Earlier consensus held that breast-conserving surgery with radiation was the preferred form of treatment for patients with early-stage breast cancer. Despite the numerous randomized trials showing no survival benefit of mastectomy over breast-conserving partial mastectomy and irradiation, breast-conserving surgery appears underutilized and mastectomy remains the more common treatment. About 25% of patients in the United States with stage I or stage II breast cancer are treated with breast-conserving surgery and radiation therapy, compared with 75% treated with mastectomy. Use of breast-conserving surgery and radiation therapy varies by region of the country, ranging from 15% in the South Central United States to 30% in the Pacific Region.

Modified radical mastectomy (total mastectomy plus axillary lymph node dissection) has been the standard therapy for most patients with breast cancer. This operation removes the entire breast, overlying skin, nipple, and areolar complex as well as the underlying pectoralis fascia with the axillary lymph nodes in continuity.

The major advantage of modified radical mastectomy is that radiation therapy may not be necessary. The disadvantage, of course, is the psychological impact associated with breast loss. Radical mastectomy, which removes the underlying pectoralis muscle, should be performed rarely, if at all. Axillary node dissection is not indicated for noninfiltrating cancers, because nodal metastases are rarely present. Skin-sparing mastectomy is currently gaining favor but is appropriate in only a small subgroup of patients. Radiotherapy after partial mastectomy consists of 5-6 weeks of five daily fractions to a total dose of 5000-6000 cGy. Some radiation oncologists use a boost dose. Currently several studies are under way examining the utility and recurrence rates after intraoperative radiation or dose-dense radiation in which the course of radiation is shortened. Current studies suggest that radiotherapy after mastectomy may improve survival, and meta-analyses suggest radiation after lumpectomy may improve survival. The use of radiation in mastectomy patients is being further researched in a large cooperative trial to better identify which subgroups will benefit. Researchers are also examining the utility of axillary irradiation as an alternative to axillary dissection in the clinically node-negative patient with sentinel node metastases.

Preoperatively, full discussion with the patient regarding the rationale for operation and various alternative forms of treatment is essential. Breast-conserving surgery and radiation should be offered whenever possible, since most patients would prefer to save the breast. Breast reconstruction, immediate or delayed, should be discussed with patients who choose or require mastectomy. Patients should have an interview with a reconstructive plastic surgeon to discuss options prior to making a decision regarding reconstruction. Time is well spent preoperatively in educating the patient and family about these matters.