The options available to a patient depend upon several factors; including the type of tumor, the extent of the disease at the time of diagnosis, age and medical history. Personal feelings about the treatment and self-image are also be important considerations. There may be several doctors involved, including a surgeon, a medical oncologist, a radiation oncologist, and a plastic surgeon. Whether a doctor in each of these fields is necessary will depend on the patient’s situation.
Treatment for breast cancer can include surgery, chemotherapy, radiation, and reconstructive surgery. The techniques in each of these fields have improved, leading to treatments that were not previously available. Consequently, breast cancer treatment has become more effective and the cosmetic results have improved.
Breast Cancer Surgery
The surgical treatment of breast cancer usually begins with a biopsy. Further treatment will typically include surgical removal of the tumor. This may be done by a lumpectomy (partial mastectomy) or by a mastectomy (removal of the whole breast). Because breast cancer may spread to lymph nodes in the axilla (armpit), breast cancer surgery can also include removal of some of these lymph nodes. Techniques for this include sentinel lymph node biopsy and axillary dissection.
Lumpectomy is the removal of the tumor and a surrounding rim (margin) of normal breast tissue. Most the breast tissue is undisturbed. Radiation treatment is then necessary for the breast. In combination with radiation, lumpectomy is as successful as mastectomy in treating breast cancer and the cosmetic result is usually excellent. Depending on the location and size of the tumor, some women may not be candidates for this procedure and may need to have a mastectomy. Some women prefer a mastectomy, possibly with breast reconstruction, instead of lumpectomy and radiation. Occasionally, if microscopic analysis of the lump later reveals that the margins are not clear of cancer, a return to surgery for further removal of tissue or mastectomy may be necessary.
A modified radical mastectomy removes the entire breast and the axillary lymph nodes. The removal of the axillary lymph nodes is called an axillary dissection. This may be the best option for women with certain types or stages of breast cancer. Some women may also prefer this treatment to a lumpectomy with radiation. If desired, a reconstruction of the breast can be performed by a plastic surgeon. A mastectomy with reconstruction is a more extensive operation and requires a longer recovery. Reconstructions may be performed at the time of mastectomy or at a later date. Usually one or two drain tubes are placed at the time of surgery and are removed one or two weeks after surgery. Additional drain tubes may be necessary if a reconstruction is performed.
Simple mastectomy removes the entire breast without performing an axillary dissection. It may be combined with a sentinel lymph node biopsy in certain situations. A simple mastectomy may also be performed when the mastectomy is being done for prophylaxis, to prevent breast cancer for women with high risk for future breast cancer.
Skin Sparing and nipple sparing mastectomies are variations of a simple mastectomy that may be combined with plastic surgery reconstruction of the breast to provide improved cosmetic outcomes while maintaining the standard of cancer care.
Axillary dissection is the removal of lymph nodes from under the armpit. This is done to determine if cancer has spread to these lymph nodes and, if so, to remove it. The lymph nodes are removed from an area that has certain anatomic boundaries. Anywhere from 5 to 25 lymph nodes may be present in this area. A drain tube is placed at the time of surgery and will remain for one to two weeks. The lymph nodes are analyzed in the laboratory to determine if cancer is present and the oncologist uses this information to make decisions about chemotherapy. Axillary dissections are far less common today and can be associated with swelling of the arm (lymphedema). There is also the possibility of nerve damage leading to numbness or muscle weakness, fluid collections in the wound cavity, and limited mobility of the arm. These problems, however, are not common.
Sentinel lymph node biopsy is a less invasive way to evaluate the axillary lymph nodes. Instead of removing many lymph nodes as in an axillary dissection, typically only 1-3 lymph nodes are removed. The advantage is a quicker recovery and lower risk of post-operative problems. A drain tube is usually not necessary. If the sentinel node is found to have cancer in it, then an axillary dissection may be necessary.
Breast reconstruction is way to recreate the breast shape after mastectomy. Most women who have a mastectomy can also have a breast reconstruction, but there are exceptions. If you are considering reconstruction, you will be referred to a plastic surgeon who will discuss various techniques with you. The surgery is fairly lengthy and requires additional postoperative recovery in the hospital.
Used in conjunction with surgery, particularly a partial mastectomy, radiation therapy is administered by a radiation oncologist in one of two forms:
External beam radiation – administered 5 days a week over approximately 3 to 6 weeks.
Partial breast irradiation – administered via a catheter placed into the breast and usually completed in 7-10 days. A consultation with a radiation oncologist is recommended prior to initiating radiation therapy. For more information about this type of radiation, click here.
Many breast cancers are sensitive to estrogen, medications that block estrogen can be highly effective in treating breast cancer.
Chemotherapy also has an important role in the treatment of breast cancer. If chemotherapy is appropriate, a medical oncologist will discuss the best form for you. Chemotherapy may be in the form of a pill taken daily or may involve intravenous medications in which case a special IV catheter may be placed.
Most patients who undergo lumpectomy and lymph node removal go home the same day. Those who have a modified radical mastectomy will go home within 23 hours of the surgery unless they had a breast reconstruction. Patients are prescribed an oral narcotic to control pain after discharge and may have a drain tube to remove fluid that can accumulate in the area of surgery. You will receive instructions on care for this drain. Once a day, the dressing covering the drain should be removed. At this time, you may take a shower and wash this area, gently dry it, and apply a small amount of Neosporin around the tube. A small gauze pad should be placed over the drain site. The drain is usually removed about a week or two after the operation. You should make an appointment to see your surgeon one week after the surgery. You may also do a set of exercises to keep your arm and shoulder flexible after the drain is removed.
As with any surgery, there are risks and possible complications, although these are generally quite rare. They may include:
- Scarring or deformity of the breast after lumpectomy
- Numbness under the arm after axillary dissection
- Muscle weakness
- Fluid collections
- Limited range of motion of the shoulder
- Bruising, swelling or scarring
- Cancer Recurrence
- Complications from anesthesia