Breast Health Information

Most women with breast cancer have some type of surgery. Operations for local treatment include breast-conserving surgery, mastectomy, and axillary (armpit) lymph node sampling and removal. Women who have breast surgery may also decide to have breast reconstruction, either at the same time or later on.

Breast-conserving surgery

In these types of surgery, only a part of the affected breast is removed, although how much is removed depends on the size and location of the tumor and other factors. If radiation therapy is to be given after surgery, small metallic clips (which will show up on x-rays) may be placed inside the breast during surgery to mark the area for the radiation treatments.

Lumpectomy removes only the breast lump and a surrounding margin of normal tissue. Radiation therapy is usually given after a lumpectomy. If adjuvant chemotherapy is to be given as well, the radiation is usually delayed until the chemotherapy is completed.

Partial (segmental) mastectomy or quadrantectomy removes more breast tissue than a lumpectomy. For a quadrantectomy, one-quarter of the breast is removed. Radiation therapy is usually given after surgery. Again, this may be delayed if chemotherapy is to be given as well.

If the pathologist finds there is cancer at the edge (margin) of the piece of tissue removed by breast-conserving surgery, the surgeon may need to go back and remove more tissue. This operation is called a re-excision. If the surgeon can't remove enough breast tissue to get clear surgical margins, a mastectomy may be needed.

For most women with stage I or II breast cancer, breast conservation therapy (lumpectomy/partial mastectomy plus radiation therapy) is as effective as mastectomy. Survival rates of women treated with these 2 approaches are the same. However, breast conservation therapy is not an option for all women with breast cancer.

Radiation therapy can sometimes be omitted as a part of breast-conserving therapy. Women who may consider lumpectomy without radiation therapy typically have all of the following characteristics:

• they are age 70 years or older
• they have a tumor 2 cm or less that has been completely removed
• the tumor is hormone receptor-positive, and the women is getting hormone therapy (such as tamoxifen)
• they have no lymph node involvement

Possible side effects: Side effects of these operations can include pain, temporary swelling, tenderness, and hard scar tissue that forms in the surgical site. As with all operations, bleeding and infection at the surgery site are also possible.

The larger the portion of breast removed, the more likely it is that there will be a noticeable change in the shape of the breast afterward. If the breasts may look very different after surgery, it may be possible to have some type of reconstructive surgery (see below), or to have the unaffected breast reduced in size to make the breasts more symmetrical. It may even be possible to have this done during the initial surgery. It's very important to talk with your doctor (and possibly a plastic surgeon) before surgery to get an idea of how your breasts are likely to look afterward, and to learn what your options might be.

Mastectomy

Mastectomy involves removing all of the breast tissue, sometimes along with other nearby tissues.

In a simple or total mastectomy the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast. Sometimes this is done for both breasts (a double mastectomy), especially when it is done as preventive surgery in women at very high risk for breast cancer. Most women, if they are hospitalized, can go home the next day.

A modified radical mastectomy involves removing the entire breast and some of the axillary (underarm) lymph nodes. This is the most common surgery for women with breast cancer who are having the whole breast removed.

For some women who have smaller tumors, one option may be a newer procedure known as a skin-sparing mastectomy, where most of the skin over the breast (other than the nipple and areola) is left intact.

A radical mastectomy is an extensive operation where the surgeon removes the entire breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast. This surgery was once very common. But because of the disfigurement and side effects it causes, and because a modified radical mastectomy has been proven to be as effective as a radical mastectomy, it is rarely done today.

Possible side effects: Aside from post-surgical pain and the obvious change in the shape of the breast(s), possible side effects of mastectomy and lumpectomy include wound infection, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If axillary lymph nodes are also removed, other side effects may occur.

Choosing between lumpectomy and mastectomy

Many women with early stage cancers can choose between breast-conserving surgery and mastectomy.

The main advantage of a lumpectomy is that it allows a woman to keep most of her breast. A disadvantage is the usual need for radiation therapy -- most often for 5 to 6 weeks -- after surgery. (A small number of women having breast-conserving surgery may not need radiation (see above), while a small percentage of women who have a mastectomy will still need radiation therapy to the breast area.)

