Breast Cancer Surgery




What Is A Mastectomy?
Types of Mastectomies
Breast Conserving Surgery
When Do Women Choose Mastectomies Over Lumpectomies?
What Happens During Surgery?
Possible Complications
Is Surgery More Successful Later In The Menstrual Cycle?
We've Come A Long Way
After Surgery

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Breast Cancer Guide

What Is A Mastectomy?

Mastectomy is a surgical procedure to remove the entire breast. All of the breast tissue is cut away, sometimes also with nearby tissue. It is nearly always carried out as a breast cancer treatment although occasionally it is performed to remove non-cancerous lumps. Some women with high breast cancer risks factors may choose to have a prophylactic (preventative) mastectomy, that is the removal of breast(s) before cancer has even developed.

Types of Mastectomies

There are different types of mastectomies performed today which vary by how much tissue is cut out and whether surrounding muscle tissue and lymph nodes are also removed. Which procedure a woman and her surgeon chooses will depend on a number of factors including the size and cell type of the cancer; how far it has spread which is determined by breast cancer staging; the woman's general health and age; and the size of her breasts. Traditionally a woman's personal preference was not taken into account, today this is changing. Statistics show that a woman's breast cancer survival rates are about the same regardless of which type of surgery is chosen. For this reason, considerations will depend more on the extent of disfigurement involved with a particular surgery, side effects and any additional associated treatments required (such as chemo or radiation therapy). Before choosing which procedure to go ahead with, the woman needs to carefully review all the pros and cons and should seek the opinion of at least 2 specialist surgeons.

Modified Radical Mastectomy
This is still one of the standard mastectomy treatments for invasive cancer, including inflammatory breast cancer. In this procedure the entire breast, most of the underarm lymph (axillary) nodes and a small part of the pectoral muscle in the chest is removed. If reconstruction surgery is not performed immediately the area where the breast used to be will look flat, but not caved in. Some surgeons will leave extra skin to facilitate reconstructive surgery later. The remaining scar usually runs from the breastbone to the armpit.

Total (or Simple) Mastectomy
This surgery is more likely to be performed for prophylactic purposes, or where cancer is in the early stages (carcinoma in situ). It involves removing the entire breast but still leaves lymph nodes under the arm and the muscle tissue underneath the breast in place. Occasionally the surgeon will remove a few of the underarm lymph nodes for biopsy; this will help determine the need for any other therapy. The more cancer found in the nodes, the more likely it has spread to other parts of the body. If the surgery is performed for prophylactic purposes, both breasts may be removed. If a woman is planning immediate breast reconstruction surgery, skin-sparing mastectomy can be done. This means, most of the skin over the breast is left intact (outside of the nipple and areola). The amount of breast tissue removed is the same as with total mastectomy but many women prefer a skin-sparing procedure because it leaves slightly less scar tissue and the reconstructed breast appears more natural. Sometimes the surgeon will leave the nipple and areola intact for prophylactic patients but cancer can grow in them later.

Learn to spot the signs of breast cancer.

Breast Conserving Surgery

This type of surgery spares most of the breast and only cuts out the cancerous lump and a small area of surrounding tissue. Once a biopsy has been carried out and a breast cancer diagnosis given, the surgeon will cut out the cancerous lump but he will also cut a wider swatch of healthy tissue for security purposes (known as a wide excision). Depending on how much tissue is removed, this can be labeled as a lumpectomy, segmental resection, tylectomy, quadrantectomy or partial mastectomy. There is no exact definition of which is which. In all cases the skin usually re-grows over afterwards and only a small scar remains. Years ago when doctors first started performing these types of surgeries they discovered that a breast cancer recurrence appeared in nearly 40 percent of patients. That is why today, physicians add several weeks of daily breast radiation to the overall treatment plan.

First introduced in 1990, this surgery removes only the breast lump and some normal tissue around it. It is recommended for stage 1 and 2 breast cancer and the survival rate is the same as that for total mastectomy – but with the added benefit that most of the breast is saved. Lumpectomies have become increasingly popular procedures because the breast remains normal looking except for a small scar and slight contour change. Side effects are minimal.

Partial Mastectomy
This involves removal of the cancerous lump and a segment of the breast (larger segment than lumpectomy). The appearance of the breast is noticeably changed as a result of this surgery but it can be reconstructed later. This surgery is also called quandrantectomy, wide excision and segmental mastectomy.

If cancer cells are discovered at the edge of the tissue removed in either lumpectomy or partial mastectomy, it is said to have positive margins. A negative or clear margin is where no cancer cells are found. If positive margins are discovered, the surgeon may need to re-operate to remove more tissue. This is called re-excision. If not enough tissue can be removed to create a clear margin, then total mastectomy will be recommended.

When Do Women Choose Mastectomies Over Lumpectomies?

Some women with early stage cancer may choose mastectomy because they want to totally rid their body of cancerous tissue, or because they fear undergoing radiation or chemotherapy (see Chemotherapy Guide).

Older women, particularly those who live far away from radiation treatment facilities may want to get the whole treatment over with and therefore choose mastectomy.

For women with stage 3 cancer, or women with more than one lump, total mastectomy may be the only choice.

In other instances, women with small breasts may not save much of the breast by choosing lumpectomy, even with stage 1 or 2 cancer.

