- How is breast cancer treated?
- Surgery for breast cancer
- Radiation therapy for breast cancer
- Chemotherapy for breast cancer
- Hormone therapy for breast cancer
- Targeted therapy for breast cancer
- Bisphosphonates for breast cancer
- Denosumab for breast cancer
- Breast cancer that comes back
- Treatment of breast cancer during pregnancy
- Clinical trials for breast cancer
- Complementary and alternative therapies for breast cancer
Surgery for breast cancer
Most women with breast cancer have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm, to restore the breast’s shape after a mastectomy, or to relieve symptoms of advanced cancer. Below is a list of some of the most common types of breast cancer surgery.
In this type of surgery, only a part of the breast is removed. How much is removed depends on the size and place of the tumor and other factors. It is sometimes called partial (or segmental) mastectomy. It is usually followed by radiation treatment. But radiation may be delayed until after chemotherapy (chemo), if chemo is needed.
Lumpectomy: This surgery removes only the breast lump and some normal tissue around it.
Partial (segmental) mastectomy or quadrantectomy: This surgery removes more of the breast tissue than in a lumpectomy (up to one-quarter of the breast).
Side effects of these operations can include pain, short-term swelling, tenderness, and hardness due to scar tissue that forms in the surgical site.
For either surgery, if cancer cells are found at any of the edges of the piece of tissue removed, it is said to have positive margins. When no cancer cells are found at the edges of the tissue, it is said to have negative or clear margins. The presence of positive margins means that that some cancer cells may have been left behind after surgery. If the lab finds positive margins in the tissue removed with 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 margins, a mastectomy may be needed.
The distance from the tumor to the margin is also important. Even if the margins are “clear,” they could be “close” — meaning that the distance between the edge of the tumor and edge of the tissue removed is too small and more surgery may be needed. Surgeons can disagree on what is a good enough margin.
The more of breast removed, the more likely it is that there will be a change in the shape of the breast afterward. If the breasts look very different after surgery, you might be able to have some type of reconstructive surgery (see “Reconstructive or breast implant surgery” below), or have the other breast made smaller so the breasts look more alike. This might even be done during the first surgery. You should talk with your doctor before surgery to get an idea of how your breasts are likely to look afterward and to learn what your options might be.
For most women with stage I or II breast cancer, breast-conserving surgery works as well as mastectomy. Survival rates of women treated with these 2 approaches are the same.
Mastectomy is surgery to remove the entire breast. All of the breast tissue is removed, sometimes along with other nearby tissues.
Simple (also called total) mastectomy: In this surgery the entire breast is removed, but not the lymph nodes under the arm or the muscle tissue beneath the breast. Sometimes both breasts are removed, especially when mastectomy is done to try to prevent cancer. If a hospital stay is needed, most women can go home the next day.
For some women who are planning on having reconstruction right away, a skin-sparing mastectomy can be done. For this, most of the skin over the breast (other than the nipple and areola) is left intact. This can work as well as a simple mastectomy. The amount of breast tissue removed is the same as with a simple mastectomy. Although this approach has not been used for as long as the more standard type of mastectomy, many women prefer it because there is less scar tissue and the reconstructed breast seems more natural.
Another option for some women is the nipple-sparing mastectomy. This is like a skin-sparing mastectomy but the nipple and areola are also left behind. This procedure is more often an option for women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple.
There are some problems with nipple-sparing surgeries. Afterward, the nipple does not have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple. In women with larger breasts, the nipple may look out of place after the breast is reconstructed. As a result, many doctors feel that this surgery is best done in women with small to medium sized breasts.
Modified radical mastectomy: This operation is a simple mastectomy combined with surgery to remove lymph nodes under the arm (called an axillary lymph node dissection).
Radical mastectomy: This is a major operation where the surgeon removes the entire breast, many of the lymph nodes under the arm, and the muscles of the chest wall under the breast. This surgery was once very common, but it is rarely done now because less extensive surgery often works just as well. But this operation may still be done if the cancer is growing into the muscles under the breast.
