Surgery is the first treatment for most people with breast cancer. This aims to remove the cancer with a margin (border) of normal tissue to reduce the risk of the cancer coming back.
The type of breast surgery recommended will be based on the type of cancer, the size of the tumour, where it is in the breast and how much surrounding tissue needs to be removed. It will also depend on how large the breasts is. The surgeon will want to give the most effective surgery for the cancer as well as the best cosmetic result possible. In breast-conserving surgery this means keeping as much as possible of the breast while trying to ensure the cancer has been completely removed.
Before surgery, some people with invasive breast cancer may be offered chemotherapy or hormone therapy to shrink the tumour, and this may result in less extensive surgery. This is called primary or neo-adjuvant treatment.
Types of surgery
There are two main types of operation.
Lumpectomy / Wide local excision
Breast-conserving surgery referred to as wide local excision or lumpectomy, where the cancer is removed with a margin of normal breast tissue.
This means removal of all the breast tissue including the nipple area. A simple mastectomy means that the entire breast is removed, the muscles underneath the breast are not affected.
For many cases of either non-invasive or invasive cancer, breast-conserving surgery followed by radiotherapy is sufficient treatment. While in other cases a mastectomy will be recommended. The consultant will explain why they think a particular operation is best.
For most cases of invasive cancer it is recommended that some or all of the lymph nodes (glands) under the arm are also removed during surgery.
Removing the lymph nodes under the arm
There are two reasons for removing lymph nodes at the time of breast surgery.
Patients with a diagnosis of invasive breast cancer should have an ultrasound under the arm before breast surgery to assess the lymph nodes. If this appears to be abnormal an FNA (fine needle aspiration) will be done to see if the cancer has spread to the lymph nodes. If the lymph nodes contain cancer cells the patient will require all the lymph nodes to be removed at the same time as the breast surgery. This is known as axillary clearance. This aims to stop the affected nodes from growing bigger and causing other problems under the arm.
Sentinel lymph node biopsy
If the tests before surgery show that the lymph nodes are not affected, the surgeon will still need to remove a sample of the lymph nodes (usually at the same time as the breast cancer surgery) to confirm this. This is known as a procedure called sentinel lymph node biopsy. Knowing whether lymph nodes are affected is important for deciding which treatments in addition to surgery may be of benefit. This procedure involves injecting a small amount of radioactive material and a dye that identifies the first, or ‘sentinel’, node(s) to receive lymph fluid from the cancer. Once removed and examined if this sentinel node(s) does not contain cancer cells it usually means that the other nodes are clear too, so no more will need to be removed.
Following a mastectomy the patient may consider breast reconstruction. This may be done at the same time as the mastectomy (immediate reconstruction) or at a later date some time in the future (delayed reconstruction).
A delayed reconstruction may be suggested if there are medical reasons why an immediate one isn’t possible. A delayed reconstruction can be done months or even years later. There are different types of breast reconstruction available, depending on your preference, your age and general fitness, your body shape, the type of breast cancer and any future treatment needed. The consultant will explain all options in detail.