MASTECTOMY OR LUMPECTOMY — FOR BREAST CANCER; OR BREAST BIOPSY FOR LUMPS OR ABNORMAL MAMMOGRAMS
What Is Breast Cancer?
Breast cancer is the abnormal growth and uncontrolled division of cells in the breast. Cancer cells can invade and destroy surrounding normal tissue, and can spread throughout the body via blood or lymph fluid (clear fluid bathing body cells) to start growing in another part of the body. Breast cancer is the most common malignancy among women. There are several types of breast cancer, distinguished mostly by their rate of growth and tendency to spread to other organs. Breast cancer often spreads to surrounding lymph nodes under the armpit, under the sternum (breastbone), and under the clavicle (collarbone).
Who gets it and what are its causes?
Every woman is at risk for breast cancer. As a woman ages, her risk of developing breast cancer rises dramatically regardless of her family history. The breast cancer risk of a 25 year-old woman is only one out of 19,608; by age 45, it is one in 93. In fact, 80% of all breast cancers are found in women over age 50.
Breast cancer also affects men. Symptoms, diagnosis, treatments and living with the disease apply to men as well as to women. Experts do not recommend routine screenings for men. Men account for 1% of cases, where in contrast, women face a one in ten lifetime risk of developing breast cancer.
There are a number of risk factors for the development of breast cancer. Family history of breast cancer in a mother or sister, early onset of menstruation and late menopause, reproductive history in regard to women who had no children or have children late in life, women who have never breastfed and those with a history of abnormal breast biopsies. However, more than 70% of women who get breast cancer have no known risk factors. In addition, some studies suggest that high fat diets, bottle feeding instead of breastfeeding or using alcohol may contribute to the risk profile.
Not all lumps detected in the breast are cancerous. Many are benign and require only the removal of the lump. While having several risk factors may boost a woman’s chances of having breast cancer, the relationship of factors is complex. The precise causes of breast cancer are unknown. The best way to assess breast cancer risk is by having clinical exams or doing regular self-examinations to detect any lump at an early stage. The second is to have a regular mammogram.
What are the symptoms?
Early detection and treatment are extremely important in curing breast cancer. The warning signs and symptoms of breast cancer could include the following:
Change in the size or shape of the breast
Lump or thickening of tissue in the breast or armpit
Dimpled or pulling of the skin over the breast
Nipple discharge
Retraction of the nipple
Scaliness of the nipple
Pain or Tenderness
Abnormality on a mammogram
Diagnosis
When breast cancer is found and treated early, the chances for survival are better. Women can take an active part in the early detection of breast cancer by having regular screening mammograms, clinical breast exams (breast exams performed by health professionals) and by performing breast self-exams.
Mammogram
More than 90% of all breast cancers are detected by a mammogram (a low-dose x-ray of the breast). Mammography remains the best way of detecting signs of breast cancer. A baseline mammogram should be done by age 40, so that a normal x-ray can be used to compare future mammograms, even when there is no reason to believe there is a lump or cyst. Mammograms for women between the ages of 40 and 50 should be at the direction of her physician, usually every 1-2 years. An annual mammogram is recommended for women over the age of 50, and for most women with have suspicious breast lumps.
Breast biopsy
A breast biopsy is the removal of breast tissue for examination by a pathologist. This can be accomplished surgically, or by withdrawing tissue through a needle.
A needle biopsy removes part of the suspicious area for examination. There are two types, aspiration biopsy (using a fine needle), and large core needle biopsy.
The fine needle aspiration uses a very thin needle to withdraw fluid and cells that can be studied. This can be done in your doctor’s office. No specialized equipment is needed. However, the use of an ultrasound helps to insure the guidance of the needle and that the specimen is taken from the right place.
A large core needle biopsy uses a larger diameter needle to remove small pieces of tissue, about the size of a grain of rice. It can be done in the rooms, a clinic or hospital. Ultrasound or x-ray is used for guidance of a large core needle biopsy.
A biopsy is recommended when a significant abnormality is found, either on physical examination and/or by an imaging test. Examples of abnormality can include a breast lump felt during physical examination and/or by an imaging test. It may also include a breast lump felt during a physical self-examination or tissue changes noticed from a mammogram test.
