More about surgery for breast cancer
Most women who are diagnosed with breast cancer will need some kind of surgery. Sometimes doctors aren't able to tell whether a woman has cancer before she has surgery. This may be because the lump is too deep in the breast for the doctor to collect cells with a needle and examine them for cancer.
The type of surgery you have will depend on:
- The size of the cancer or lump
- Whether the cancer has spread to other parts of your body
- What type of surgery you prefer.
Before you have surgery, your surgeon or breast cancer nurse will talk to you in detail about the different options available to you. You'll be given time to think about what's best for you, and a chance to ask questions. You may find it helpful to learn as much as you can about the different types of surgery and how your breast will look after each type.
Here we describe the different types of surgery and tell you who they are most suitable for.
Breast-conserving surgery
Breast-conserving surgery is an operation for breast cancer that lets you keep your breast. Your surgeon will remove only the part of your breast that has cancer. The aim is to get rid of your breast cancer while changing the appearance of your breast as little as possible.
Doctors sometimes call this operation a lumpectomy. It's done instead of removing your whole breast (a mastectomy).
Is this operation suitable for me?
You may be able to have breast-conserving surgery if:[8]
- You have ductal carcinoma in situ: This means the cancer hasn't spread from the milk ducts in your breast
- You have early breast cancer. This means the cancer hasn't spread outside your breast, or has spread only as far as the nearest lymph nodes. Lymph nodes are small, round or oval lumps. They help fight infections in your body. Breast cancer usually spreads to the lymph nodes in the armpit before it spreads anywhere else
- You have just one lump in your breast. If you have more than one lump, or lots of small patches of cancer cells, breast-conserving surgery may not be suitable. It's hard to remove all the cancer cells without changing the way your breast looks. And if you have lots of small patches of cancer, the cancer is more likely to come back than if you have a single lump. Removing your breast can help stop this[9] [10]
- Your lump is small compared with the size of your breast. If you have a small lump, you'll have only a small scar, and maybe a small dent in your breast
- You can have radiotherapy. You may need radiotherapy after breast-conserving surgery to destroy cancer cells left after surgery. Doctors try to avoid giving radiotherapy to the same area twice, so you may not be able to have breast-conserving surgery if you've had radiotherapy before. If you are pregnant, you may want to avoid radiotherapy as it can harm your baby.
Up to 8 in 10 women with early breast cancer are able to have breast-conserving surgery. And there's good evidence from lots of studies that women who have only their lump removed live just as long as women who have their entire breast removed.[2] [1]
But breast-conserving surgery isn't right for everyone. If you have a large lump and a small breast, or if you have cancer under your nipple, it can be difficult to remove the cancer without changing the way your breast looks. You may get a better result with a mastectomy and breast reconstruction. There are several kinds of breast reconstruction available, including surgery to put in breast implants.
If you have a family history of cancer or tests show you have a high risk of breast cancer, you have a bigger chance that the cancer will come back in the same place.[3] Some women choose to have a mastectomy rather than risk needing more surgery later.
Mastectomy
A mastectomy is an operation that removes all of the breast tissue, including skin and the nipple, from the side of the chest that has cancer. A mastectomy is usually essential if you have breast cancer that is in more than one place in your breast.
You'll be left with a flat scar that goes across your chest. Most scars run diagonally or horizontally.
There are two main types of mastectomy.
- Total mastectomy: All of the breast tissue is removed along with some of the skin over the breast and the nipple. Some lymph nodes in the armpit also are removed.
- Radical mastectomy: With this type of surgery, you'll have some of the muscles under your breast removed as well as all of your breast tissue, some skin, the nipple and the lymph nodes in your armpit. Radical mastectomy was once a common operation for breast cancer. Doctors had hoped that women would be cured because anything that could have had cancer cells left in it was removed. It's now known this isn't the case, and the only reason this surgery is done is because the breast cancer has spread very far through the breast and into underlying tissues.