The classic treatment for lobular carcinoma in situ (abnormal cell growth in the breast lobes) was the removal of both breasts. This condition is considered a cancer risk factor, rather than cancer itself. Today women with LCIS are usually monitored with a regular mammogram and surgery is only recommended if it spreads. Some women however are not prepared to live with the risk of cancer developing, so opt for mastectomy. This is particularly true of women who have tested positive for BRCA mutations via breast cancer genetic testing and where there is a strong family history of the disease.

With ductal carcinoma in situ, that is a mass of cancerous cells which are still in the mammary duct and have not invaded the breast, the traditional cure was also mastectomy. Some women will still choose it, preferring the peace of mind knowing that it is a cure. However these tumors are small and can be dealt with by lumpectomy and radiation. In fact this combination-treatment is just as effective as a mastectomy in this instance. Then again, some women choose not to even treat ductal carcinoma in situ, preferring to wait and see if it invades the breast tissue or not.

What Happens During Surgery?

Most total- and partial mastectomies are performed in hospital under general anesthesia. The operation can last anywhere between 1 and 2 hours, depending on how much of the tissue is to be removed. Lumpectomy can be performed with local anesthesia. When she wakes the woman will find that the breast area is covered with bulky bandages. She will also have an IV still in place for antibiotics and pain medications. A mastectomy requires several days hospitalization, with fewer days for less extensive surgeries. Drainage tubes from the underarm or breast are left in place for a few days. Dressings are changed regularly and stitches are removed on about day 5. It normally takes about 2 weeks for the surgical incision to heal. Many women are surprised to learn how little pain they feel in the breast area. However it is common to feel pain and swelling in the arm area which may or may not disappear with time. Some women describe a pins and needles feeling in the armpits.

Possible Complications

Occasionally some women experience what is known as post-mastectomy pain syndrome. This is a severe pain which has been described as shooting and burning. This complication is being studied but it probably related to nerve damage. One therapy that appears to be effective is rubbing the affected area with 0.025 percent capsaicin and taking amitriptyline pills. Amitriptyline is an anti-depressant but also helps to reduce nerve pain.

Some women report a 'phantom limb' sensation in the area of the missing breast. They may benefit from gentle massage in the area once the wound has healed.

Is Surgery More Successful Later In The Menstrual Cycle?

You may have heard of some studies which suggest that the outcome for premenopausal women who undergo breast cancer surgery is better if the surgery is performed during the second half of their menstrual cycle. The theory is that the cancer cells will be 'sticker' and less likely to shoot off to other parts of the body during surgery (Medical Center in Albany, N.Y., 1988). Other subsequent research into the area has come up with conflicting results, with larger studies indicating there is no difference. The National Surgical Adjuvant Breast and Bowel Project (NSABP) are currently carrying out a 900 women study on the subject.

We've Come A Long Way...

Until the mid 1970s the classical treatment for breast cancer in America was radical mastectomy. The operation, called the Halsted procedure (after the surgeon who invented it), removed the breast, muscle tissue of the chest wall and all lymph nodes and fat from the nearby armpit. It required a surgical incision from the armpit down to the midline of the chest which left a very large and ugly scar. The woman was not only permanently disfigured but also disabled because so much muscle tissue was removed. She was also prone to infections because all the lymph nodes were removed. The surgery was based on the premise that cancer expands out in an orderly fashion from the original site of infection to other parts of the body via the lymph nodes. Eventually scientists discovered that cancer can metastasize, or spread, to other parts of the body through the blood stream, even small cancers, without touching the lymph nodes. This is why the procedure did not always cure women of cancer. By 1979 radical mastectomies had virtually disappeared. They were replaced by the modified radical mastectomy. In this procedure the breast, underarm lymph nodes and part of the chest muscle are still removed but the chest wall retains its shape and the woman does not lose strength or mobility in her arms. Today however it is only likely to be performed if cancer is particularly invasive. As a procedure, it too has been usurped and has largely been replaced by total mastectomy.

Useful: See Breast cancer prevention and books on breast cancer providing information on treatments, risk factors and survivor stories.

After Surgery

After surgery the woman will need to decide if she wants to live with a missing breast(s) or if she is going to have reconstruction surgery. Most hospitals will initially provide women with a prosthesis breast that fits into the bra without irritating the scar area. A variety of prosthesis’s are available and they can even be custom made. For example it is possible to permanently install a prosthesis into a bra. If you are considering using prosthesis, contact the American Cancer Society's Reach to Recovery Program. It is staffed by volunteer women who use breast prosthesis themselves. They can provide information about fittings and suppliers. The society also sponsor a problem called ENCORE which helps women find prosthesis and special clothing.

Also, find out about: Hormone Therapy For Breast Cancer

Questions To Ask The Surgeon

1. How many mastectomies have you performed?
Ideally he should perform at least 15 a month.
2. Do you perform skin-sparing surgery?
That is removing the breast but saving the skin for cosmetic purposes.
3. Do you offer nipple-sparing surgery?
4. Do you perform a sentinel-node biopsy?
That is taking a sample of lymph nodes to test for spread of cancer.
5. Do you ever recommend chemo before surgery (neoadjuvant therapy). If not, why not? If so, when do you?

Related Articles on Breast Cancer

For more cancer information, see the following:

Cancer Guide
Breast Self Examination

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