Possible side effects of breast surgery
Aside from pain after the surgery and the change in the shape of the breast(s), the possible side effects of mastectomy and breast-conserving surgery include wound infection, build-up of blood in the wound, and build-up of clear fluid in the wound. If axillary lymph nodes are also removed, other side effects are possible, such as swelling of the arm and chest (lymphedema).
Choosing between breast-conserving surgery and mastectomy
Many women with early stage cancers can choose between breast-conserving surgery and mastectomy. One advantage of breast-conserving surgery is that it saves the way the breast looks. A downside is that you will need radiation treatment after surgery. This often takes several weeks. On the other hand, some women who have a mastectomy will also need radiation.
When choosing between breast-conserving surgery and mastectomy, be sure to get all the facts. You may have an initial gut feeling for mastectomy as a way to “take it all out as quickly as possible.” This feeling can lead women tend to prefer mastectomy even when their surgeons don’t. But the fact is that for most women with stage I or II breast cancer, breast-conserving surgery (along with radiation) is as good as mastectomy. There is no difference in the survival rates of women treated with these 2 methods. Other factors, though, can affect which type of surgery is best for you. And breast-conserving surgery is not an option for all women with breast cancer. Your doctor can tell you if there are reasons why breast-conserving surgery is not right for you.
It is important to know that having a mastectomy instead of breast-conserving surgery plus radiation only lowers your risk of developing a second breast cancer in the same breast. It does not lower the chance of the cancer coming back in other parts of the body. It is important that you don’t rush into making a decision, but instead take your time deciding whether a mastectomy or breast-conserving surgery plus radiation is right for you.
Lymph node surgery
To find out if the breast cancer has spread to lymph nodes under the arm (axillary lymph nodes), one or more of these lymph nodes may be removed and looked at under the microscope. This is an important part of staging, and the results affect treatment and outcomes. When the lymph nodes contain cancer cells, there is a higher chance that cancer cells have also spread through the bloodstream to other parts of the body. The presence of cancer cells in the lymph nodes under the arm is often an important factor in deciding what treatment, if any, is needed after surgery. There are 2 major ways these lymph nodes are checked:
Axillary lymph node dissection: In this operation, about 10 to 40 (though in most cases less than 20) lymph nodes are removed. Axillary lymph node dissection is usually done at the same time as the mastectomy or breast-conserving surgery, but it can be done in a second operation. This was once the most common way to check for breast cancer spread to nearby lymph nodes, and it is still done in some patients.
Sentinel lymph node biopsy: A sentinel lymph node biopsy is a way of learning whether cancer has spread to the lymph nodes under the arm without removing so many of them. For this test, a radioactive substance and/or a dye are injected near the tumor. This is carried by the lymph system to the first nodes, called the sentinel lymph nodes, that get lymph from the tumor. These lymph nodes are the one most likely to contain cancer cells if the cancer has spread. The surgeon removes the sentinel nodes, and they are then looked at by the pathologist. If the sentinel nodes contain cancer, more lymph nodes may be removed (either right away or in a separate surgery). If they are free of cancer, further lymph node surgery is not usually needed. This type of biopsy calls for a great deal of skill, so it is best to have it done by a team who has experience with it.
Up to now, if the sentinel nodes had cancer, the surgeon would do a full axillary dissection to see how many other lymph nodes were involved. But this may not always be needed. In some cases, it may be just as safe to leave the rest of the lymph nodes behind. Right now, skipping the axillary dissection is only an option for patients having breast conserving surgery (for tumors that are not large) followed by radiation. It is not thought to be an option for patients having a mastectomy.
Side effects: As with other operations, pain, swelling, bleeding, and infection are possible. The main possible long-term effect of lymph node surgery is lymphedema of the arm. This happens in about 3 out of 10 women who have a full axillary lymph node dissection, but is less common after a sentinel lymph node biopsy. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling comes up later or lasts a long time. Ways to help prevent or reduce the effects of lymphedema are discussed in the section, “Lymphedema after breast cancer treatment.” If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away.