A mastectomy is a more serious operation than breast-conserving surgery and it may take you longer to recover. Fluid can build up around the top of the scar on your chest and also in your upper arm. This can be uncomfortable and make your arm stiff. But there are exercises that can help.
You can have breast reconstruction after a mastectomy, including surgery to put in implants.
Surgery on the lymph nodes
During breast surgery, your surgeon will probably remove some or all of the lymph nodes in your armpit. This is because these nodes are usually the first place breast cancer spreads to. If you have a type of early breast cancer called ductal carcinoma in situ (DCIS), you won't need to have any lymph nodes removed. This is because the cancer is only in the ducts of the breast and there's no risk that they'll spread to the lymph nodes.
If you're having breast-conserving surgery and your breast cancer is in the upper part of your breast near your armpit, your surgeon may be able to reach your lymph nodes through the same cut he or she makes in your breast. But if your cancer is somewhere else, the surgeon will need to make another cut.
If you're having a mastectomy, your surgeon will be able to reach the lymph nodes through the same cut.
You and your doctor will need to decide how many nodes to remove. This will depend on how likely it is that your cancer has spread. Your doctor will consider the size of your tumour and how it looks under a microscope (this is called the grade of your cancer). You'll have fewer side effects if fewer nodes are removed.[3]
- You may have all 20 or so lymph nodes removed from your armpit. This is called an axillary clearance. The aim is to remove any cancer that might have spread there by removing all of the lymph nodes.
- Or your surgeon may remove between four and 10 lymph nodes to see if they contain cancer cells. This is called axillary sampling. If the nodes in the lowest part of your armpit are clear of cancer, it's unlikely that any of the nodes higher up will have cancer in them.
- Sentinel node biopsy is a newer treatment doctors use to avoid removing lymph nodes unless absolutely necessary. You'll have fewer side effects if fewer nodes are removed.[3] An injection of a blue dye, a radioactive material or both is put into your breast. This shows up the lymph node (or nodes) that fluid from the breast drains into first.[4] These nodes, called the sentinel nodes, are then removed and tested for cancer. If there are no cancer cells in these nodes, it's likely that the other lymph nodes are free from cancer as well. If there are cancer cells in the sentinel node, you will need other nodes nearby removed. To learn more, see Sentinel node biopsy for early breast cancer.
If the lymph nodes in your armpit have cancer cells in them, then you may need radiotherapy or chemotherapy.
Pros and cons of breast surgery
Breast-conserving surgery has some advantages over a mastectomy.[7] [5] [6]
| Breast-conserving surgery | Mastectomy | |
|---|---|---|
| How well does it work? | You will probably live for as long as you would if you had a mastectomy. | You're not likely to live any longer than if you had breast-conserving surgery. |
| Will my breast cancer come back? | The chance of breast cancer coming back after breast-conserving surgery is the same as the chance of it coming back after a mastectomy. | There is always a small risk that breast cancer will come back in the scar, so removing all the breast tissue can't guarantee that your breast is totally free of cancer. The chance of your cancer coming back is the same with a mastectomy as with breast-conserving surgery. |
| What are the side effects of surgery? | You will probably have some pain after your operation and you may get an infection in your wound. | You're likely to get more serious side effects than you would from breast-conserving surgery. You may be in some pain and get swelling under your arm and in your wound. There's also a chance you may get some nerve pain. These problems will get better with time. |
| Will I need another operation? | About 1 in 10 women need a second operation to remove more tissue. This is usually done as an insurance policy to make sure that the cells on the border between the cancer and the healthy tissue don't turn into cancer later. There is a risk that the tissue around the tumour in your breast will be abnormal and your surgeon will advise you to have a mastectomy. | Not usually. Women who need further surgery after breast-conserving surgery often say they wish they had chosen to have a mastectomy in the first place. |
