Breast conservation therapy: Lumpectomy removes only the breast lump and a surrounding margin of normal tissue. If examination of the tissue removed by lumpectomy finds there is cancer at its the edge of the piece of tissue removed (margin), the surgeon may need to remove additional tissue. This operation is called a re-excision. Radiation therapy is usually given at some time after a lumpectomy. If there is to be chemotherapy, the radiation is usually delayed until the chemotherapy is no longer being given.

Partial or segmental mastectomy or quadrantectomy removes more breast tissue than a lumpectomy (up to one-quarter or more of the breast). Radiation therapy is usually given after surgery.

Side effects of these operations include temporary swelling and tenderness and hardness due to scar tissue that forms in the surgical site.

Mastectomy: In a simple or total mastectomy the surgeon removes the entire breast but does not remove underarm lymph nodes or muscle tissue from beneath the breast. This operation is sometimes used to treat stage 0 breast cancers.

Modified radical mastectomy involves the removal of 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.

Radical mastectomy is an extensive operation removing 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 modified radical mastectomy has been proven to be as effective as radical mastectomy, it is rarely done.

Possible side effects of mastectomy and lumpectomy include wound infection, hematoma (accumulation of blood in the wound), and seroma (accumulation of clear fluid in the wound). If axillary lymph nodes are also removed, additional side effects may occur, which are described in the section below on "Axillary Dissection."

Choosing between lumpectomy and mastectomy: The advantage of lumpectomy is that it saves the appearance of the breast. A disadvantage is the need for several weeks of radiation therapy after surgery. However, a small percentage of women who have a mastectomy still need radiation therapy to the breast area.

Women with a small lump who choose lumpectomy and radiation can expect the same chance of survival as those who choose mastectomy. Although most women and their doctors prefer lumpectomy and radiation therapy, your choice will depend on a number of factors, such as:

• How you feel about losing your breast
• How far you have to travel for radiation therapy
• Whether you are willing 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'

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
• Women whose initial lumpectomy along with re-excision has not completely removed the cancer
• Women with certain serious connective tissue diseases such as scleroderma, which 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) that doesn’t shrink very much with chemotherapy
• Women with a cancer that is large relative to a smaller-sized breast.

Surgical Treatments for Breast Cancer

Axillary dissection: To determine if the breast cancer has spread to axillary (underarm) lymph nodes, some of these lymph nodes are removed (in an operation called axillary dissection) and examined under the microscope.

As noted previously, axillary dissection is part of a radical or modified radical mastectomy procedure and is usually combined with a breast-conserving procedure such as lumpectomy.

Whether cancer cells are present in the lymph nodes under the arm is an important factor in selecting adjuvant therapy. It was once believed that removing as many lymph nodes as possible would reduce the risk of spread to other parts of the body and improve the chance of curing the cancer.

It is now known that breast cancer cells that have spread beyond the breast and axillary lymph nodes are best treated by systemic therapy. Axillary dissection is used as a test to help guide other breast cancer treatment decisions.

The main side effect of removing axillary lymph nodes is lymphedema (swelling of the arm). About 10% to 30% of women who have underarm lymph nodes removed develop lymphedema. Ways to help prevent or reduce the effects of lymphedema are discussed in the section "What Happens After Treatment for Breast Cancer?". If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team promptly.

You may also have temporary or permanent limitations in arm and shoulder movement after surgery. Numbness of the upper inner arm skin is another common side effect because the nerve controlling this skin sensation travels through the lymph node area.

Sentinel lymph node biopsy (SLNB): Although lymph node dissection is a safe operation and has low rates of serious side effects, doctors have have developed another way of learning if cancer has spread to lymph nodes without removing all of them first. This procedure is called sentinel lymph node biopsy.

In this procedure the surgeon finds and removes the "sentinel node" --the first lymph node into which a tumor drains, and the one most likely to contain cancer cells. The surgeon first injects a radioactive substance and a blue dye into the area around the tumor. Lymphatic vessels carry these substances into the sentinel node and provide the doctor with a "lymph node map." The doctor can either see the blue dye or detect the radioactivity with a Geiger counter. He or she then removes the node for examination by the pathologist.

