Surgical Options for Breast Cancer and Consent Guidelines for Indigenous Women

Surgical Options for Breast Cancer and Consent Guidelines for Indigenous Women
Book Chapter
Jennifer Erdrich, Felina Cordova-Marks, Amanda Bruegl
Indigenous and Tribal Peoples and Cancer, 31 August 2024 [Springer]
Open Access
Key Points

• Women diagnosed with breast cancer and preparing for surgery can choose between breast-conserving therapy (BCT) and mastectomy. Breast cancer survival for BCT and mastectomy are equivalent.
• Surgical patterns show that American Indian/Alaska Native (AI/AN) women in the United States have more mastectomy and less breast-conserving therapy for early-stage breast cancer compared to non-Hispanic White (NHW) women.
• For all women, regardless of race, informed consent for lumpectomy vs. mastectomy is a complex, time-intensive process entailing comprehensive counseling. Additional historical and cultural considerations must inform consent guidelines for Indigenous women preparing for breast cancer surgery.
• We propose innovative solutions to overcome the challenges that limit Indigenous women’s access to their preferred surgical choice.

Abstract
    Breast-conserving therapy (BCT) consists of lumpectomy followed by radiation. A lumpectomy removes the tumor and surrounding rim of normal breast tissue, leaving most of the breast volume and shape intact. A mastectomy removes the entirety of the breast tissue. Randomized trials with long-term follow-up demonstrate that, regardless of the stage of disease, survival is equivalent for both treatment options. While the risk of recurrence with lumpectomy alone is higher, modern multidisciplinary care combining lumpectomy with radiation and various forms of systemic therapy achieves a similar low risk of recurrence, allowing clinicians to offer BCT or mastectomy as equally safe standard care options. This establishes a surgical choice that is highly personal and should be individualized to consider multiple unique factors, including age, family history, hereditary gene mutations, size of the tumor relative to total breast volume, ability to complete multimodality breast care and surveillance, future plans regarding fertility and lactation, and overall best outcome for the individual’s body-image, lifestyle, and peace of mind.
BCT consistently shows decreased surgical complications, decreased pain, faster recovery, more favorable cosmetics, and better-preserved sexuality and body image. This is not to say that it is the best choice for every woman. BCT is contraindicated for women with inflammatory breast cancer. For some, mastectomy is preferred for personal reasons, even with a full understanding of equivalent survival following BCT. Provided the patient is well-informed and has worked with her clinical team to ensure her decisions are safe, she should be supported in her surgical choice.