Breast Cancer Surgery
“What are the surgery options for breast cancer?”
“Should I Conserve my breast or remove?”
“Do I need Chemoport?”
Breast Cancer Surgery
Surgery is a central part of treating breast cancer, and for most women it is where the cancer is physically removed. We will decide together which operation is right for you.
Surgery is almost never the whole treatment. It is combined with some or all of chemotherapy, endocrine therapy, targeted therapy, immunotherapy and radiation, depending on what your cancer is.
Surgery is not always the first step
For some cancers, particularly triple negative and HER2 positive cancers, we now give drug treatment before surgery as the preferred approach. This is not a sign that your cancer is worse.
Treating first does three things. It shrinks the tumour, it often makes breast conservation possible, and it shows us how your cancer responds to treatment. That last point is the important one, because the response tells us what else you need after surgery, and there is no other way to find it out.
Your plan is built around:
- The biology of your cancer, meaning its type, grade and receptor status
- The stage
- Your general health, age and other medical conditions
- Your own preferences
Breast cancer surgery addresses two areas: the tumour in the breast, and the lymph nodes in the armpit.
Breast Conservation Surgery (BCS)
Breast conservation surgery, also called lumpectomy or wide local excision, removes the cancer along with a rim of surrounding healthy tissue. The rest of the breast is preserved. The armpit is assessed at the same operation.
“Breast conservation is safe. Randomised trials with more than twenty years of follow-up show the same survival as mastectomy in early breast cancer.”
This is one of the best established facts in breast cancer treatment, and it is worth knowing before you make a decision you cannot reverse.
Radiation after breast conservation
Radiation to the breast after conservation surgery substantially reduces the chance of the cancer returning in that breast, and it is recommended for the great majority of patients.
Radiation is also shorter than it used to be. Most patients now receive it over about three weeks rather than five, and for selected patients an even shorter course is appropriate. Treating part of the breast rather than the whole breast is another option in suitable cases.
There is a small, carefully defined group of older women with small, hormone-receptor-positive, node-negative cancers who are taking endocrine therapy, in whom radiation can reasonably be left out. That is a decision made case by case, not a general rule.
Who is suitable for breast conservation?
Breast conservation is possible for most women with newly diagnosed early breast cancer. It depends on:
- The size of the tumour relative to the size of your breast
- Whether the cancer is confined to one area
- Whether you are able to complete radiation afterwards
If the tumour is large, chemotherapy given before surgery will often shrink it enough to make conservation possible. If it does not shrink sufficiently, mastectomy may still be the better operation.
Modified Radical Mastectomy (MRM)
Modified radical mastectomy removes the whole breast together with the lymph nodes in the armpit. The remaining skin is closed over the chest wall.
MRM is the right operation when the whole breast needs to be removed and the armpit nodes are known to be involved and require clearance. Situations where mastectomy is appropriate include:
- More than one tumour in separate areas of the breast, called multicentric disease
- A large tumour that has not responded sufficiently to chemotherapy
- Cancer involving the skin, or a cancer that cannot be removed with clear margins by conservation
- Previous radiation to that breast
- Patient choice. Some women prefer mastectomy even when conservation is possible, and that is a valid decision.
A note on BRCA
Carrying a BRCA1 or BRCA2 mutation does not automatically mean you need a mastectomy for the cancer you have. Breast conservation remains an option for many carriers.
What a BRCA result does change is the conversation about future risk in both breasts, and about risk-reducing surgery. Where a carrier chooses mastectomy, a skin-sparing or nipple-sparing approach with reconstruction is often more appropriate than a modified radical mastectomy. We will go through all of this with you properly before you decide.
Recovery
Patients usually stay in hospital overnight and go home the following day. Drains are placed and are typically removed within ten to fourteen days. Most people are back to normal activity in around two weeks.
Oncoplastic Surgery
Oncoplastic surgery is done at the same time as a lumpectomy. It fills the space left by the tumour and restores the natural shape of the breast, so that removing the cancer does not mean accepting a deformity.
In my practice, oncoplastic technique is offered to every woman having breast conserving surgery. A good cosmetic outcome is not a luxury. It affects how a woman feels about herself for the rest of her life, and it is part of the treatment.
Oncoplastic surgery can also include work on the other, healthy breast to restore symmetry. This can be done at the same operation as the lumpectomy.