When deciding between a lumpectomy and mastectomy, be sure to get all the facts. You may have an initial gut preference for mastectomy as a way to "take it all out as quickly as possible." Women tend to prefer mastectomy more often than their surgeons do because of this feeling. But the fact is that in most cases, mastectomy does not give you any better chance of long-term survival or a better outcome from treatment. Studies following thousands of women for more than 20 years show that when a lumpectomy can be done, mastectomy does not provide any better chance of survival than lumpectomy.

Although most women and their doctors prefer lumpectomy and radiation therapy when it's a reasonable option, your choice will depend on a number of factors, such as:

• how you feel about losing your breast
• how you feel about getting radiation therapy
• how far you would have to travel and how much time it would take to have radiation therapy
• whether you think you will want to have more surgery to reconstruct your breast after having a mastectomy
• your preference for mastectomy as a way to 'get rid of all your cancer as quickly as possible'
• your fear of cancer recurrence

For some women, mastectomy may clearly be a better option. For example, lumpectomy or breast conservation therapy is usually not recommended for:

• women who have already had radiation therapy to the affected breast

• women with 2 or more areas of cancer in the same breast that are too far apart to be removed through 1 surgical incision, while keeping the appearance of the breast satisfactory

• women whose initial lumpectomy along with re-excision(s) has not completely removed the cancer

• women with certain serious connective tissue diseases such as scleroderma or lupus, which may make them especially sensitive to the side effects of radiation therapy

• pregnant women who would require radiation while still pregnant (risking harm to the fetus)

• women with a tumor larger than 5 cm (2 inches) across that doesn't shrink very much with neoadjuvant chemotherapy

• women with a cancer that is large relative to her breast size

Other factors may need to be taken into account as well. For example, young women with breast cancer and a known BRCA mutation are at very high risk for a second cancer. These women may want to consider having a mastectomy, or even a double mastectomy, to both treat the cancer and reduce this risk.

Axillary lymph node dissection (ALND)

To determine if the breast cancer has spread to axillary (underarm) lymph nodes, some of these lymph nodes may be removed and looked at under the microscope. This is an important part of staging and determining treatment and outcomes. When the lymph nodes are affected, there is an increased likelihood that cancer cells have spread through the bloodstream to other parts of the body.

As noted above, axillary lymph node dissection is part of a radical or modified radical mastectomy procedure. It may also be done along with a breast-conserving procedure, such as lumpectomy. Anywhere from about 10 to 40 (though usually less than 20) lymph nodes are removed.

The presence of cancer cells in the lymph nodes under the arm is an important factor in considering adjuvant therapy. Axillary dissection is used as a test to help guide other breast cancer treatment decisions.

Possible side effects: As with other operations, pain, swelling, bleeding, and infection are possible.

The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling of the arm). This occurs because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system. Removing the lymph nodes sometimes causes this fluid to remain and build up in the arm.

About 1 of 4 women who have underarm lymph nodes removed develops lymphedema. It also occurs in up to 5% of women who have a sentinel lymph node biopsy (see below). Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling lasts a long time. If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away.

You may also have short or long-term limitations in moving your arm and shoulder after surgery. Numbness of the skin of the upper, inner arm is another common side effect because the nerve that controls sensation here travels through the lymph node area.

Sentinel lymph node biopsy (SLNB)

Although axillary lymph node dissection (ALND) is a safe operation and has low rates of serious side effects, in many cases doctors may instead do a sentinel lymph node biopsy, which is a way of learning if cancer has spread to lymph nodes without removing all of them.

