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Breast Cancer Surgery

Breast cancer treatment usually begins with surgery to remove the tumourTumour:
An abnormal mass of tissue that occurs when cells divide more than they should or do not die when they should. Tumours may be benign (not cancer) or malignant (cancer). A tumour is also called a neoplasm.
. Your health care team may also recommend an initial treatment of ChemotherapyChemotherapy:
A treatment method that uses medication to destroy cancer cells.
or hormone therapyHormone therapy:
A treatment method for breast cancer that uses medication to block the production of the hormone estrogen, or the way that it works in the body.
, to shrink the tumour before surgery.

Options for surgery include:

Surgery may also include:

If surgery is part of your breast cancer treatment plan, knowing what to expect during breast cancer surgery can help you prepare for it.

Types Of Surgery

Breast conserving surgery (sometimes called a partial mastectomy or lumpectomyLumpectomy:
Surgery to remove a breast tumor and a small margin of surrounding normal tissue.
) only removes part of the affected breast and is less invasive than a mastectomy. The amount of tissue removed will depend on the size and location of the tumour, among other factors. Breast conserving surgery aims to remove the cancer and a small amount of normal breast tissue around it, as a safety margin to try to be sure that all of the cancer has been removed.  Breast conserving surgery is usually followed by radiation therapyRadiation therapy (Sometimes called radiotherapy):
A treatment method that uses a high energy beam to destroy cancer cells by damaging the DNA of cancer cells so that they can’t continue to grow.
to try to destroy any cancer cellsCell:
The basic structural and functional unit of all organisms.
that might be left in the remaining breast tissue.  For most women with stageStage:
A way of classifying breast cancer that describes how far a cancer has spread. It identifies whether breast cancer is at an early, locally advanced or metastatic stage. The stage of breast cancer can sometimes be represented as a number (e.g. between 0 and 4).
I or II breast cancer, the combination of breast conserving surgery and radiation has been shown to be as effective as mastectomy in treating breast cancer.

Breast conserving surgery is not always a treatment option, and sometimes more of the breast needs to be removed.  A simple mastectomy removes the entire breast and nipple.  In some women, more tissue may need to be removed. A modified radical mastectomy removes lymph nodes in the underarm area in addition to the entire breast and nipple. Though rarely performed anymore, a radical mastectomy goes further and removes underlying muscle tissue from the chest wall as well.  This is done in cases where the tumour has invaded the pectoral muscle. After a mastectomy, small tubes may be placed temporarily in the area operated on or under the arm to help drain fluid and blood that collects during healing.

Your treatment plan

The surgical option that is best for you will depend on many factors, including the characteristics of your breast cancer, the size and location of the tumour, whether or not you require radiation therapy after surgery, your risk of recurrenceRecurrence:
Cancer that returns after treatment.
(the cancer coming back), and your personal preferences. It may take some time for you to consider your options and weigh the benefits and limitations of each type of surgery.

Most women will have the choice of either lumpectomy or mastectomy. For some women, a surgeon may recommend a mastectomy over a lumpectomy, for example if the tumour is very large and you have very small breasts, or if you have extensive ductal carcinoma in situDuctal carcinoma in situ (DCIS):
The most common type of noninvasive breast cancer. In DCIS, the cancer is confined to the lining of the milk ducts.
(DCIS).

Having your breast removed can be a very emotional and difficult decision, and it can be hard to predict how you will react to losing a breast until it happens. It’s normal to feel anxious, sad, uncertain or even angry about having to lose a part of your body that you may associate with your identity as a woman. If you require (or choose) to have a mastectomy, ask your surgeon about your options for breast reconstruction. Some women will have the choice to have breast reconstruction at the same time as their mastectomy while others will have to wait until their treatment is complete. Some women also choose not to have reconstruction and may opt for a breast prosthesisProsthesis (breast):
An artificial breast form that looks like a breast and is worn either inside a bra or attached to the body with special adhesive.
instead.

Learn about and take some time to consider the options available to you, and discuss any concerns you have with your health care team. Their advice and your preferences are important considerations in helping you decide on your treatment plan, including the type of surgery you have, and reconstruction if you choose it.