Reconstructive or breast implant surgery
After having a mastectomy (or some breast-conserving surgeries), a woman may want to think about having the breast mound rebuilt. These operations are not meant to treat the cancer. They are done to restore the way the breast looks. If you are having breast surgery and are thinking about having breast reconstruction, you should talk to a plastic surgeon before your operation. There are choices to be made, such as when the surgery can be done and exactly what type it will be.
You can get more detailed information about the different types of surgery and their possible side effects in our document, Breast Reconstruction After Mastectomy. You may also find it helpful to talk with a woman who has had the type of reconstruction you are thinking about. Our Reach To Recovery volunteers can help you with this. Call us if you would like to speak to one of these volunteers.
What to expect with surgery
For many people, the thought of surgery can be scary. But knowing what to expect before, during, and afterwards may help ease your fears.
Before surgery: A few days after your biopsy you will know whether or not you have cancer, but the extent of the disease will not be known until after surgery. You will most likely meet with your surgeon a few days before the operation to talk about what will happen. You will be asked to sign a consent form giving the doctor permission to do the surgery. Take your time and read the form carefully to be certain that you understand what you are signing. This is a good time to ask any questions you might have.
You may be asked to donate blood ahead of time in case you need it during the surgery. Your doctor will also ask you about medicines, vitamins, or supplements you are taking. You might need to stop taking some of them a week or two before surgery.
You will also meet with the health professional who will be giving you the anesthesia (drugs to make you sleep and not feel pain) during your surgery. The type of anesthesia used depends largely on the kind of surgery being done and your medical history.
During surgery: For your surgery, you may be offered the choice of outpatient (where you go home the same day) or you may be stay in the hospital. General anesthesia (you are in a deep sleep) is used for most breast surgeries. You will have an IV line put in (usually into a vein in your arm). It will be used to give medicines that may be needed during the surgery. 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.
How long the surgery will take depends on the type of surgery being done. For example, a mastectomy with lymph node removal will 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 vital signs (blood pressure, pulse, and breathing) are stable.
After surgery: After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your condition is stable. The length of your stay in the hospital depends on the type of surgery you had, your overall state of health, whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. You and your doctor should decide how long you need to stay in the hospital — not your insurance company. Still, it is important to check your insurance coverage before surgery.
As a rule, women having a mastectomy stay in the hospital for 1 or 2 nights and then go home. But some women may be placed in a 23-hour, short-stay unit before going home.
Less involved operations such as breast-conserving surgery and sentinel lymph node biopsy are usually done on an outpatient basis and an overnight hospital stay is not needed.
After surgery you may have a bandage over the surgery site that wraps snugly around your chest. You may have one or more tubes (drains) from the breast or underarm area to remove fluid that collects during the healing process. You will be taught how to care for the drains. Most drains stay in place for 1 or 2 weeks. Once the flow has gone down to about an ounce a day, the drain will be removed.
Most doctors will want you to start moving your arm soon after surgery so that it won’t get stiff. Many women who have breast-conserving surgery or mastectomy are surprised by how little pain they have in the breast area. But they are less happy with the strange feelings (numbness, pinching/pulling) in the underarm area.
Talk with a member of your health care team about what you should do after the surgery to care for yourself. You should get written instructions that will tell you about the following:
- How to take care of the wound and dressing
- How to take care of the drains
- Bathing and showering
- How to know if you have an 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 start wearing a bra again
- When and how to wear a breast form (sometimes called a prosthesis)
- What to eat and what not to eat
- What medicines to take (including pain medicines and maybe antibiotics)
- What activities you should or should not do
- What feelings you might have about how you look
- When to see your doctor for a follow-up appointment
- 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 about 7 to 14 days after the surgery. Your doctor should explain the results of your pathology report and talk to you about whether you will need more treatment.
Chronic pain after breast surgery
Nerve pain after a mastectomy or breast-conserving surgery that doesn’t go away over time is called post-mastectomy pain syndrome or PMPS. The 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.
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 might not be able to use it normally.
PMPS can be treated. Medicines commonly used to treat pain may not work well for nerve pain. But there are other medicines and treatments that do work for this kind of pain. Talk to your doctor to get the pain control you need.
Last Medical Review: 09/04/2012
Last Revised: 02/22/2013