Considerations: In general the more advanced the disease the fewer considerations there will be as the treatment options will be fewer. While long-term survival is everyones' primary goal, personal considerations can be the best place to start finding your path as these are different for every patient. These are both immediate and long-term considerations
Immediate Personal Considerations
1) Nipple and breast sensation - this is best maintained by the lumpectomy and radiation approach. Most mastectomies can be done now preserving the nipple itself, but it will have significantly reduced sensation, despite likely preserved nipple reactivity.
2) Breast appearance - This is obviously in the eye of the beholder. Many women have no more ideal shape to their breast than that of the ones they were first given. Other women may choose comfort and simplicity and "go flat" rather than reconstruct. In general, trying to do the same or similar procedure(s) to both sides is the most assured path to symmetry.
Large breasted women can better tolerate more of a lumpectomy without undo distortion of the breast. This may require rearrangement and elevation of the breast tissue to fill any void. In smaller breasted women or in a patient after multiple lumpectomies, an indentation deformity can often occur, particularly with the addition of radiation. This indentation and underlying scar tissue can tether a nipple's projection to one side. This may require rearrangement of the breast tissue, the grafting of fat from the abdomen and/or a procedure on the opposite side for symmetry.
Mastectomies now are done in an entirely different way than even 25 years ago with preservation of the nipples in most cases. This means that it is now, finally, a realistic goal to have mastectomies and reconstructions look and feel real, compared to 15 years ago. This is because much less of a reconstructed breast is missing. The nipple is often preserved, implants and flap techniques have improved, and we now have ways of moving fat and performing a lift at the time of the mastectomy.
Long-term Personal Considerations:
Surveillance Distant and Local. This is an important consideration for patients that is often NOT discussed. This is how you are going to live the rest of your life.
For distant disease spread, a PET scan or CT scans plus bone scan are the two ways to do this, if needed. Options to survey for local disease recurrence includes physical exam, mammography, ultrasound and MRI. Depending on the choice of treatment, this may be repeated every 6 months or yearly along with a visit to the surgical oncologist. Mammograms sometimes can be more uncomfortable after a lumpectomy and radiation. Again, this frequent imaging is done to look for a local recurrence, particularly in a lumpectomy site.
Should the patient choose or have to have a mastectomy, surveillance for local recurrence involves only a physical exam. No mammograms are ever done after a mastectomy. An ultrasound or MRI would be the choice to investigate anything found on exam.
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