What Your Surgeon is Telling You
Explaining Your Surgical Options
Surgery is a key part of any curative treatment for breast cancer. There are three types of surgery a woman with breast cancer might undergo as part of the treatment for the cancer. These are mastectomy (with or without breast reconstruction), lumpectomy, and surgery to examine the lymph nodes in the armpit area.
A mastectomy is complete surgical removal of the breast. It was the first effective surgery for breast cancer. Mastectomy remains a common treatment for breast cancer. After a mastectomy a woman can undergo breast reconstruction surgery (plastic surgery) to re-create a breast. The option of breast reconstruction has made mastectomy more acceptable to some women.
A lumpectomy is removal of the cancerous lump only, leaving the rest of the breast intact. Lumpectomy should be combined with radiation therapy if a woman wants the best cure rate for her cancer. The combination of lumpectomy and radiation is often referred to as breast conservation. Breast conservation offers patients with early breast cancer the same cure rate as mastectomy. This treatment is discussed in more detail below.
Surgery to remove and examine lymph nodes from the armpit area is usually performed at the same time as mastectomy or lumpectomy. This surgery has two goals. The first is to determine if cancer has spread to the lymph nodes in the armpit area. Lymph nodes are small glands which filter cancer cells. The armpit area is called the axilla and its lymph nodes are called axillary lymph nodes. If cancer cells are found in the axillary lymph nodes it means the cancer is more aggressive, and more treatment after surgery - often drug therapy like chemotherapy or hormonal drugs is usually recommended. Examining these lymph nodes for cancer can be very important in determining which women will be offered drug therapy after surgery.
The most modern method of examining these lymph nodes is called sentinel lymph node surgery. Sentinel lymph node surgery is a special way of finding and removing only the one or two lymph nodes that filter the cancer. This is a very accurate way to determine if the cancer has spread to the axillary lymph nodes. The risks of sentinel lymph node surgery are lower than the older (but still useful) method of axillary dissection.
The traditional surgery for examining the lymph nodes removes a great many of the axillary lymph nodes. This is called an axillary dissection. In an axillary dissection, ten or more lymph nodes might be removed. Axillary dissections have a higher risk of side effects compared to sentinel node surgery. The main risk of axillary dissection is long term arm swelling called lymphedema. This is uncommon with axillary dissection and quite rare with sentinel lymph node surgery. Other side effects of these surgeries include arm pain and stiffness (usually temporary) and numbness on the inside of the upper arm.
Most breast cancer patients should have sentinel lymph node surgery because it is just as effective in examining the lymph nodes for cancer and has fewer side effects than axillary dissection. Some patients may still need an axillary dissection, and this introduces the other goal of lymph node surgery: to remove cancer-containing lymph nodes in the axilla.
If there are many lymph nodes with cancer left in the axilla, they can grow and form a mass, which can damage the nerves to the arm and cause arm swelling. Such an axillary recurrence can cause great pain and misery and is best prevented. For this reason, patients with proven cancer in the lymph nodes are often treated with removal of those lymph nodes by a full axillary dissection, rather than just a sentinel lymph node surgery which might leave cancer-containing lymph nodes behind. If doctors know beforehand that there is cancer in the axillary lymph nodes, a sentinel lymph node surgery may not be done at all; instead, an axillary dissection is performed. Usually, this is not the case because very few women have obvious cancer in their lymph nodes, and if there is cancer in the lymph nodes, it is invisibly small and only found after examination under a microscope.
If a patient has sentinel lymph node surgery first, and the one or two removed nodes have cancer in them, most doctors recommend (or at least offer) an axillary dissection to insure that an axillary recurrence does not occur. But some doctors are reconsidering this policy of doing axillary dissection in all patients with cancer in the sentinel lymph nodes. These doctors believe that a woman with a tiny amount of cancer in the sentinel lymph nodes doesn't need an axillary dissection. There is a large trial (experiment) underway in the United States to help answer this question. Until the results of that trial are available most doctors will suggest an axillary dissection when the sentinel lymph nodes contain cancer.
But almost all doctors now agree that patients without cancer in the sentinel lymph nodes do not need axillary dissection. This is because such patients almost never have axillary recurrence, and even when it does occur it can be controlled with surgery later.
This is very good news for patients because it means that most women with early stage breast cancer those without cancer in the sentinel lymph nodes - can have a sentinel node surgery and avoid axillary dissection and its side effects, without compromising their treatment.
Almost all women with breast cancer will have at least one of these three types of surgeries - mastectomy, lumpectomy, and/or removal of axillary nodes either by sentinel node surgery or axillary dissection. For most patients the surgery will involve either lumpectomy and sentinel lymph node surgery, or mastectomy and sentinel lymph node surgery. If the sentinel lymph nodes surgery shows that the nodes have cancer within them, a full axillary dissection is often recommended. After surgery other treatments with radiation therapy or drug therapy may follow.