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Breast Cancer Surgery Options
The two types of surgery used for primary treatment of breast cancer are a partial mastectomy (lumpectomy) and a total or complete mastectomy. With either of these procedures, lymph nodes under the arm (axillary nodes) are removed for biopsy and more are removed if there is documented spread to these nodes. In addition, reconstructive surgery may be done to rebuild the breast to look similar to its preoperative appearance. Other surgery that may be considered is a prophylactic (preventive) mastectomy of the opposite breast in limited circumstances.
It is important to note that both types of surgery are associated with similar long-term survival, but each one has its unique set of side effects and complications. Because of this, a woman’s perspective on quality of life is an important consideration in deciding which surgery to have.
A lumpectomy involves the removal of less breast tissue than a mastectomy, with removal of only the tumor and immediately surrounding (healthy) breast tissue rather than the entire breast. Lumpectomy is used in conjunction with radiation therapy to sterilize any remaining tumor cells elsewhere in the breast. The combination of surgery and radiation is called breast-conserving treatment. Lumpectomy is usually done for ductal carcinoma in situ (DCIS) or for stage I invasive breast cancer (a tumor that is less than 4-5 cm). A pathologist will examine the margin (outside) of the breast tissue to see if cancer cells are present.
A lumpectomy is not usually recommended for women who have larger tumors. However, if a woman has a strong desire to save the breast, neoadjuvant chemotherapy can be considered to shrink the breast cancer to a level that a partial mastectomy may be feasible and safe.
A mastectomy is necessary for larger tumors or scattered tumors in the breast. Treatment guidelines developed by the National Comprehensive Cancer Network (NCCN) recommend that women with stage IIIA, IIIB, or IIIC breast cancer receive neoadjuvant chemotherapy before mastectomy. Some women with small tumors may wish to have a mastectomy because it offers greater peace of mind about recurrences in the breast or late complications associated with radiation. A mastectomy instead of lumpectomy may also be desired in order to avoid the need for breast radiation therapy altogether.
Because of advances in surgical techniques and knowledge about breast cancer, most mastectomies performed today are much less extensive and disfiguring than those done a decade or two ago. Mastectomy once meant removal of the entire breast with cancer, the chest wall muscles underneath the breast, and all the axillary nodes. This type of mastectomy is called a radical mastectomy, and it is rarely done, and only for extensive tumors or tumors that have invaded the chest wall. Most often, a total mastectomy is performed, which preserves the underlying muscles.
For women with normal-appearing lymph nodes, the usual approach is to perform sentinel node biopsy. The sentinel node is the one closest to the tumor, defined as the one to which cells will first travel. Any spread of cancer is most likely to travel first to the sentinel node. If no cancer cells are detected, then all downstream (farther away) lymph nodes are likely to be free of tumor also, and no further surgery is necessary. If cancer is detected in the sentinel node, the surgeon must remove other nodes in the region because they may also be infected with breast cancer cells.
Removal of lymph nodes (known as axillary dissection) is a necessary treatment to prevent further growth and spread of the cancer, and it also allows the pathologist to determine the extent of lymph node involvement. The process of examining the nodes is known as lymph node staging, and the results are a factor in determining the final treatment plan, with regard to adjuvant therapy.
In general, at least 15 lymph nodes are removed, but the number can range from 10 to 30 depending on several factors, such as how many nodes the surgeon thinks are involved with cancer, how many nodes a woman has in the area, whether the features of the tumor indicate a favorable prognosis (outcome), and whether the choice of treatment will be affected by the number of nodes involved.
The removal of a large number of lymph nodes is sometimes associated with several side effects, including numbness or loss of sensation of the skin in the armpit and lymphedema..
Breast reconstructive surgery is done by an experienced plastic surgeon. This surgery is usually done at the time of total mastectomy or later (within months after mastectomy).
Immediate reconstruction can be done for early-stage (stage I or some stage II) breast cnacers, but it is usually best to wait for reconstruction if the breast cancer is more advanced (stage III or some stage II). Increasingly, a “skin-sparing mastectomy” and temporary breast implants are used as the initial process of breast reconstructive surgery, with the final stages of reconstruction performed after all the cancer treatments are completed. If you are to have a mastectomy and think you will want reconstructive surgery, it is best to discuss your choice with your cancer surgeon and a plastic surgeon before the mastectomy so they can properly plan your treatment, even if the reconstructive surgery will not be done until later.
Reconstructive surgery cannot be done for all types of breast cancer. Women who do not want or cannot have reconstructive surgery can be fitted with a breast prosthesis. This prosthesis is a breast form (made of artificial materials) that you put in your bra to make your breast look natural and balanced.
Other types of surgery may be appropriate for women with breast cancer. Many women who are at higher than average risk for ovarian cancer or cancer in the contralateral (opposite) breast choose to have prophylactic removal of the ovaries (ovarian ablation) to reduce the risk of ovarian cancer or a second breast cancer. Women at higher risk for breast cancer may also wish to have prophylactic mastectomy of the contralateral breast as a precaution against the future development of cancer, oftentimes with immediate breast reconstructive surgery.
Your doctor can help you determine whether you are at high risk for either ovarian or another breast cancer. He or she may refer you to a genetic counselor, a specially trained health professional who can provide information and advice about inherited conditions and help you decide if you are at high risk. Prophylactic removal of the ovaries or the breast has substantial side effects, such as infertility (the inability to have children), potential risks to bone and heart health, early menopause, and negative body image. These side effects must be weighed against the potential benefits of the surgery.
- American Cancer Society: www.cancer.org, Detailed Guide to Breast Cancer; Breast Cancer Profiler Tool(decision-making tool)
- ASCO's patient Web site: www.cancer.net, Breast Cancer Treatment
- Breastcancer.org: www.breastcancer.org, Treatment and Side Effects
- Susan G. Komen for the Cure: www.komen.org, Understanding Cancer: Treatment
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