If the sentinel node contains cancer, the surgeon will perform an axillary dissection--removal of more lymph nodes in the armpit. This may be done at the same time or several days after the original sentinel node biopsy. The timing of the axillary dissection depends on how easily the cancer can be seen in the lymph node at the time of surgery. Sometimes it is obvious and other times it will only be found by thorough microscopic study by a pathologist.

If the sentinel node is cancer-free, the patient will not need more lymph node surgery and can avoid the side effects of full lymph node surgery, discussed further on (see the section on lymphedema in "What Happens After Treatment for Breast Cancer?").

This limited sampling of lymph nodes is not always appropriate. It is most suitable if there is a single tumor less than 5 cm in the breast, no prior chemotherapy or hormone therapy has been given, and the lymph nodes do not feel enlarged.

Sentinel lymph node biopsy is a complex technique that requires a great deal of skill. Therefore, doctors recommend that sentinel lymph node biopsy be done only by a team known to have experience with this technique. If you are considering having such a biopsy, ask your health care team if this is something they do regularly.

Reconstructive surgery and breast implant surgery: These procedures are not done to treat cancer but to restore the breast's appearance after mastectomy. If you are going to have a mastectomy and are thinking about having reconstruction immediately, it's important to consult with a plastic surgeon who is an expert in breast reconstruction before the surgery.

Decisions about the type of reconstruction and when it will be done depend on each woman’s medical situation and personal preferences. Your breast can be reconstructed at the same time as the mastectomy (immediate reconstruction or at a later time (delayed reconstruction). Reconstruction may use implants and/or tissue from other parts of your body (autologous tissue reconstruction).

See our document Breast Reconstruction After Mastectomy for more information. You may also find it helpful to talk with a woman who has had the type of reconstruction you are considering. Our Reach to Recovery volunteers can help you.

What to Expect with Surgery

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

Before surgery: Today, the common procedure for biopsy lets 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 the surgery for local treatment.

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. 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 that 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 you 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 will 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 2 before the surgery. 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.

General anesthesia is usually given whenever the surgery involves a mastectomy or an axillary node dissection. You will be given an IV (intravenous) line 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.

Surgery: For your surgery, you may be offered the choice of an outpatient procedure or you may be admitted to the hospital. How long you stay in the hospital depends on the surgery being performed, 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.

As a general rule, 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, care is continued at home with a home care nurse visiting you to monitor and provide care.

Lumpectomy and sentinel lymph node biopsy are usually done in an outpatient surgery center, and an overnight stay in the hospital is usually not necessary.

The length of the operation depends on the type of surgery being done. For example, a mastectomy with axillary lymph node dissection will take from 2 to 3 hours. After your surgery, you will be taken to a 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: You will have a dressing (bandage) over the surgery site. You may have one or more drains (plastic or rubber tubes) from the breast or underarm area to remove blood and lymph fluid that collects during the healing process. Care of the drains includes 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, often the drain will be removed.

Doctors rarely put the arm in a sling to hold it in place. Most doctors will want you to start moving the arm so that it won’t get stiff. Women who have a lumpectomy or mastectomy are surprised by how little pain they have in the breast area. But they are less happy with the strange sensations (numbness, pinching/pulling feeling) in the underarm area.

Care of the surgery site and arm should be discussed with your doctor. Written instructions about care after surgery are usually given to you and your caregivers. 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
• Any restrictions of activity
• What to expect regarding sensations or numbness in the breast and arm
• What to expect regarding feelings about body image
• A follow-up appointment and referral to a Reach to Recovery volunteer. Through our Reach to Recovery program, a specially trained volunteer who has had breast cancer can provide information, comfort, and support. (See our document Reach to Recovery for more information.)

Most patients see their doctor within 7 to 14 days following 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 will be referred to a medical oncologist and/or radiation oncologist.

Revised 9/04