Conservative breast surgery with radiation vs. mastectomy for Paget's Disease

Last Modified: August 15, 2004

Dear OncoLink "Ask The Experts,"
What are the pros and cons of choosing Conservative breast surgery with radiation over a mastectomy when Paget's disease of the nipple is suspected and no underlying cancer is detected by mammogram? My concerns are the side effects of radiation treatment but also the threat of recurrence.

Lawrence J. Solin, MD, FACR, Professor of Radiation Oncology at the University of Pennsylvania, responds:

Paget's disease of the nipple is an uncommon breast problem. Biopsy findings typically show pathologic involvement of the nipple by non-invasive, in situ carcinoma cells (Paget's cells) that have a specific appearance under the microscope. This disease can spread within the ducts of the breast adjacent to the nipple. High quality mammography can often be useful to detect such intraductal extension as evidenced by abnormal calcifications on mammography in the subareolar area.

As Paget's disease tends to be a localized process, most patients can be adequately managed with local treatment only (for example, mastectomy, so-called lumpectomy, or lumpectomy plus radiation treatment). However, because Paget's disease is uncommon, treatment approaches are based on reports of small case series and extrapolation of information from other forms of breast cancer (for example, ductal carcinoma in situ [DCIS] or early stage invasive breast carcinoma).

The advantages of breast conservation treatment are that the breast can be retained in the large majority of patients and extensive surgery is avoided. However, the disadvantages include that a course of radiation treatment is usually given to minimize the risk of local recurrence. A course of radiation treatment typically delivered over approximately 6-7 weeks, and even with radiation treatment, there is the low risk of local recurrence.

The advantages of mastectomy include that mastectomy is highly effective with a low risk of recurrence. Breast reconstruction can usually be offered. However, the major disadvantage is that the patient loses her own breast.

A multidisciplinary approach to management generally gives the best overall results, both for control of disease as well as for cosmetic outcome. Both a breast surgeon and a radiation oncologist can provide valuable input and guidance for optimizing individual patient management.