Patient information: Surgery for breast cancer: Mastectomy and breast conserving therapy

BREAST CANCER OVERVIEW

Breast cancer is the most common female cancer in the United States. Finding and treating breast cancer in the early stages allows many women to be cured.

This article will focus on the surgical treatment of breast cancer. An introduction to breast cancer and an overview of treatment for breast cancer is also available. (See "Patient information: Breast cancer guide to diagnosis and treatment".)

BREAST CANCER STAGING

In addition to removing the cancer from the breast and lymph nodes, surgery also provides important information about the "stage" of the cancer. The stage of the breast cancer is based upon its appearance under the microscope, the size of the tumor in the breast, and other factors.

Staging is discussed in detail in a separate article. (See "Patient information: Breast cancer guide to diagnosis and treatment".)

FACTORS AFFECTING SURGICAL TREATMENT

Several factors must be considered when choosing the best surgical treatment for your breast cancer. You should discuss these factors with your physician as you decide which treatment is best for you.

Microscopic findings — The surgeon must determine if a breast cancer is invasive or noninvasive (in situ). (See "Patient information: Breast cancer guide to diagnosis and treatment", section on 'Types of breast cancer'.)

Invasive breast cancer — Invasive breast cancers usually require surgical treatment (mastectomy or breast conserving therapy) as well as treatment after surgery (called adjuvant treatment).

Noninvasive (in situ) breast cancer — Noninvasive or in situ breast cancer is divided into two types: lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS).

• LCIS — Women with LCIS have an increased risk of developing breast cancer in the future. However, LCIS itself does not require treatment. Management of LCIS is discussed separately. (See "Lobular carcinoma in situ".)

• DCIS — Women with DCIS are treated similarly to those with invasive breast cancer, although there is less concern about spread to the lymph nodes or rest of the body. Treatment after surgery (called adjuvant treatment) is not usually necessary. (See "Breast ductal carcinoma in situ and microinvasive carcinoma".)

Size of the breast tumor — Larger tumors are more likely to recur and usually require more aggressive treatment. Treatment of large tumors is discussed in a separate article. (See "Patient information: Locally advanced and inflammatory breast cancer".)

Spread to the lymph nodes — Lymph nodes (or glands) are usually the first place for breast cancer to spread. If a breast cancer has spread to lymph nodes, it is called node-positive; a cancer that has not spread to the lymph nodes is called node-negative. If a breast cancer has spread to the lymph nodes, it is twice as likely to have also spread elsewhere, and therefore, to recur.

When cancer has spread to the lymph nodes, there is still a chance it has not spread anywhere else in the body. In this case, the goal of surgery is to remove cancer from both the breast and the lymph nodes. (See 'Management of lymph nodes' below.)

SURGICAL TREATMENT

Surgical removal of the tumor is usually the first step in treating early stage breast cancer. If the breast tumor is large or more advanced, treatment with chemotherapy may be recommended before surgery. (See "Patient information: Locally advanced and inflammatory breast cancer", section on 'Treatment of locally advanced breast cancer'.)

There are two options for breast surgery:

• Mastectomy involves removing the entire breast. (See 'Mastectomy' below.)

• Breast conserving surgery removes just the cancerous area and a small amount of surrounding normal tissue (also called lumpectomy). Breast conserving surgery plus radiation therapy is referred to as breast conserving therapy, or BCT. (See 'Breast conserving therapy (BCT)' below.)

In centers that specialize in breast cancer treatment, approximately 75 percent of women with early stage breast cancer are candidates for BCT, while the remainder have mastectomy.

MASTECTOMY

Mastectomy may be necessary because of the location of your tumor, the size or shape of your breast, or it may be your preference. There are two main types of mastectomy: modified radical mastectomy and simple mastectomy. (See "Mastectomy and breast conserving therapy for invasive breast cancer".)

Modified radical mastectomy — During a modified radical mastectomy (MRM), the tumor is removed along with all of the breast tissue on the side of the tumor, some of the underlying chest wall tissue, and the lymph nodes in the armpit (the axillary lymph nodes) (figure 1).

Simple mastectomy — A total or simple mastectomy involves removing the entire breast without removing the axillary lymph nodes. A technique called sentinel lymph node biopsy is performed to be sure that the cancer has not spread to the lymph nodes. (See 'Management of lymph nodes' below.)

Breast reconstruction — Reconstruction of the breast is an important option for women who undergo mastectomy. You may choose to have breast reconstruction immediately after the mastectomy or at a later time. There are several options for reconstruction, and all women planning to undergo mastectomy should see a plastic or reconstructive surgeon to discuss these options before having breast surgery. (See "Breast reconstruction in women with breast cancer".)