The reason it matters is that even small lumpectomies can leave a significant defect. The immediate result after lumpectomy and radiation is often good, but over time, as radiation changes and scarring continue, the breast can shrink, dimple and pucker.
With oncoplastic techniques, even large lumpectomies become possible, and the cosmetic results are substantially better than lumpectomy alone.
Breast Reconstruction Surgery
Reconstruction means creating a new breast shape after the whole breast has been removed, or after part of it has been removed.
All my patients are told about reconstruction before surgery, not after. Reconstruction is not needed to cure breast cancer, but it is often needed for a woman’s sense of herself, and that is a legitimate reason to have it.
Reconstruction does not make your cancer treatment less effective, and it does not make a recurrence harder to detect. Where it can affect timing is in relation to radiation, which is why we plan the two together from the start.
If you choose not to have reconstruction
A post-mastectomy bra and an external prosthesis are a good option, and many women are very satisfied with them. This is usually fitted about six weeks after surgery, once the incisions have healed.
Prostheses come in different materials, including silicone gel, foam and fibrefill, and in different textures, sizes, shapes and skin tones. Fitted into a pocket in a bra or swimsuit, and correctly weighted, they let you hold normal posture. Custom-made prostheses are also available.
If you are considering reconstruction
When. The breast can be reconstructed at the same operation as the mastectomy, called immediate reconstruction, or later as a separate operation, called delayed reconstruction. The timing often depends on whether you will need radiation afterwards.
How. A new breast can be formed with an implant, with your own tissue taken from elsewhere on your body, or with a combination of the two. Each has advantages, and the right choice depends on your build, your treatment plan and what matters to you.
Hidden Scar Breast Surgery
Hidden scar surgery places the incision where the scar will not be visible once it heals. We use this approach for both cancer operations and benign lumps, and it can be combined with either a lumpectomy or a nipple-sparing mastectomy.
The cancer operation is not compromised in order to hide the scar. The same tissue is removed, and the same margins are taken. What changes is where we enter.
We place the incision in one of three positions:
- The natural crease under the breast, called the inframammary fold
- Around the border of the nipple and areola
- In a skin crease in the armpit
You may be suitable if:
- Your tumour is small relative to the size of your breast
- Your tumour is confined to one area
- The tumour and a clear margin around it can be fully removed through that approach
- The cancer has not spread to the nipple
Wire Localisation Excisional Biopsy
Some cancers are picked up on a mammogram while they are still too small to feel. To remove one of these safely, we first have to mark exactly where it is.
The established method is a guidewire. Under local anaesthetic, a fine wire is placed into the breast so that its tip sits next to the cancer or the suspicious area. This is done with ultrasound or mammogram guidance, whichever shows the lesion better.
You are then taken to theatre, and under general anaesthetic the marked area is removed. In every case, the tissue that has been taken out is X-rayed before you leave theatre, to confirm the right area was removed. It is then sent to the pathologist.
Newer markers such as magnetic seeds and radar reflectors can be placed days ahead of the operation rather than on the morning of surgery, which many patients find easier. We will tell you which method we are using and why.
Simple Mastectomy
Simple mastectomy, total mastectomy and complete mastectomy all mean the same operation.
The whole breast is removed, along with most of the overlying skin and the nipple and areola. The armpit lymph nodes are not cleared.
In most cases where this is done for cancer, a sentinel lymph node biopsy is still performed at the same time, usually through a small separate incision, so that we know whether the nodes are involved. Sparing the axilla means we do not remove all the nodes. It does not mean the nodes go unchecked.
Skin and Nipple Sparing Mastectomy
This operation removes the entire breast tissue while preserving all of the skin and the nipple and areola. The incision is usually placed in the fold below the breast.
It is always done in combination with reconstruction, either implant based or using the patient’s own tissue, since the preserved skin envelope needs to be filled.
Skin and nipple sparing mastectomy is a good option for women considering preventive mastectomy because they are at high risk, such as those carrying a BRCA mutation.
It is also offered to selected women with early breast cancer who are not suitable for breast conservation. Suitability depends on where the tumour sits relative to the nipple, on the size of the breast and on the blood supply to the skin, and we will assess this for you individually.
