MJA: Collins, Box

There is no difference in the rate of survival or distant metastasis between women having mastectomy and those having breast-conserving surgery where appropriate.
Radiotherapy after lumpectomy significantly reduces the risk of local recurrence. Omission of radiotherapy, even in carefully selected patients, leads to an increased risk of local recurrence.
Breast-conserving surgery is suitable for tumours which are unifocal and in which clear margins can be obtained. Tumour diameter of 3-4 cm is often regarded as a practical limit. Relativity of tumour size to breast size and achievement of an acceptable cosmetic result are equally important considerations.
A breast-conserving protocol comprises clear local excision in which clear margins are obtained by any surgical technique, combined with axillary dissection and followed by adjuvant radiation therapy to the breast. A second operation may be required to achieve clear margins. Variations (such as omission of axillary dissection) may be used in selected cases.
Mastectomy is an appropriate treatment for women whose tumours extend widely within the breast, have ill-defined margins which defy clear local excision, directly involve the nipple or overlying skin, or who do not choose breast conservation. Nipple involvement does not always preclude breast conservation.