Lymph Node Removal

Breast cancer surgery often includes the removal of lymph nodes from the underarm area of the affected breast(s) for further examination in a lab. This procedure is done to see if the cancer has spread (metastasizedMetastatic (metastases):
The spread of cancer from its original (primary) location to another part of the body. A tumour that is formed by cancer cells that have spread to another part of the body is called a “metastatic tumour” or a “metastasis.”
) beyond the breast. Non-invasiveNoninvasive (breast cancer):
Breast cancer that does not spread beyond the tissue where it originally developed (i.e., confined to the milk ducts or lobules of the breast).
types of breast cancer (e.g., ductal carcinoma in situ, or DCIS), do not need any lymph nodes to be checked, because they do not metastasize.

Examination of the lymph nodes is important because the presence or absence of cancer in the lymph nodes helps your oncologistOncologist:
A doctor or surgeon who specializes in treating cancer. A medical oncologist specializes in drug therapy (chemotherapy) for cancer. A radiation oncologist specializes in treating cancer with radiation.
understand whether and how your disease might progress. The information gained from the lymph nodes helps you and your health care team make informed decisions about your treatment plan.

There are two procedures to remove lymph nodes:

Benefits of sentinel node biopsy over axillary node dissection

In 2011, the American College of Surgeons Oncology Group reported on a clinical trialClinical trial:
One of the most common types of experimental studies in humans is the clinical trial. Clinical trials are designed to test new ways to prevent, detect, and treat specific diseases.
in women with early stage invasiveInvasive (breast cancer):
Cancer that spreads from where it started in the breast (i.e., the breast ducts or lobules) into surrounding, healthy breast tissue.
breast cancer and signs of metastasis in their sentinel nodes. The study included women who were having breast conserving surgery and radiation, and who had just 1 or 2 positive lymph nodes found by sentinel node biopsy. The study found that the use of sentinel node biopsy alone compared with sentinel node biopsy followed by axillary node dissection led to similar survival rates along with fewer side effects. This research is expected to influence changes in clinical guidelines and to lead to fewer axillary node dissections.

Your surgeon will advise you about whether axillary node dissection is recommended in your case. If only one or two sentinel nodes are positive for the presence of cancer cells, an axillary node dissection may not be recommended if you will be receiving radiation therapy. For some breast cancer patients, however, axillary node dissection may still be recommended when cancer cells are found by sentinel node biopsy.

Side effects of surgery and lymph node removal

Surgical techniques used to treat breast cancer have improved significantly in recent years. Any medical procedure, and especially one as complex as surgery, can have side effects and complications. Some of the possible short-term side effects of breast cancer surgery include fatigue, infection, pain or tenderness, swelling and weakness or stiffness of the arm or shoulder areas.

Some of the possible side effects of having lymph nodes removed with an axillary node dissection include a feeling of pins and needles, numbness or nerve pain, shoulder pain, weakness or stiffness of the shoulder area, and axillary web syndromeAxillary web syndrome:
A condition that may occur after a sentinel node biopsy or an axillary node dissection where thick, ropelike structures or “cords” develop under the skin of the inner arm. These cords of tissue can feel painful and tight, limiting range of motion in the arm.
. Axillary web syndrome occurs when tight cords form under the skin of the inner arm, which can make it difficult and painful to lift the arm. 

A life-long risk and another possible long-term side effect is lymphedemaLymphedema:
A condition where lymph fluid (or tissue fluid) cannot easily get out of the arm and back into the circulation, resulting in swelling in part or all of the arm and hand. It can occur after breast cancer treatment following the surgical removal of lymph nodes from the underarm area or radiation treatment to this area.
. Lymphedema is a condition where lymph fluid (or tissue fluid) cannot easily get out of the arm and back into your circulation. It results in swelling which can affect part or all of the arm and hand. There are ways to help prevent and manage lymphedema. Ask your health care provider about your risk for developing lymphedema and for prevention and management strategies. You can also check out our web page on lymphedema for more information.

To help you make an informed decision about your treatment, ask your health care team about the benefits and limitations of surgery and lymph node removal, and about the possible side effects and how to manage them.

What to Expect During Breast Cancer Surgery

In the weeks and days before your surgery, your surgeon will review your medical history and medications, and order additional tests. This ensures that your health care team has all of the information they need to plan your treatment and keep you safe during surgery. You will be asked to avoid food for a period of time before the surgery to help prevent vomiting while you are under anesthesia.