Before a biopsy is performed, it is important to make sure that the threat of cancer cannot be disproved or ruled-out by a simpler, less invasive examination. It may be obvious that a lump is harmless when examined by an ultrasound.
Surgical Treatment
Mastectomy
The surgical removal of the breast for the treatment or prevention of breast cancer.
There are four types of mastectomies: partial mastectomy, or lumpectomy, in which the tumour and surrounding tissue is removed; simple mastectomy, where the entire breast is removed; modified radical mastectomy, in which the entire breast and all axillary lymph nodes are removed; and the radical mastectomy, where the entire breast, axillary lymph nodes, and chest muscles are removed.
The size, location, and type of tumour are very important when choosing the best surgery to treat a woman’s breast cancer. The size of the breast is also an important factor. A woman’s psychological concerns, and her lifestyle choices should also be considered when decisions are made.
The severity of a cancer is evaluated according to a complex system called Staging. This takes into account the size of the tumour, and whether it has spread to the lymph nodes, adjacent tissues and/or distant parts of the body. A mastectomy is usually the recommended surgery for more advanced breast cancers. Women with earlier stage breast cancers, could have breast-conserving surgery (lumpectomy).
There are many factors that make a mastectomy the treatment of choice for a patient. A large tumour is often an indication of a later stage of breast cancer, when the removal of the entire breast is recommended. In addition, large tumours are difficult to remove with good cosmetic results. This is especially true if the woman has small breasts. Sometimes multiple areas of cancer are found in one breast(called Multicentricity), making removal of the whole breast necessary. A cancer that has already attached itself to nearby tissues, such as the skin or chest wall, is most likely to be removed with a mastectomy. Immediate reconstruction post-mastectomy should always be considered.
What is breast reconstruction?
In some cases it is possible to reconstruct the breast that has been removed, although the end result will not feel like your original breast. Reconstruction will not be able to give back the exact appearance and shape of your original breast. There are several different kinds of reconstruction. These have different recovery times and will cause different levels of discomfort. Sometimes reconstruction can be done at the same time as the mastectomy operation (immediate reconstruction) but sometimes a second operation is offered at a later stage (delayed reconstruction). With some reconstructions further surgery is needed to match the appearance of the reconstructed breast with the original breast. This may include operating on the unaffected breast to achieve symmetry. Your surgeon will talk with you about these options and give you some more information if reconstruction is suited to your case and is something that you would like to consider.
Breast conserving surgery (Lumpectomy) are done for earlier stage breast cancers. Under certain conditions this may be insufficient,- e.g. multicentricity, incomplete resection, positive margins – leading to completion Mastectomy. The surgeon is sometimes unable to remove the tumour with a sufficient amount or margin of normal tissue surrounding it. The entire breast needs to be removed in this situation. Some larger tumours can be treated with chemotherapy first (neo-adjuvant chemotherapy) to shrink the tumour, making Lumpectomy possible instead of Mastectomy.
In most cases, an axillary node sample (to remove some lymph nodes in the armpit) or an axillary node clearance (to remove all of the lymph nodes in the armpit) may be performed at the same time as the lumpectomy. These operations are done to assess whether the cancer has spread to any of the lymph nodes (also called glands) as this information helps to plan any further treatments you may need. If these operations are suggested then your surgeon will explain which is best for you and why. Alternately you may be offered sentinel lymph node biopsy to check that the lymph nodes are clear – again if this is recommended for you, then you will be given some more information about it.
Radiation therapy is always recommended following a lumpectomy. If a woman is unable to have radiation, a mastectomy is the treatment of choice. Pregnant women cannot have radiation therapy, for fear of harming the foetus. A woman with certain collagen vascular diseases, such as systemic lupus erythematosis or scleroderma, would experience unacceptable scarring and damage to her connective tissue from radiation exposure. Any woman who has had therapeutic radiation to the chest area for other reasons cannot tolerate additional exposure for breast cancer therapy. Diminished lung capacity due to other diseases also makes a woman a poor candidate for radiation therapy.
