Surgery is a Standard Component of Treatment for Most Breast Cancer Patients
Surgery is often used in combination with other forms of treatment, which may include chemotherapy, immunotherapy, endocrine therapy, and radiation therapy. Sometimes surgery is recommended before other therapies. In other circumstances, chemotherapy will be recommended before surgery. This decision depends on the specific subtype of breast cancer as well as the breast cancer stage among other factors.
Surgery involves removing the breast cancer with an operation and oftentimes involves surgical evaluation of the lymph nodes under the arm. In most scenarios, there are two options for surgery: breast conserving surgery or mastectomy.
Different Surgical Options: Breast Conserving Surgery, Mastectomy, and Axillary Lymph Node Surgery
Breast conserving surgery
Breast conserving surgery (BCS), also known as lumpectomy or partial mastectomy, is surgery to remove breast cancer and a small amount of normal, healthy breast tissue that surrounds the cancer. The goal of BCS is to remove all the breast cancer and preserve the remaining health breast tissue. BCS is an option for most early-stage breast cancers. Studies indicate that BCS followed by radiation therapy results in equivalent survival and is as effective in preventing a recurrence of breast cancer as removal of the entire breast (mastectomy) for early-stage breast cancer. It is important to understand that not every breast cancer patient is a candidate for BCS. Specifically, patients with large cancers, multiple cancers, prior breast or chest radiation, specific genetic mutations, or history of a chronic inflammatory conditions such as systemic lupus erythematous or scleroderma may not be good candidates for radiation.
In BCS, patients retain most of their breast tissue including the nipple in most scenarios as well as sensation to the skin of the breast.
Mastectomy
Mastectomy is a surgery to remove the vast majority of tissue from a breast, including the cancer site. Classically, a mastectomy includes removing the breast tissue as well as breast skin and the nipple. In these settings, closure is generally performed by the breast cancer surgeon in a flat fashion. More recently, newer surgical techniques allowed for preservation of the breast skin and nipple. In these settings, surgery is most commonly performed in conjunction with a reconstructive plastic surgeon. It is important to know that the reconstruction may involve more than one surgery. Patients may elect to have removal of just the breast with cancer in it, which is called a unilateral mastectomy, or they may elect to have both breasts removed, which is called a bilateral mastectomy. In many cases, patients that undergo mastectomy for the breast cancer may not require radiation. Scenarios where radiation may still be recommended are if there is cancer in the lymph nodes, the tumor is very large, or if there is cancer at a margin on the mastectomy specimen.
It is important to understand that a mastectomy, even with reconstruction, is different from a breast augmentation. Sensation to the breast skin and nipple will be permanently altered. In most scenarios, a drain will be placed as well to prevent fluid accumulation. The drain tubes are sewn into place, and the ends are attached to a small drainage bag or bulb. These stay in place about 7-14 days on average and help speed the healing process.
Axillary lymph node surgery
The first place that a breast cancer spreads in most cases is the lymph nodes that live beneath the arm in a space call the axilla. Surgical evaluation of lymph nodes is a common secondary component to breast cancer surgery. For many breast cancers, the surgical team may recommend a “sentinel lymph node biopsy.” In this procedure, the surgeon will remove between 1-4 lymph nodes. These nodes will then be sent to the pathologist (another physician) who will assess the lymph nodes under the microscope to make sure that the cancer has not spread. If a patient elects to proceed with BCS, a separate small incision is usually required to access the lymph nodes. If a patient is undergoing a mastectomy, usually no additional incision is required. Sometimes, if the cancer has spread to the lymph nodes, a “complete axillary dissection” may be recommended. This involved removal of more lymph nodes from the same area.
How to Prepare for Breast Cancer Surgery
Before surgery, patients meet a breast cancer surgeon. The surgeon explains treatment options and what to expect from surgery. Patients can prepare for this meeting by creating a list of questions to ask. Below are some examples:
What are options for breast cancer surgery?
How much breast needs to be removed?
What are the options for reconstruction?
Can the reconstruction be started at the same time as the cancer surgery?
How will the breast look after surgery? Will the breasts look the same?
How much time will be spent in the hospital?
How much time is needed for recovery?
What are the activity restrictions after surgery?
When is it safe to return to work?
Additionally, optimizing sleep, nutrition, and emotional well-being before surgery can benefit the recovery process.
What to Expect with Breast Cancer Surgery
For BCS, patients generally spend about a half day at the hospital before going home (“outpatient surgery”). Patients meet with the nursing staff, the anesthesia team, and the surgeon prior to going back to the operating room. In many cases, patients also will need to meet the radiology team to have the cancer “localized” prior to surgery. Localization means that the radiologist will place a wire or device into the cancer location so that the surgeon can find it easily in the operating room. The surgery itself lasts between 1-2 hours and then patients will recover in the post-operative recovery area prior to being dismissed to go home.
For mastectomy, patients will either be able to go home the same day or may stay in the hospital overnight, depending on your surgeon and hospital’s policies. Like with BCS, mastectomy patients will meet with the nursing staff, the anesthesia team, and the surgeon prior to going back to the operating room. The mastectomy itself is variable in terms of time and depends on if the case unilateral or bilateral, if it is skin-sparing or nipple-sparing, and if there is a reconstruction portion with the plastic surgery team.
For either surgical approach, patients will need to stop eating prior to the surgical date. In most cases, a patient will be asked to not eat after midnight before surgery. It is also very important to inform the healthcare team about any medicines, vitamins, or supplements being taken as these can sometimes interfere with the surgery. In many scenarios, patients will be asked to stop their blood-thinning medications to decrease the risk of bleeding. It is also very important to arrange a transportation plan for after surgery, as patients who have undergone surgery are generally recommended against driving for a period of time.
After surgery, the surgical team will call once the final pathology results are available. This takes about 1-2 weeks.
Risks of Breast Cancer Surgery
While breast surgery is overall lower risk than many other surgeries, there are still some risks of which to be aware:
Bleeding. For BCS or mastectomy, this presents usually within 24 hours after surgery. Large swelling, increased pain, and bruising are signs and symptoms to watch for. Rarely, the surgical team has to take a patient back to the OR to stop the bleeding.
Collection of fluid at the operative site, called a seroma.
Infection.
Pain.
Scar. Anytime an incision is made in the skin, a scar will be present afterwards.
Problems with wound healing.
Risks related to anesthesia include confusion, nausea and vomiting.
For lymph node surgery, patients may notice a change or loss of sensation on their inner arm and potentially arm swelling (called “lymphedema”)
Positive margins. It is possible that the surgeon may recommend returning to the OR to remove more tissue if cancer is close or involving one of the margins after surgery.
About Dr. Robert Pride
Dr. Robert Pride is a breast surgical oncologist specializing in breast cancer, high-risk breast lesions, and benign breast disease. He was a Division I athlete at Dartmouth College before attending the University of Central Florida College of Medicine for medical school. He completed his general surgery residency at the prestigious Mayo Clinic in Rochester, MN. He then completed fellowship training in breast surgical oncology at the Harvard Medical School hospitals in Boston, MA which included Massachusetts General Hospital, Brigham and Women's Hospital, and the Dana Farber Cancer Institute. He has published numerous articles and book chapters about breast disease and has presented at several major national breast conferences. He was born and raised in Colorado and joined Western Surgical Care in 2023. He practices at Sky Ridge Medical Center in Lone Tree.
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