Breast Cancer Treatment Options: Surgery

Surgery is the most common treatment for breast cancer. There are two main objectives for surgery. The first is to remove the tumor and the second is to evaluate the lymph nodes to determine if the cancer has spread.

Removing the Tumor

There are two types of surgery to remove the cancer, Lumpectomy and Mastectomy:

Lumpectomy

This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. This is an outpatient procedure so you are home the same day. The survival rate for lumpectomy is the same as for mastectomy where the whole breast is removedHowever, the chances of the cancer coming back in the breast after a lumpectomy alone is 39.2%. You can reduce the chances of the cancer coming back in the breast after a lumpectomy by having radiation therapy. With radiation, the chances of the cancer coming back in the breast is 14.3%. This is why radiation is critical after a lumpectomy. You will have radiation 5 days a week for 6 weeks. In general, each treatment is short (about 15 minutes), but you must commit to having radiation therapy if you want to have a lumpectomy.

Lumpectomy may not be an option if you:

• have already had radiation therapy;
• have two or more areas of cancer in the same breast that are far apart;
• have a connective tissue disease that makes you sensitive to radiation.

Mastectomy

Mastectomy means your surgeon will remove all your breast tissue - the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. You have a 5 percent chance of recurrence with a mastectomy. There are two types of mastectomy:

• Conventional mastectomy means your surgeon will remove your entire breast. You usually are in the hospital overnight for one day. You will be flat-chested after this procedure, but can wear a prosthesis or have delayed reconstruction.
• Skin-sparing mastectomy is a mastectomy where your surgeon carves out the breast tissue much like you carve out a cantaloupe through a small incision around the areola, leaving the skin behind. This creates an envelope for the plastic surgeon to then "stuff." The envelope retains the same shape as your breast. The cosmetic results of this operation are very good (see image below), however this is an all-day procedure. You are in the hospital about four days, and it takes a couple of weeks to recover. Both skin-sparing and conventional mastectomy have the same survival and local recurrence rates.

Evaluating the Nodes

The second main objective of surgery (after removing the tumor) is to evaluate the lymph nodes. The surgeon does this for two main reasons. The first is that knowing whether the cancer has spread to the lymph nodes tells us about how aggressive the cancer is, and will affect the treatment you receive. This is called staging. The other reason is that if there is cancer in the lymph nodes, we need to treat that cancer to prevent it from growing.

In the past, we could only evaluate the lymph nodes by removing them all. However, this procedure (called an axillary node dissection) has a lot of potential side effects...80% of people will have some numbness under their arm, 15% of people may have some swelling of their arm, and 9% of people may have some decreased range of motion of their shoulder. Taking out all of the lymph nodes does not improve your survival - especially if none of them have cancer.

Today, physicians are using a new procedure called Sentinel Lymph Node Biopsy, which concentrates on locating the sentinel nodes - the first nodes to receive the drainage from breast tumors. Evaluating the sentinel lymph nodes is like looking at the foyer of a house. To enter a house, you must pass through the foyer first. Similarly, for cancer to spread to the rest of the lymph nodes in the armpit, it must pass through the sentinel nodes first. If the foyer is very clean, it is very unlikely that someone tracked mud to the rest of the house (unless of course they jumped over the foyer - which is pretty unlikely!). So if there is no cancer detected in the sentinel nodes, it is very unlikely (<5%) that there is cancer in the remaining lymph nodes and therefore you do not need to have all of the nodes removed. However, if there is mud in the foyer, there might be mud in other parts of the house. Like the mud in the foyer, if breast cancer is going to spread, it will first spread to the lymph nodes under the arm. So if the sentinel lymph node has cancer cells in it, it is possible that there may be cancer in the remaining nodes. In general, your surgeon will remove the remaining nodes to see whether there is any cancer there and also "to clean the house."

The side effects of sentinel node biopsy include blue urine for a couple of days, skin that is temporarily stained blue because of the dye used in the procedure and in less than 1 percent, an allergic reaction.

There is a clinical trial to determine whether surgeons really need to remove all the lymph nodes to clean up the entire house or if radiation will work instead. For more information on this clinical trial and others, click here.

If the cancer has spread

If your cancer has spread beyond your breast to other organs, such as your bones, lungs or liver, it may not be possible to eliminate the cancer at this stage. However, its spread may be controlled with chemotherapy, hormonal therapy or both.

Reconstructive surgery

If reconstruction is an option, your surgeon will refer you to a plastic surgeon who will describe the procedures to you and show you photos of women who have had different types of reconstruction. Your options will include reconstruction with a synthetic breast implant or reconstruction using your own tissue to rebuild your breast. These operations can be performed at the time of your mastectomy or later.

Reconstruction with implants: Using artificial materials to reconstruct your breast entails implanting a silicone shell filled with saline. If you do not have enough muscle and skin to cover an implant, your physician may use a tissue expander, which is an empty implant shell that inflates as fluid is injected. The expander is placed under your skin and muscle, and your physician gradually fills it with fluid - usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant. Recovery may take several weeks. Usually, an implant makes your breast firmer than a normal breast. Implants may cause pain, swelling, bruising, tenderness or infection. They age over time, requiring replacement. They can rupture, deflate and shift over time.

Reconstruction with a TRAM flap: Transverse rectus abdominis myocutaneous (TRAM) flap surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen giving you a tummy tuck. The reconstructed breast looks and feels more natural than an implant, and is permanent.. If you have little body fat, are a smoker, or have had previous abdominal surgery, this type of reconstruction may not be an option for you - check with your plastic surgeon. This is a bigger surgery than implants, and you may experience pain, infection and tummy weakness.. Latissimus Dorsi Flap. This procedure uses muscle from the back and rotates it around to the chest wall to make a breast. It can be combined with an implant.

Reconstruction of your nipple and areola: Once the breast has been reconstructed, you may have further surgery to make a nipple and areola. This is a minor procedure, where your surgeon first creates a small mound to resemble a nipple, and then tattoos the skin around the nipple to create an areola.