Prophylactic mastectomy, or removal of the breast to prevent future breast cancer, is controversial. Women with a strong family history of breast cancer and/or who test positive for a known cancer-causing gene may choose this option. Patients who have had certain types of breast cancers that are more likely to recur may elect to have the unaffected breast removed. Although there is some evidence that this procedure can decrease the chances of developing breast cancer, it is not a guarantee. It is not possible to be certain that all breast tissue has been removed. There have been cases where breast cancers have occurred after both breasts have been removed.
The decision to have mastectomy or lumpectomy should be carefully considered.
It is important that the woman be fully informed of all the potential risks and benefits of different surgical treatments before making a choice.
What are the risks of this operation?
Possible risks and complications include:
- Bleeding from the stitches or inside the wound. You should not be concerned if you find a small amount of blood spotting your wound dressing, but if more bleeding than this occurs after your discharge you should contact your surgeon
- Infection. If your wound becomes inflamed, red, hot, sore or oozes pus you should contact your surgeon.
- Thrombosis. This is a risk with all surgery and occurs when a blood clot forms in a vein, usually in the leg. You may be given blood thinning (anticoagulation) injections and you will be advised to wear support stockings whilst in hospital to help prevent this.
- Numb areas in the arm/shoulder or pins and needles. Surgery can cause damage to the nerves – some of this will improve over time, although the scar itself will remain numb permanently.
- Immobility or a ‘frozen’ shoulder. This is caused by not moving the arm following surgery. You will be given information on gentle exercises and advice on preventing this.
- Risk of lymphoedema. This is swelling of the arm caused by the surgery or radiotherapy. You will be given information on exercises and advice on preventing this.
How will I recover from the operation?
The operation itself takes about one and a half hours and is under a general anaesthetic. After the operation time is spent in the Recovery Room until you are awake enough to return to the ward. You may find that you have an intravenous infusion or ‘drip’ in your arm for a few hours. This is to give you fluids directly into a vein until you feel able to drink, usually later on in the same day.
Expect to feel sore for a few days. Regular painkillers will be offered on a regular basis. If these are not effective please inform the nursing staff so that alternative pain relief can be offered to you.
What are drains?
Drains are plastic tubes, which allow blood and fluid to drain away from the wound and collect in a bottle or bag. Not everyone will have a drain inserted. Others may have one or two drains coming from under the wound. Drains also help to minimise bruising. If drains are used, the length of time until they are removed will vary from 7-10 days – your surgeon will be happy to discuss this with you in more detail.
When can I return home?
This depends on whether or not you have drains, or want to go home with a drainage bag or bottle still in place. If you would prefer to go home with your drains in place, it is often possible to go home on the day following the operation. If you decide that you do not want to go home with the drain, you may be in hospital for three to five days.
How should I care for the wound?
Your wound will be covered with a waterproof dressing and you will be able to bath or shower as usual during this time. You may find bathing relieves discomfort and helps you move your arm. Most surgeons use dissolvable stitches (sutures) which do not require removal, but if stitches or clips need removing, this will be done around 10 days after the operation. Steri-strips (little strips of plaster) may be used to give extra support to the wound. You can get these wet and they will start to loosen after about 10 days when they can be eased off as you would a plaster. Many people find it difficult to look at the wound, especially in the early days. However, being able to look at the wound seems to be a way of helping in the adjustment and acceptance process. You may prefer to have someone with you when you first look at the operation site.
What will happen after discharge?
Although adjustment may not be easy after the operation, be kind to yourself and take time to recover. The length of time needed to rest and recover after this operation depends very much on you as an individual. There are no real restrictions on what you may or may not do, but heavy lifting is not advised for at least six weeks. You can expect to feel a little sore for a few days. You will be offered pain killers regularly. If these are not effective, please tell the nurses or doctors. If your lymph nodes have been removed you may have a numb feeling on the inside of your arm. Sometimes it can be quite painful. It does improve with time, although some areas sometimes remain numb.
Any drainage tubes that have been used will be removed usually 7-10 days after your operation. This can be a little uncomfortable and some patients find it painful. Some women experience a ‘seroma’ which is a collection of fluid underneath the arm or under the wound. It may be uncomfortable but is not harmful. If a seroma develops, and is causing you concern, you may wish to visit your surgeon. He can advise you whether you will need to have the fluid drained.