Skin-sparing mastectomy — During a modified radical or simple mastectomy, most of the skin overlying the breast, including the nipple and areola, is removed. If the woman has immediate breast reconstruction, most of her skin can be used in the reconstructive surgery. This is called a skin-sparing mastectomy.

With this technique, the nipple and areola are usually removed but may be "reconstructed" to allow the breast to appear more natural. In selected cases (typically with a small tumor that is not located anywhere near the nipple), the nipple and areola are not removed. This is called a nipple-sparing mastectomy.

Complications of mastectomy — Mastectomy is generally a safe surgery, although complications can occur, including bleeding, collection of fluid, wound infection, and arm swelling. (See "Patient information: Lymphedema after breast cancer surgery".)

Radiation therapy after mastectomy — Radiation therapy is sometimes recommended after a mastectomy to decrease the chance of a recurrence, especially in women who have large tumors (5 cm in size or larger), have tumors close to the chest wall, or who have four or more positive lymph nodes [1]. The benefit of radiation after mastectomy for women with fewer involved lymph nodes is controversial.

More information about radiation therapy is available below. (See 'Radiation therapy' below.)

BREAST CONSERVING THERAPY (BCT)

Breast conserving therapy refers to surgical removal of the tumor and a small portion of normal surrounding breast tissue, followed by radiation therapy to the remaining breast tissue (figure 1). Breast conserving surgery is also called a lumpectomy, quadrantectomy, or partial mastectomy. Lumpectomy is the most commonly performed BCT procedure in the United States and Canada. (See "Mastectomy and breast conserving therapy for invasive breast cancer".)

A quadrantectomy, which is more often used outside of North America, refers to removal of the tumor and about one-fourth of the breast tissue on that side (figure 1). The remainder of this article will use the word lumpectomy, although the information also applies to women who have had a quadrantectomy.

During the surgery, lymph nodes in the armpit are also removed to check for spread of cancer cells to this area. For most women undergoing BCT, this will be done using a sentinel lymph node biopsy. (See 'Management of lymph nodes' below.)

Radiation therapy

Invasive breast cancer — Radiation therapy (RT) refers to the exposure of a tumor to high-energy x-rays in order to slow or stop its growth. Exposure to x-rays damages cells. Unlike normal cells, cancer cells cannot repair the damage caused by exposure to x-rays over several days. This prevents the cancer cells from growing further and causes them to eventually die.

RT for breast cancer is mostly given as external beam RT, meaning that the radiation beam is generated by a machine that is outside the patient. Exposure to the beam typically takes only a few seconds (similar to having an x-ray). In general, RT is given daily, five days per week, for approximately five to six weeks.

Radiation is generally recommended for all women who have had breast conserving surgery for invasive breast cancer, even if the tumor is very small. The goal of this treatment is to kill any remaining cancer cells.

In situ breast cancer — Most women with ductal carcinoma in situ (DCIS) will be advised to have radiation therapy after breast conserving surgery. However, this is a controversial issue that should be discussed with your doctor. (See "Breast ductal carcinoma in situ and microinvasive carcinoma".)

Cosmetic outcomes — With modern surgical techniques, cosmetic results are good to excellent in most women after breast conserving therapy (ie, the treated and untreated breast are almost identical or there are only slight differences). The effects of BCT on the appearance of the breast take about three years to stabilize. Factors such as weight gain and the normal age-related sagging of breast tissue also affect the shape and size of the breasts.

Complications following BCT — Following breast conserving surgery or radiation, complications can sometimes occur, including skin infection, collection of fluid, rib fracture, and shortness of breath.

MASTECTOMY VERSUS BREAST CONSERVING THERAPY

Studies show that women with localized breast cancer are equally likely to survive their cancer whether they are treated with BCT or a mastectomy [1,2].

Factors to consider — Although cancer outcomes are similar, there are several factors that you should consider when trying to decide between BCT and mastectomy.

• Tumor size — Some women who have a large tumor and small breasts are advised to undergo mastectomy rather than BCT. However, chemotherapy may be given before surgery to shrink the tumor; this may allow the woman to have breast conserving surgery, if she desires it.
• Tumor margins — If cancer cells are found at the edges of the tissue removed during breast conserving therapy AND a large amount of tissue was removed, mastectomy may be recommended.
• Need for future surgery — Radiation therapy causes changes in the skin of the treated breast, reducing the blood supply and the skin's ability to stretch and heal. These changes may be important if surgery is needed on the treated breast after radiation therapy (eg, to improve the breast's appearance or treat a cancer recurrence). (See "Techniques and complications of breast and chest wall irradiation for early stage breast cancer".)

• Individual needs and expectations — You should discuss your expectations and concerns about preserving your breast with your doctor. It is particularly important to consider how the choice of BCT or mastectomy is likely to affect your confidence in your cancer treatment as well as your self-esteem, sexuality, and overall quality of life.