| Will I need radiotherapy? | Most likely. You'll probably need radiotherapy to kill any clumps of breast cancer cells in your breast that are too small for your doctor to find. Radiotherapy reduces the chance of the cancer coming back in the same breast. | Not usually. Although you may need treatment in your armpit area if cancer cells are found in the lymph nodes there. |
| What about my lymph nodes? | You won't need to have your lymph nodes checked if you have ductal carcinoma in situ. But, otherwise, your surgeon will check your lymph nodes for cancer. This may be done through the same cut that your cancer was removed, or you may need to have another cut. | Your surgeon will remove some of your lymph nodes and check them for cancer. If they contain cancer, then your surgeon will may remove all of the nodes. |
| How will my breast look? | You'll be able to keep your breast, although it won't look the same as it did before. Your scar will be small compared with a mastectomy scar. The exact size of your scar will depend on how much tissue was taken away. Between 6 in 10 and 9 in 10 women rate their breast as looking 'good' to 'excellent' after breast-conserving surgery. | Your breast is completely removed. But you can have breast reconstruction, either at the same time as the mastectomy or at some time later. |
| How will it affect me afterwards? | You may feel better about having less of your breast removed. You'll be able to wear the same clothes, and you may find it easier to get back into your routine. You won't need to wear a false breast or have surgery to reconstruct your breast. | You may miss your breast, and some women say they feel disfigured by losing a breast. But breast reconstruction can help. |
References
- Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. New England Journal of Medicine. 2002; 347: 1233-1241.
- Early Breast Cancer Trialists' Collaborative Group. Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: an overview of the randomised trials. Lancet. 2000; 355: 1757-1770.
- Schijven MP, Vingerhoets AJ, Rutten HJ, et al. Comparison of morbidity between axillary lymph node dissection and sentinel node biopsy. European Journal of Surgical Oncology. 2003; 29: 341-350.
- Goyal A, Newcombe RG, Mansel RE. Axillary lymphatic mapping against nodal axillary clearance (ALMANAC) trialists group: clinical relevance of multiple sentinel nodes in patients with breast cancer. British Journal of Surgery. 2005; 92: 438-442.
- Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. European Journal of Cancer. 2000;36(15):1938-1943.
- Schain WS, d'Angelo TM, Dunn ME, et al. Mastectomy versus conservative surgery and radiation therapy: psychosocial consequences. Cancer. 1994; 73: 1221-1228.
- Al-Ghazal SK, Blamey RW. Cosmetic assessment of breast-conserving surgery for primary breast cancer. Breast. 1999;8(4):162-168.
- National Institute for Clinical Excellence. Guidance on cancer services: improving outcomes in breast cancer. August 2002. NICE manual update. Available at http://www.nice.org.uk/csgbcguidance (accessed on 28 September 2006).
- Fisher ER, Sass R, Fisher B, et al. Pathologic findings from the National Surgical Adjuvant Breast Project (protocol 6). II. Relation of local breast recurrence to multicentricity. Cancer. 1986; 57: 1717-1724.
- Kurtz JM, Jacquemier J, Amalric R, et al. Breast-conserving therapy for macroscopically multiple cancers. Annals of Surgery. 1990; 212: 38-44.
Glossary
- lymph nodes
- Lymph nodes (also called glands) are small, bean-shaped lumps that you cannot usually see or easily feel. They are located in various parts of the body, such as the neck, armpit and groin. Lymph nodes filter and remove unwanted things, such as bacteria and cancer cells.
- radiotherapy
- This is also called radiation therapy. It is a treatment that uses high-energy to kill cancer cells. It's most often used for tumours that are hard to treat with surgery alone. You won't feel any pain during this treatment, but you may get some side effects afterwards.
- mastectomy
- A mastectomy is an operation that removes all of the breast tissue, including skin and the nipple, from the side of the chest that has cancer.
- chemotherapy
- The use of chemicals or drugs to treat or prevent disease, usually cancer.
© BMJ Publishing Group Limited ("BMJ Group") 2007. All rights reserved
This information does not replace medical advice. If you are concerned you might have a medical problem please ask your Boots pharmacy team in your local Boots store, or see your doctor.
