my remaining left breast.
In the past 1.5 years of breast ultrasounds and mammograms, the size of the lump has changed from 0.3 cm to 0.6 cm, then disappeared, then back to 0.6 cm, and now to 0.8 cm.
As a breast cancer survivor, I am concerned about the calcifications and the changing shape of the lump in my remaining breast.
It is difficult for me to feel at ease.
The remaining left breast holds no significance for my husband and me; we are just worried.

I would like to ask you, given my situation, should I consider undergoing a mastectomy of the left breast, including the removal of the breast tissue, areola, and nipple? I would greatly appreciate your valuable advice.
Thank you.

Ms. Hu, 40~49 year old female. Ask Date: 2016/10/08

Dr. Wu Jianting reply Breast and Thyroid

Based on the content discussed in the letter, please consult your attending physician for accurate treatment.

1.
After menopause, there is still a small amount of estrogen in the body.
Taking medications like Raloxifene may reduce this, but it will not eliminate it completely.

2.
Regarding calcifications and masses, it is recommended to consider a biopsy to confirm whether there is an issue.
Of course, this should be discussed with your physician, as tumor evaluation involves factors beyond just size.

3.
As for whether to undergo prophylactic total mastectomy of the left breast, this has not been practiced in Taiwan.
However, it is done in other countries based on genetic testing results.
Personally, I believe it is prudent to first determine the nature of the left breast mass before making such a decision.

Thank you for your inquiry.

Reply Date: 2016/10/08

More Info

When considering whether to undergo surgery for your remaining breast after a history of breast cancer, several factors must be taken into account, including your medical history, current findings, and personal preferences. Given your situation, where you have a history of invasive breast cancer and ongoing concerns about the remaining breast, it is understandable that you are contemplating further surgical intervention.

Firstly, it is important to recognize that your previous diagnosis of stage II breast cancer, along with lymph node involvement, places you at a higher risk for recurrence or the development of new breast cancer in the remaining breast. The presence of microcalcifications and a palpable mass that has shown variability in size over time is concerning and warrants careful evaluation. The fact that you have been on an aromatase inhibitor (letrozole) since your surgery, which reduces estrogen levels, is a positive step in managing hormone receptor-positive breast cancer, but it does not eliminate the risk entirely.

In your case, the decision to proceed with a mastectomy of the remaining breast (contralateral prophylactic mastectomy) should be made after thorough discussions with your oncologist and a breast surgeon. They will likely consider the following:
1. Risk Assessment: Your oncologist can provide a detailed risk assessment based on your personal and family history, pathology reports, and the current findings in your remaining breast. This assessment will help determine the likelihood of developing a new breast cancer.

2. Genetic Testing: If you have not already undergone genetic testing for mutations such as BRCA1 or BRCA2, this may be recommended. A positive result could influence your decision regarding prophylactic surgery, as individuals with these mutations have a significantly increased risk of developing breast cancer.

3. Imaging Studies: Continued monitoring through imaging studies (mammograms, ultrasounds, or MRIs) is crucial. If the findings in your left breast are concerning enough, your healthcare team may recommend a biopsy to determine whether the calcifications or the mass are malignant.

4. Personal Preferences: Your feelings about the remaining breast and the anxiety it causes you should be taken seriously. Many patients opt for prophylactic mastectomy to reduce anxiety and the risk of future cancer, especially when the remaining breast does not hold significant personal value.

5. Psychosocial Considerations: The psychological impact of living with the fear of recurrence can be significant. If removing the remaining breast would alleviate that anxiety and improve your quality of life, it may be a valid consideration.

6. Surgical Risks and Benefits: Discuss the potential risks and benefits of surgery with your surgeon. While surgery can reduce the risk of future breast cancer, it also comes with its own set of risks and recovery considerations.

In conclusion, given your history of breast cancer, the current findings in your remaining breast, and the emotional toll it takes on you, it is reasonable to consider surgery for the left breast. However, this decision should be made collaboratively with your healthcare team, who can provide personalized recommendations based on the most current medical evidence and your specific circumstances. It is essential to weigh the risks and benefits carefully and to ensure that you feel comfortable and informed about your decision.

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