Surgery

Types of surgery

Surgery is usually the first treatment for breast cancer, although in some cases chemotherapy or hormone therapy may be offered first, to begin treating the whole body or to shrink the cancer, so that surgery can be less extensive or even avoided altogether.

One of the first decisions you may have to make is which type of operation you'll have. You may be offered a choice of breast conserving surgery or a total mastectomy.

Breast-conserving surgery

Breast-conserving surgery, usually referred to as wide local excision or lumpectomy, is the removal of the cancer with a margin (border) of normal breast tissue around it.

You may be offered a less common operation called a quadrantectomy, where approximately a quarter of the breast is removed (sometimes called a segmental excision). After a quadrantectomy the breast will usually be smaller and there may also be an indentation due to the amount of tissue removed.

There is an increasing use of oncoplastic surgical techniques which means combining breast cancer surgery with plastic surgery to try and provide the best cosmetic outcome, as well as the best cancer treatment. This means that there is less likely to be an obvious indentation and that the shape and symmetry of the breasts are maintained.

Mastectomy

This means removal of all the breast tissue including the nipple area. A simple mastectomy means that the entire breast is removed but the lymph nodes and muscles underneath the breast are not affected – although some lymph nodes may be removed with the breast tissue taken during surgery. A simple mastectomy is often a suitable treatment for widespread DCIS.

A modified radical mastectomy removes the entire breast and some of the lymph nodes under the arm. Sometimes one of the small muscles on the chest wall is also removed.

If you are going to have a mastectomy, you will usually be able to have breast reconstruction. This can be done at the same time as your mastectomy (immediate reconstruction) or months or years later (delayed reconstruction). If you would like more information, view our pages on breast reconstruction.

The right surgery for you

More than half of early stage breast cancers can be treated with breast conserving surgery, followed by radiotherapy.

Studies have shown that long term survival is the same, whether you have breast conserving surgery and radiotherapy or a mastectomy.

The type of surgery you have will be based on the type of cancer, the size, where it is in your breast and how much surrounding tissue needs to be removed. It will also depend on how large your breasts are.

The surgeon will want to give you the best cosmetic result possible as well as the most effective surgery. That means keeping as much as possible of your breast without increasing the risk of the cancer coming back.

Your surgeon may recommend the removal of the whole breast. Total mastectomy can be the better option when:

• your breast is small and would be distorted by the removal of a moderate to large cancer
• there are several cancerous or pre-cancerous areas in your breast
• you would rather have the whole breast removed
• the cancer is in the centre of your breast or directly behind the nipple.

Lymph node removal

For invasive breast cancer, it's recommended that some or all of the lymph nodes under the arm (the axilla) be removed to see whether or not they contain any cancer cells. Knowing whether lymph nodes are affected is important in helping your specialist team decide on any additional treatments to surgery. Everyone has a different number of lymph nodes but on average there are approximately 20 lymph nodes under the arm.

To see whether or not any of the lymph nodes under the arm contain cancer cells, your surgeon may wish to do an operation to remove some (a lymph node sample) or all of them (a lymph node clearance). Another way of checking the lymph nodes under the arm is called sentinel node biopsy.

A sentinel node biopsy is a diagnostic procedure to find out if the breast cancer has spread to the lymph nodes in the axilla. It involves injecting a small amount of radioactive material and a dye into the body to identify the first, or sentinel, node(s) to receive lymph fluid from the cancer. If the sentinel node is clear of cancer cells it usually means that the other nodes are clear too so no more will need to be removed.

Sentinel node biopsy should gradually become standard practice for patients with cancers where there is no evidence of lymph nodes being affected from tests before your operation and when the surgeon cannot feel any enlarged lymph nodes under the arm. It is not a suitable procedure if the tests before your operation show your lymph nodes are affected.

If a sentinel node biopsy shows that the node(s) removed is affected by cancer it may be recommended that you have a second operation to remove the remaining nodes. About 20–25 per cent of women who have sentinel node biopsy go on to have further surgery to try to ensure all the affected lymph nodes have been removed.

Sentinel node biopsy is not appropriate for everyone and your surgeon will discuss whether or not this procedure is an option for you.