When you are admitted to the hospital before your surgery you will be asked to sign an informed consent form. Signing this form means that you understand the procedure you are going to have and the risks associated with it, and agree to having the procedure done knowing this information. Make sure that you read and understand this form and ask any questions you may have before signing it.

When it’s time for surgery, you may be given medication to help you relax before going to the operating room. In the operating room you will see a lot of people and equipment, which may feel somewhat unsettling. The surgeon will come in while you are still awake to say hello and check that you are comfortable. They will go over key information about the surgery with the an anesthesiologistAnesthesiologist:
A doctor who specializes in administering anesthesia during surgery and other medical procedures.
and other members of the operating team while you are awake. For your safety, you will be asked to listen and speak up if any information is wrong or missing. You will be connected to several machines so that your surgical team can closely monitor you during your surgery. When it’s time for the surgery to begin, you will be given anesthesia to put you to sleep, and the anesthesiologist will stay with you and monitor you throughout the entire surgery.

When your surgery is complete you will be moved to a recovery room where nurses will monitor you as the anesthesia wears off. Don’t be afraid to ask for anything you need to make you comfortable – from pain medication to a warm blanket. If your surgery is an outpatient procedure, you will be able to go home the same day. If you had a mastectomy or a lumpectomy with a lymph node dissection, you may have a short stay in hospital after the surgery. If you are well enough, you may be able to go home the same day, as long as you have someone to stay with you at home.

As much as possible, your surgeon and health care team will want to get you up and moving after the surgery. This may start with getting up and walking a few hours after surgery and doing arm exercises to help prevent stiffness and keep the arm mobile. For women who have had a mastectomy, normal activities can usually start up again within a few weeks of surgery, but this will be decided by you and your surgeon based on how your recovery is going.

Any tissue that was removed during your surgery will be sent to a pathologist to be examined in a lab. After your surgery you will have follow-up appointments with your health care team, and the results from the pathology report will be discussed with you. These results will help your health care team recommend other treatments that may be necessary, such as chemotherapy, radiation, hormone therapy or HER-2 targeted therapyHER-2 targeted therapy:
A treatment method that uses medication to target HER-2 receptors that stimulate breast cancer growth.
.

Tips for Preparing for Breast Cancer Surgery

Get answers to your questions and concerns. Make sure any questions you have about the surgery have been answered so that you know what to expect ahead of time. Write down your concerns and questions ahead of time, so you have a list to refer to when you see your surgeon.

Some questions you may want to ask your surgeon include:
  • Why do I need to have this surgery?

  • How much of my breast tissue will be removed?

  • What are the risks and side effects of this surgery?

  • Will any lymph nodes have to be removed? If yes, how many?

  • What can I expect once my surgery is complete? Will I need pain medication?

  • Will I need a hospital stay? If so, how long?

  • What kind of care will I need after the surgery?

  • What kind of follow-up appointments and treatments will I need after my surgery?

  • What are my options for breast reconstruction or prosthesis and how soon after my surgery can this be done?

Have a second set of ears at your appointments.
Ask someone you trust to go with you to appointments with your surgeon. They can take notes for you, ask questions you may not think of and help you remember what the surgeon said. 

Take care of yourself.
Eat well, try to get plenty of sleep or rest, and reduce the amount of caffeine and alcohol you have before your surgery. Do things that help you to relax. Go for a walk, exercise, take a long bath or try some meditation. If you are a smoker, it really helps your recovery to cut back on smoking for a week or two before surgery, even though it can be especially difficult during such a stressful time. Taking care of yourself may help to reduce feelings of anxiety while improving your energy level and sense of well-being.

Express your feelings.
Share your feelings about surgery with a friend, family member or someone else you trust. Or write your thoughts, concerns, feelings and questions down in a journal. Seek out support when you need it.  Your family doctor may be a good resource for added support if you are having trouble coping. Your local cancer treatment centre also has resources (e.g. social workers, spiritual care workers, psychologists and peer support groups) that you can access through your surgeon or other members of your health care team.

 

Sources:

American Cancer Society. Surgery for breast cancer. Accessed January 9, 2014.

Breastcancer.org. Surgery. Accessed January 9, 2014. 

Breastcancer.org. Axillary Web Syndrome. Accessed January 9, 2014.

Canadian Cancer Society. Surgery for breast cancer. Accessed January 9, 2014