There are several types of surgery for the treatment of breast cancer and your doctor will make a recommendation based on the results of your biopsy.
A lumpectomy is often used in early stage breast cancer. It’s sometimes called a partial mastectomy or a wide local excision. The surgeon removes the cancer and a small amount of surrounding tissue. During or after your surgery, a pathologist examines the tissue.
If there are no cancer cells in the surrounding tissue, you can be cautiously confident that all the cancer has been removed.
If cancer or pre-cancerous cells are found in the margin around the tissue, you’ll need further surgery to remove more tissue. About 25% of women who have a lumpectomy need further surgery because tissue examination shows that there could still be some cancer left behind. You may also be advised to have a course of radiotherapy.
Lumpectomy with reduction mammoplasty
If you have large breasts, you may want to consider combining your lumpectomy with a reduction mammoplasty. In this procedure, after the cancerous tissue is removed, an oncoplastic surgeon reduces the size of your breast, repositioning it and giving it a smaller, naturally rounded shape. If only one of your breasts has cancer, the other one can be reshaped at the same time so that they match up.
A mastectomy involves complete removal of your breast tissue. There are several types of mastectomy and the choice will depend on the results of your biopsy. For example:
- Simple or total mastectomy – removal of your entire breast, without removing your lymph nodes or pectoral muscles.
- Skin-sparing mastectomy – your nipple and areola (skin around the nipple) are usually removed along with the breast tissue, but the rest of the skin over your breast is kept.
- Nipple-sparing mastectomy – your breast tissue is removed but your breast skin including your nipple and areola are kept. In Australia, this type of surgery is rarely offered because there are few surgeons who know how to do it. If you’re keen to explore this option, ask your doctor to refer you to an oncoplastic surgeon who performs the procedure.
- Radical mastectomy – (now rarely performed). This may include removal of your nipple/areola, some overlying skin, some of your pectoral muscles and the lymph nodes under your arm.
Your doctor may do a mastectomy instead of a lumpectomy because:
- The area of cancer is large compared to your breast.
- The cancer has spread to more than one area of your breast.
- You had a lumpectomy but the tissue surrounding the cancer was examined and further surgery is required to make sure all the cancer is removed.
- You’ve had radiotherapy previously and the cancer has recurred (radiotherapy can’t be used twice in the same breast), or you can’t have radiotherapy (this could be because you have a certain skin condition, difficulty lying flat or can’t attend a radiotherapy centre)
- You have a strong family history of breast cancer and/or a positive result to a genetic test showing that you have hereditary breast cancer because you carry the BRCA1 or BRCA2 gene. In this case, you may choose to have a mastectomy to minimise the risk of having cancer in the future.
- It's your preference.
A healthy woman may also have a mastectomy to reduce the risk of breast cancer if she’s at high risk of developing it in the future. Genetic testing can help define your risk.
Some women may require a course of radiotherapy after a mastectomy.
Lymph node surgery
Whether you have a lumpectomy or mastectomy, your surgeon will most likely want to check if the cancer has spread to the lymph nodes under your arm. This can be done by biopsy of the nodes before surgery. It can also be done during surgery by removing some of the nodes, (axillary lymph node dissection) or by looking for the first lymph nodes that the cancer drains into, (the sentinel nodes) and just removing those. Removing only the sentinel nodes reduces the chances of lymphoedema (a serious side-effect where fluid collects in tissue) following surgery.
Sentinel lymph node dissection usually involves an injection of radioactive liquid into your breast before your surgery and then, during surgery, blue dye may also be injected to help identify the lymph nodes nearest to the cancer. Only these nodes are removed. If they‘re clear of cancer, no other nodes need to be removed.
If your lymph nodes are already enlarged and appear abnormal, or if sentinel lymph node dissection shows the presence of cancer, your surgeon will most likely do an axillary lymph node dissection or clearance to remove most of the lymph nodes under your arm.
When you’re planning surgery for breast cancer, you may want to consider your options for breast reconstruction. There are a number of options to choose from — from no reconstruction at all (going flat) — to an implant, or a flap reconstruction using tissue from your buttock or abdomen.
You may want to consider whether to reconstruct your nipple (if surgery is going to remove it) and whether to have reconstruction done at the same time as your breast cancer surgery, or wait until some time later. There are a number of options regarding the timing, and you can discuss these with your doctor.
If you’re having a lumpectomy, you may just have a dent in your breast that can be left as is or filled with your own fat.
Depending on your circumstances, it’s possible your other breast will need work for both breasts to have a symmetrical look. (See ‘lumpectomy with reduction mammoplasty’ above.)
As each situation is different, you should discuss your options with a plastic or oncoplastic surgeon experienced in breast reconstruction.
While breast reconstruction may achieve a good cosmetic effect, your breast will not feel the same as before.