In this procedure the surgeon finds and removes the "sentinel node" (or nodes) -- the first lymph node(s) into which a tumor drains, and the one(s) most likely to contain cancer cells if they have started to spread. To do this, the surgeon injects a radioactive substance and/or a blue dye into the area around the tumor or into the skin over the tumor. Lymphatic vessels will carry these substances into the sentinel node(s) over the next few hours. The doctor can use a special device to detect the radioactivity in the nodes that the radioactive substance flows into or can look for lymph nodes that have turned blue. (These are separate ways to find the sentinel node, but are often done together as a double check.) The doctor then makes an incision in the skin over the area and removes the nodes. These nodes (often 2 or 3) are then looked at closely by the pathologist. (Because fewer nodes are removed than in an ALND, each one can be looked at very closely for any cancer, which helps make this test about as accurate as ALND.)

If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed. The patient can avoid the potential side effects of a full ALND (see above).

If the sentinel node(s) has cancer, the surgeon will do a full axillary lymph node dissection to see how many other lymph nodes are involved. This may be done at the same time or several days after the original sentinel node biopsy. The timing depends on how easily the cancer can be seen in the lymph node at the time of surgery. If it is obvious that the sentinel node contains cancer, the surgeon can do an axillary dissection right away. But at other times the cancer may only be found by thorough microscopic study by a pathologist after the SLNB is complete.

A sentinel lymph node biopsy is not always appropriate. It is most suitable if there is a single tumor less than 5 cm across in the breast, no chemotherapy or hormone therapy has been given, and the lymph nodes do not feel enlarged.

Sentinel lymph node biopsy requires a great deal of skill. It should be done only by a surgical team known to have experience with this technique. If you are thinking about having this type of biopsy, ask your health care team if they do them regularly.

Reconstructive surgery

Following a mastectomy (or some breast-conserving surgeries), a woman may want to consider having the breast mound rebuilt; this is called breast reconstruction. These procedures are not done to treat cancer but to restore the breast's appearance after surgery. If you are going to have breast surgery and are thinking about having reconstruction, it is important to consult with a plastic surgeon who is an expert in breast reconstruction before your surgery.

Decisions about the type of reconstruction and when it will be done depend on each woman's medical situation and personal preferences. You may have a choice between having your breast reconstructed at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). There are several types of reconstructive surgery. Some use saline (salt water) or silicone implants, while others use tissues from other parts of your body (autologous tissue reconstruction).

What to expect with surgery

For many, the thought of surgery can be frightening. But with a better understanding of what to expect before, during, and after the operation, many fears can be relieved.

Before surgery: The common biopsy procedures let you find out if you have breast cancer within a few days of your biopsy, but the extent of the breast cancer will not be known until after imaging tests and the surgery for local treatment are done.

You usually meet with your surgeon a few days before the operation to discuss the procedure. This is a good time to ask specific questions about the surgery and review potential risks. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward. If you are thinking about breast reconstruction, ask about this as well.

You will be asked to sign a consent form, giving the doctor permission to perform the surgery. Take your time and review the form carefully to be certain that you understand what you are signing. Sometimes, doctors send material for you to review in advance of your appointment, so you will have plenty of time to read it and won't feel rushed. You may also be asked to give consent for researchers to use any tissue or blood that is not needed for diagnostic purposes. Although this may not be of direct use to you, it may be very helpful to women in the future.

You may be asked to donate blood before some operations, such as a mastectomy combined with natural tissue reconstruction, if the doctors think a transfusion might be needed. You might feel more secure knowing that if a transfusion is needed, you will receive your own blood. If you do not receive your own blood, it is important to know that in the United States, blood transfusion from another person is nearly as safe as receiving your own blood. Ask your doctor about your possible need for a blood transfusion.

Your doctor will review your medical records and ask you about any medicines you are taking. This is to be sure that you are not taking anything that might interfere with the surgery. For example, if you are taking a blood-thinning medicine (even aspirin), you may be asked to stop taking the drug about a week or two before the surgery. Be sure you tell your doctor about everything you take, including vitamins and herbal supplements. Usually, you will be told not to eat or drink anything for 8 to 12 hours before the surgery, especially if you are going to have general anesthesia (will be "asleep" during surgery).

You will also meet with the anesthesiologist or nurse anesthetist, the health professional who will be giving you the anesthesia during your surgery. The type of anesthesia used depends largely on the kind of surgery being done and your medical history.