Lymphnode Surgery
Checking the armpit lymph nodes is part of breast cancer surgery, because whether the nodes are involved affects the whole treatment plan.
Before surgery, the armpit is assessed with ultrasound. If a node looks abnormal, it is sampled with a needle. If the nodes look normal on imaging, they still need to be checked during the operation, because imaging cannot pick up small deposits.
Sentinel lymph node biopsy
The sentinel node is the first node that fluid from the breast drains into, so it is the first place cancer would be expected to appear. A tracer is injected and followed to find these nodes, which are then removed and examined. The tracer may be a blue dye, a radioactive tracer, or one of the newer fluorescent or magnetic tracers.
If the sentinel nodes are clear, no further armpit surgery is needed.
Sentinel node biopsy has largely replaced full armpit clearance for women whose nodes look normal, and it carries a much lower risk of arm swelling and shoulder problems.
What if the sentinel node contains cancer?
This is where practice has changed significantly, and it is worth understanding.
It used to be routine that a positive sentinel node meant going on to a full axillary clearance. That is no longer the case. Good quality trial evidence has shown that many women with only one or two involved sentinel nodes do not benefit from removing the rest of the nodes, provided they are receiving radiation and appropriate drug treatment. In other situations, radiation to the armpit gives the same control as surgery, with fewer long-term side effects.
So a positive sentinel node does not automatically mean more surgery. The decision depends on how many nodes are involved, which breast operation you are having, and what other treatment is planned. We will explain which applies to you.
Targeted axillary dissection
This applies if your lymph nodes were already known to contain cancer when you were diagnosed, and you had chemotherapy before surgery.
Chemotherapy clears the cancer from the lymph nodes in a substantial proportion of these patients. Where that happens, a full armpit clearance may no longer be necessary, and avoiding it spares you the long-term risk of arm swelling and shoulder problems.
The difficulty is being certain the nodes are genuinely clear. A sentinel node biopsy on its own is not reliable enough after chemotherapy in someone who started out node-positive, because treatment can alter the way fluid drains through the armpit. Targeted axillary dissection is how we solve that.
It works in two stages. When the abnormal node is first biopsied and found to contain cancer, a tiny marker clip is placed inside that node. It stays there throughout your chemotherapy.
At surgery we then remove two things: the sentinel nodes, found in the usual way with a tracer, and that specific clipped node, located with a wire or a seed marker placed shortly before the operation. The clipped node is often, but not always, one of the sentinel nodes, and that is exactly why both are taken.
Removing both together gives a far more reliable answer than either would alone. If everything removed is clear, no further armpit surgery is needed.
“This only works if the clip was placed at the time of your original node biopsy, which is a decision made at diagnosis, months before the operation.”
So if you are being told that your nodes are involved and that chemotherapy will come first, ask whether a clip is being placed. It costs nothing at that stage, and it preserves an option you may be very glad of later.
Axillary lymph node dissection
A full clearance removes the majority of the nodes in the armpit. It remains the right operation where there is significant nodal disease, and in that setting it is an important part of treatment.
Because it is more extensive, it carries a higher risk of:
- Lymphoedema, meaning swelling of the arm
- Seroma, a collection of fluid at the operation site
- Numbness, tingling or pain in the arm and the upper inner arm
- Shoulder stiffness and reduced movement
Where a clearance is needed, we will tell you what to watch for, and arrange physiotherapy and lymphoedema monitoring from the start rather than waiting for a problem to appear.
Chemoport
A chemoport is a small device placed under the skin of the chest and connected to a large vein. It gives safe, reliable access to your bloodstream for chemotherapy and for blood tests.
Putting one in is a day procedure, usually done under local anaesthetic. You go home the same day.
Why I recommend it
- It protects the small veins in your arms, which chemotherapy drugs damage over time
- It means no repeated attempts to find a vein at every cycle, which for most patients is the worst part of the day
- Blood samples can be taken through it without a fresh needle each time
- It stays in place for the length of your treatment and is removed once you no longer need it
The port needs simple care, including a flush at set intervals, and we will show you and your family what to watch for. Infection is uncommon but it must be reported quickly, so tell us at once if the skin over the port becomes red, painful or swollen, or if you develop a fever.
I strongly recommend a chemoport for anyone having chemotherapy. It makes the months of treatment considerably easier to get through.
