Breast cancer surgery
The least extensive operation that provides appropriate cancer control.
More surgery is not necessarily better surgery.
The purpose of breast cancer surgery is to remove the cancer with an appropriate margin, evaluate the lymph nodes when necessary and support the treatments that may follow.
The choice of operation depends on the extent of disease, breast anatomy, genetic risk, prior treatment, likely radiotherapy and patient preference.
The principal surgical options
Breast-conserving surgery
Breast-conserving surgery removes the tumor and a surrounding margin while preserving the remainder of the breast.
It is generally followed by radiotherapy, although recommendations depend on the patient's age, pathology and overall treatment plan.
Breast-conserving surgery may not be appropriate when the disease is too extensive relative to the breast, when clear margins cannot be obtained or when radiotherapy cannot be given.
Mastectomy
Mastectomy removes most or all breast tissue.
It may be recommended because of the extent or distribution of disease, persistent positive margins, genetic risk, previous radiotherapy or other clinical factors. Some patients may also choose mastectomy after discussing medically reasonable alternatives.
Mastectomy does not always eliminate the need for radiotherapy or systemic treatment.
Nipple-sparing mastectomy
Nipple-sparing mastectomy removes breast tissue while preserving the breast skin and nipple–areola complex.
It is available only for appropriately selected patients. Tumor location, breast anatomy, blood supply, smoking status and the possibility of cancer involving the nipple may affect eligibility.
The preserved nipple may have reduced or absent sensation after surgery.
Lymph-node surgery
Lymph-node evaluation may be performed to determine whether breast cancer has spread to the nodes under the arm.
Sentinel lymph-node biopsy removes a limited number of selected nodes. More extensive axillary surgery may be required in some circumstances.
The extent of lymph-node surgery should be discussed in relation to tumor stage, preoperative treatment and current clinical guidance.
Questions to ask before choosing an operation
- What is the clinical reason for recommending this operation?
- Is breast-conserving surgery medically possible?
- Will radiotherapy be required after breast-conserving surgery?
- Could radiotherapy still be required after mastectomy?
- How will the operation affect breast appearance and sensation?
- What is the likelihood of needing another operation for margins?
- Will lymph-node surgery be performed?
- Is immediate reconstruction appropriate?
- Could systemic treatment be required before surgery?
- How will postoperative complications be managed after I return home?
A note about newer surgical approaches
Endoscopic and robot-assisted approaches may allow the incision to be placed away from the front of the breast in selected mastectomy procedures.
A less visible incision does not necessarily mean a smaller internal operation. Breast tissue still needs to be removed, and reconstruction may still be required.
Patients should ask about surgeon experience, selection criteria, costs, operative time, complications, long-term follow-up and conventional alternatives.