Surgery: Depending on the likely extent of your surgery, you may be offered the choice of an outpatient procedure (where you go home the same day) or you may be admitted to the hospital.

General anesthesia is usually given whenever the surgery involves a mastectomy or an axillary node dissection, and is most often used during breast-conserving surgery as well. You will have an IV (intravenous) line put in (usually into a vein in your arm), which the medical team will use to give medicines that may be needed during the surgery. Usually you will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery.

The length of the operation depends on the type of surgery being done. For example, a mastectomy with axillary lymph node dissection will usually take from 2 to 3 hours. After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your condition and vital signs (blood pressure, pulse, and breathing) are stable.

After surgery: How long you stay in the hospital depends on the type of surgery being done, your overall state of health and whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. Decisions about the length of your stay should be made by you and your doctor and not dictated by what your insurance will pay, but it is important to check your insurance coverage before surgery.

In general, women having a mastectomy and/or axillary lymph node dissection stay in the hospital for 1 or 2 nights and then go home. However, some women may be placed in a 23-hour, short-stay observation unit before going home. In this situation, a home care nurse may visit you to monitor and provide care.

Less involved operations such as lumpectomy and sentinel lymph node biopsy are usually done in an outpatient surgery center, and an overnight stay in the hospital is usually not needed.

You will have a dressing (bandage) over the surgery site that may snugly wrap around your chest. You may have one or more drains (plastic or rubber tubes) coming out from the breast or underarm area to remove blood and lymph fluid that collects during the healing process. Your health care team will teach you how to care for the drains, which may include emptying and measuring the fluid and identifying problems the doctor or nurse needs to know about. Most drains stay in place for 1 or 2 weeks. When drainage has decreased to about 30 cc (1 fluid ounce) each day, the drain will usually be removed.

Doctors rarely put the arm in a sling to hold it in place. Most doctors will want you to start moving your arm soon after surgery so that it won't get stiff.

Many women who have a lumpectomy or mastectomy are often surprised by how little pain they have in the breast area. But they are less happy with the strange sensations (numbness, pinching/pulling feeling) they may feel in the underarm area.

Ask your health care team how to care for your surgery site and arm. Usually, they will give you and your caregivers written instructions about care after surgery. These instructions should include:

• the care of the surgical wound and dressing
• how to monitor drainage and take care of the drains
• how to recognize signs of infection
• when to call the doctor or nurse
• when to begin using the arm and how to do arm exercises to prevent stiffness
• when to resume wearing a bra
• when to begin using a prosthesis and what type to use (after mastectomy)
• what to eat and not to eat
• use of medications, including pain medicines and possibly antibiotics
• any restrictions of activity
• what to expect regarding sensations or numbness in the breast and arm
• what to expect regarding feelings about body image
• when to see your doctor for a follow-up appointment
• referral to a Reach to Recovery volunteer. Through the Reach to Recovery program, a specially trained volunteer who has had breast cancer can provide information, comfort, and support.

Most patients see their doctor about 7 to 14 days after the surgery. Your doctor should explain the results of your pathology report and talk to you about the need for further treatment. If you will need more treatment, you may be referred to a radiation oncologist and/or a medical oncologist. If you are thinking about breast reconstruction, you may be referred to a plastic surgeon as well.

Post-mastectomy pain syndrome

Post-mastectomy pain syndrome (PMPS) is chronic nerve (neuropathic) pain after lumpectomy or mastectomy. Studies have shown that between 20% to 60% of women develop PMPS after surgery, but it is often not recognized as such. The classic signs of PMPS are chest wall pain and tingling down the arm. Pain may also be felt in the shoulder, scar, arm, or armpit. Other common complaints include numbness, shooting or pricking pain, or unbearable itching.

PMPS is thought to be linked to damage done to the nerves in the armpit and chest during surgery. But the causes are not known. Because major surgeries are less often used to treat breast cancer today, PMPS is becoming less of a problem.

It is important to talk to your doctor about any pain you are having. PMPS can cause you to not use your arm the way you should and over time you could lose the ability to use it normally.