Although the likelihood of surviving localized breast cancer is the same with mastectomy or BCT, the choice of surgical procedure may have a considerable effect on your quality of life. The overall experience of having breast cancer is equally distressing for women who choose BCT and for those who choose mastectomy. However, compared to women who choose mastectomy, women who choose BCT tend to have a more positive body image and experience fewer changes in their feelings of sexual desirability.

Reasons to avoid BCT — Certain factors clearly favor mastectomy over BCT. These include:

• Having two or more separate tumors in different areas of the breast
• Having tumor spread throughout the breast tissue
• Previous radiation of the breast or chest
• Pregnancy in the first or second trimester, which makes radiation inadvisable

Factors that do not affect your decision — Several factors do not play a role in the choice between BCT and mastectomy:

• The spread of cancer cells to lymph nodes in the armpit
• The specific location of the tumor within the breast; however, certain tumor locations may negatively affect the cosmetic results of BCT
• A family history of breast cancer
• A high likelihood that cancer will metastasize (recur elsewhere in the body)

MANAGEMENT OF LYMPH NODES

Surgery is the only accurate way to determine if breast cancer has spread to the lymph nodes in the axilla, or armpit. A complete removal of the axillary lymph nodes was previously recommended for women undergoing either mastectomy or BCT. However, complications such as arm swelling (called lymphedema) were common in these women.

A procedure called sentinel lymph node biopsy is now the preferred way to determine if cancer has spread to the axillary lymph nodes. (See "Sentinel lymph node biopsy for breast cancer: Indications and outcomes".)

Sentinel lymph node biopsy — The idea of a sentinel lymph node (SLN) is based on the fact that breast tumor cells first involve one or a few lymph nodes before involving lymph nodes in other areas or spreading (metastasizing) to distant organs. To identify this sentinel node, the surgeon injects blue dye, a radioactive material, or a combination of both into the area surrounding the tumor, where it enters lymphatic channels and may flow to lymph nodes.

If a sentinel lymph node is identified, it is removed and examined under the microscope. If this node does not contain any cancer cells, there is only a small chance that other axillary nodes will be positive; removal of all the axillary lymph nodes is not necessary [1]. In contrast, if the SLN is positive, there is a chance that other nodes will contain tumor cells, and a removal of all the axillary lymph nodes on the affected side is usually recommended.

In situ cancer — Women with ductal carcinoma in situ (DCIS) have a small (less than 5 percent) chance of having axillary lymph node metastases. In general, SLN biopsy is not recommended for women with DCIS unless a mastectomy is being performed.

TREATMENT AFTER SURGERY

Treatment after surgery, called adjuvant treatment, is often recommended for women with invasive breast cancer. Adjuvant treatment is discussed in a separate article. (See "Patient information: Early stage breast cancer treatment in postmenopausal women" and "Patient information: Early stage breast cancer treatment in premenopausal women".)

SURVEILLANCE AFTER INITIAL TREATMENT

After being treated for breast cancer, there is a risk that breast cancer will recur. Breast cancer survivors are advised to see their oncologist every three to six months for the first three years after treatment, every 6 to 12 months for the next two years, and then annually.

Women who have undergone BCT are advised to continue breast self-exams and mammography. The benefit of screening mammography after mastectomy and breast reconstruction is controversial. (See "Follow-up for breast cancer survivors: Recommendations for surveillance after therapy".)

A summary of the American Society of Clinical Oncology's recommendations for surveillance after breast cancer treatment is provided in the table (table 1).

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Lymphedema after breast cancer surgery
Patient information: Breast cancer guide to diagnosis and treatment
Patient information: Locally advanced and inflammatory breast cancer
Patient information: Early stage breast cancer treatment in postmenopausal women
Patient information: Early stage breast cancer treatment in premenopausal women

Professional Level Information:
An overview of breast cancer and treatment for early stage disease
Hormone receptors in breast cancer: Measurement and clinical implications
Mastectomy and breast conserving therapy for invasive breast cancer
Techniques and complications of breast and chest wall irradiation for early stage breast cancer
Lobular carcinoma in situ
Breast ductal carcinoma in situ and microinvasive carcinoma
Breast reconstruction in women with breast cancer
Sentinel lymph node biopsy for breast cancer: Indications and outcomes
Follow-up for breast cancer survivors: Recommendations for surveillance after therapy

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Cancer Institute

       1-800-4-CANCER
       (www.nci.nih.gov)

• American Society of Clinical Oncology

      (www.cancer.net/portal/site/patient)

• National Comprehensive Cancer Network

      (www.nccn.com)

• American Cancer Society

       1-800-ACS-2345
      (www.cancer.org)

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• Susan G. Komen Breast Cancer Foundation

       (www.komen.org)

Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com Breast Cancer Forum

      (http://breastcancer.about.com/forum)

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