When can I drive?
You can drive as soon as you can make an emergency stop without discomfort in the wound. This may be about 10 days after the operation. You must also be comfortable wearing a seatbelt.
You should speak to your insurance company about any restrictions following surgery.
What exercises should I do?
Arm exercises should be performed regularly after the operation to encourage the full range of movement back to your arm and shoulder. We suggest you perform the exercises three or four times each day after taking some pain relieving medication to allow easier movement.
You should continue with the exercises given to you in hospital until you feel that your arm and shoulder movements are back to normal. Some women prefer to continue these exercises indefinitely to prevent any problems developing. There is no reason why gentle exercise (such as swimming) should not be resumed as soon as you feel comfortable, usually about three or four weeks after surgery. More strenuous exercise can be resumed when your own doctor advises.
Removal of the lymph nodes from your armpit can leave a small numb area right up in the armpit which can be permanent. Numbness on the inner part of the arm usually returns to normal within a few weeks and you may feel some pins and needles while it is healing. This feeling should not restrict your mobility in any way.
What follow up treatment will I have?
This will be discussed at your follow-up appointment when the results from your operation and your treatment plans are finalised. As part of your follow up care it is likely you will be seen by an oncologist. In some cases surgery is all that is necessary. In others, further treatment is advised to reduce the risk of recurrence. Further treatment can include:
Radiotherapy
Radiotherapy is often advised after breast surgery. This is the use of high energy X-rays to destroy any remaining cancer cells. . Radiation stops the cancer cells from dividing. It works especially well on fast-growing tumours. Unfortunately, it also stops some types of healthy cells from dividing. Healthy cells that divide quickly, like those of the skin, are affected the most. This is why radiation can cause skin problems. Radiotherapy is localised treatment to the chest wall. It is not usually painful and you will not be radioactive at any stage in the treatment. Radiotherapy is given in specialist centres, as an outpatient treatment from Monday to Friday for about three weeks. This will be explained in more detail to you when you have your operation results discussed.
Endocrine treatment
Some breast tumours need the female hormone oestrogen to grow. A test will be done to see if you would benefit from anti-oestrogen tablets (oestrogen receptor). Tamoxifen or an aromatase inhibitor such as anastrazole or letrozole are commonly prescribed. There are a number of other similar tablets available and the choice will be discussed with you.
The tablets are taken daily and are prescribed for about five years. The main side effects are occasional hot flushes and muscle aches. These may be worse when you first start taking them. Generally the tablets should be trouble free and effective. Not all women will require these anti-oestrogen tablets. Note that these should not be confused with hormone replacement therapy (HRT) which should not be taken after a diagnosis of breast cancer.
Chemotherapy
This is treatment with anti-cancer drugs; the aim is to target cancer cells whilst doing the least damage to your normal cells. It is a systemic treatment which means that the drugs are usually injected into the blood stream and act throughout the body. The drug treatment may be given by injection, usually into a vein in the arm, or it can be given as tablets by mouth. is usually given in cycles, followed by a period of time for recovery and then followed by another course of drugs. Treatment time may range between four to nine months. There may be significant side effects with some types of chemotherapy, including nausea and vomiting, temporary hair loss, mouth sores, vaginal sores, fatigue, weakened immune system and infertility. However, chemotherapy for early breast cancer uses medications that cause few side effects.
Herceptin® (Trastuzumab)
Herceptin is a drug which can be given to some patients following their initial treatment. It can reduce the chance of breast cancer returning or slow down the rate of growth in an existing tumour. However it is only appropriate for around 1 in 4 patients who have a particular type of protein on their cancer cells. This is known as being ‘HER-2 positive’. When your breast cancer is diagnosed it will be tested to see if it is HER-2 positive and if this treatment is possible for you then you will be given some more information. If any of the treatments above are recommended for you, a more detailed explanation will be given. It may be that you are offered a combination of all of these treatments – this is common practice. It is important to remember that your medical team plan things differently for each individual, so try not to compare yourself to others.