Consideration of Breast Surgery for Breast Cancer

The treatment for breast cancer usually starts with surgery.

The purpose of surgery is twofold:

• remove the cancer from the breast and
• to biopsy the lymph nodes underneath the arm to see if the cancer has the ability to spread.

Typically for invasive ductal carcinoma, there are two options for surgery. Each surgical option has both good and bad associated with it.

• The first option is called a partial mastectomy with sentinel lymph node biopsy. This is a smaller operation in which the cancer is removed from the breast. This is either done by being able to feel the cancer or to utilize radiology to place a small wire to guide incision placement. Typically, when the biopsy was done under ultrasound or mammogram guidance, a small metallic clip marker is left to show the area that was biopsied. The wire is placed near that clip. After the breast cancer, clip, and wire (if it was necessary to place) is removed, additional margins are taken. A margin is a small amount of healthy tissue next to the cancer that is removed to ensure that the cancer is completely gone. If you imagine sitting in a room, all four walls, floor, and ceiling are removed around the cancer. Once that is done, a separate incision is made under the axilla on the same side as the cancer. Cancer cells will travel in a predictable course from the breast, to the axilla, and then to the rest of the body. The name sentinel lymph node is similar to a sentry guarding the gate. If the enemy is trying to attack, they will go to the sentry first. A blue dye is injected into the breast during the surgery to mimic the spread of cancer cells. The dye is carried by the lymphatic system to the first lymph node that, if cancer would be there, would affect it first. The lymph node is removed and examined by the pathologist during the operation. If there is cancer in that first lymph node, the entire packet of lymph nodes is removed to understand the extent of cancer spread. If there is no cancer, only the first lymph node is removed. If the all of the lymph nodes are removed, a drain tube may be necessary to help that incision heal. At the end of surgery, aside from scars, the breast typically looks pretty normal. The nipple is intact and the size and shape of the breast is unchanged.
  Following healing from a partial mastectomy, it will be necessary for a patient to have radiation. The purpose of radiation is to prevent cancer from returning to the same area in the breast where it started. It is used for local control of the cancer. Radiation can be given either externally or, in some cases, through a special device implanted in the breast (SAVI). Most patients will have external radiation. Radiation utilizes invisible high power x rays that destroy cancer cells. Radiation typically is given five days a week (Monday through Friday) for about seven weeks. Patients are able to drive themselves to appointments but working schedule must necessarily be adjusted to allow for daily treatments. Side effects are usually irritation to the skin as the tissue is being burnt from the inside. The radiation oncologist will discuss all of the potential side effects and ask that patients sign consent that they understand. Radiation can be difficult to arrange without insurance but it is not impossible. Resources that are available to help can be given at this office. Radiation is almost never free so cost consideration must be factored. The cost, so to speak, of a partial mastectomy and keeping the breast intact, is the need for radiation.
  
  
• The other option available for breast cancer is modified radical mastectomy. During this operation the entirety of breast tissue from clavicle to sternum to inframammary crease to axilla is removed from the chest wall. This is done through an incision that encircles and ultimately removes the nipple. At the same time, just as in the case of partial mastectomy, a sentinel lymph node biopsy is performed. Unlike the partial mastectomy, a separate incision is not necessary as there is more working room. A drain tube is always used as there is a larger space underneath to heal. Depending on the size of the breast removed, the drain tube may be necessary for one to three weeks. Patients will record output of drain daily so the surgeon can understand if the drain is still necessary. Sometimes after the drain is removed, fluid will accumulate under the skin in the area where the breast was, requiring percutaneous drainage with a small needle in the office. Before modified radical mastectomy, the patient may also give some thought of whether they might want reconstruction now or in the future. If that is not planned, the excess skin is trimmed so that the incision will lie flat against the chest wall. If the patient will have plastic surgery, as much skin as is possible will be left so that the plastic surgeon does not have to stretch as much. If a patient wishes to have plastic surgical reconstruction at the same time as surgery, a consultation will be arranged separately as it is necessary to coordinate both surgeons to be there together. When a patient has both surgeries at once, it is necessary for a patient to have the operation at a main hospital rather than the surgery center as recovery is more extensive. In the event that a patient wants to consider reconstruction in the future, they will advise so that skin can be left. Unless the tumor is adherent to the chest wall or very large, post operative radiation is usually not required following mastectomy.

The staging of cancer involves the size of the cancer, how many lymph nodes were affected by cancer, and if the cancer would have spread elsewhere in the body. If there is cancer within the lymph nodes, additional scans are ordered to ensure that cancer is not somewhere else. Those scans usually start with CT but sometimes PET is used as well. In the event that a patient does not have insurance, discounted rates are available. The final staging then determines if chemotherapy is necessary.

The decision for chemotherapy is made after the staging process is complete. It has nothing to do with the type of surgery that was done to remove the cancer. Chemotherapy is a very broad word that means medication given to treat or prevent cancer. The medication can either be given in pill form and or through the vein in an IV. If prolonged treatment is anticipated, a special implanted IV called a Mediport is placed. This is done as a second surgery (as the need for it is usually not known at the first surgery). Chemotherapy can have numerous side effects; however, the effects are dependent on the drug used. It is not helpful to compare other patients’ experiences with chemotherapy as the drugs selected for them may have been completely different. Chemotherapy is administered by a medical oncologist. The relationship with the oncologist lasts for years as patients transition into survivors.

To summarize, the patient chooses the surgery that is best for them:

• Partial Mastectomy with Sentinel Lymph Node has the advantage of breast preservation but downside of radiation.
• Modified Radical Mastectomy has the advantage of avoidance of radiation but downside of loss of breast.

In either case, chemotherapy may be necessary.