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Nearly everyone with breast cancer will have surgery as a part of their treatment plan. You’ll be involved in deciding what kind of surgery is right for you. Spending some time learning about your surgery options and talking with your medical team about what you can expect can help you make an informed decision.
Read on to learn about the different types of breast cancer surgery, potential complications, and what to bring on the day of your procedure.
Why is surgery a part of breast cancer treatment?
Surgery is the first step of the treatment process for many people with breast cancer. Surgery is the gold standard for breast cancer treatment because clearing the area of tumor cells helps decrease the risk of the cancer returning.
The purpose of breast cancer surgery is to remove the breast tumor and any involved lymph nodes in the armpit area. This area under the arm is called the axilla. The axilla has lymph nodes, or glands, that filter fluid in the body. 1
Normally, the fluid from breast tissue drains to vessels and then to the lymph nodes under the arm. When someone has invasive breast cancer, the cancer can spread through the fluid to the lymph nodes in the axilla or others nearby.2 Knowing whether cancer has reached the lymph nodes helps your medical team determine what stage of breast cancer you have. The surgeon will usually assess your lymph nodes during the procedure to remove the tumor in your breast.
For early-stage breast cancer, the goal of treatment is to cure the cancer by eliminating it and reducing the risk of it coming back. This is called curative treatment. A surgeon will remove the tumor, and your medical team will determine if additional treatments like chemotherapy, radiation therapy, targeted therapy, or hormonal therapy may be beneficial. 3
For people with advanced breast cancer, surgery is not likely to cure the cancer, but some people still benefit from having surgery. When surgery is used to treat symptoms rather than cure or treat the cancer, it’s called palliative treatment. 3
Preoperative (neoadjuvant) therapy
Depending on your situation, your medical team may recommend getting chemotherapy, targeted therapy, or hormonal therapy before surgery. Therapy given before surgery is called preoperative or neoadjuvant. Neoadjuvant therapy can shrink a tumor to make surgery a less extensive procedure.4 Although uncommon, some people also benefit from having radiation therapy before surgery.
Choosing a surgeon
Taking the time to find the right surgeon for you can help you have a better experience. You should feel comfortable asking questions and be involved in any decisions made.
The National Comprehensive Cancer Network recommends that you find a surgeon who is experienced and specializes in your kind of surgery. You can also ask your doctor to refer you to a hospital or cancer center specializing in breast cancer treatment. 2
If you plan on having breast reconstruction surgery, your surgeon will work with a plastic surgeon. The plastic surgeon will help you feel satisfied with how your breast looks after the cancer is removed. It’s recommended that you choose a plastic surgeon who is board-certified and specializes in the type of reconstruction procedure you want to have. 5
Types of breast cancer surgery
The two major types of breast cancer surgery are mastectomy and lumpectomy (breast-conserving surgery).
Mastectomy
A mastectomy is the removal of all breast tissue. A single or unilateral mastectomy is the removal of one breast, while a double or bilateral mastectomy is the removal of both breasts. If you have cancer in one breast, it’s your choice whether you want to remove one or both breasts.
Some people want a bilateral mastectomy because they are concerned that their cancer might come back in the other breast. However, multiple studies show that removing the normal breast does not improve your survival. The chance that cancer develops in the other breast is very low (less than 1% per year).6 For this reason, the side effects of more extensive surgery may outweigh the benefit. If you have a genetic mutation that increases your risk of bilateral breast cancer, your surgeon may recommend a bilateral mastectomy as a preventative measure. 6
Decades ago, the standard breast cancer surgery was a radical mastectomy in which the entire breast and the chest wall muscles under the breast were removed.6 It is rare in our current era for someone to have a radical mastectomy. Types of mastectomies performed these days include:
- a total or simple mastectomy, in which the whole breast is removed
- a skin-sparing mastectomy, in which the breast tissue, nipple, and areola are removed, but some skin is preserved to allow for breast reconstruction
- a nipple-sparing mastectomy, in which the breast tissue is removed but the skin, nipple, and areola are preserved (2,6)
Your surgeon will discuss your options with you and help you decide which type of mastectomy would be best for your situation.
Lumpectomy (breast-conserving surgery)
A lumpectomy, also called breast-conserving surgery, allows you to keep most of your breast while removing the tumor or abnormal cells. A lumpectomy preserves the contour and sensation of the breast.
During a lumpectomy, a surgeon removes the tumor and a small area of normal-looking tissue surrounding it. The rest of the breast tissue remains intact. 2
The normal-looking tissue surrounding the tumor that the surgeon removes is called a surgical margin. The margin can tell us whether or not the surgeon was able to remove all of the tumor.7 A pathologist will examine the margin under a microscope to determine if it contains any cancer cells.
If the pathologist does not see any cancer cells, this is called a negative margin. A negative margin likely means that the surgeon was able to remove all of the tumor cells, and you won’t need any more surgery.2 If there are cancer cells present in the tissue, this is called a positive margin. A positive margin may mean having additional surgery to remove the rest of the tumor. (2,7)
Sentinel lymph node biopsy
During a mastectomy or lumpectomy, the surgeon may assess your lymph nodes through a sentinel lymph node biopsy (SNLB). Sometimes, a surgeon will perform an SNLB as a separate procedure. 8
During an SNLB, the surgeon injects a blue dye containing a radioisotope into the breast. As the dye drains to the lymph nodes, the surgeon can see which node(s) any cancer cells might drain to first. These are called sentry nodes. The surgeon will remove the sentry nodes, and a pathologist will test them for cancer. 2
If the sentinel nodes are negative for cancer, the other lymph nodes are likely negative, and you won’t need to have them removed. If the sentinel nodes are positive, the remaining lymph nodes may be removed through axillary lymph node dissection (ALND). 2
If you have ductal carcinoma in situ, also known as Stage 0 breast cancer, the surgeon will not generally remove lymph nodes unless there is a concern that there may be invasive cancer within the tumor.
Breast reconstruction
Some people choose to have breast reconstruction after their cancer is removed. In this procedure, a plastic surgeon rebuilds the breast tissue to restore the shape and look of the breast. Depending on the type of surgery you had and how much tissue was removed, you may be able to use your own skin and fat (flaps) to rebuild the breast mound. Others choose to have implants or a combination of implants and flaps. If your nipple was removed, a plastic surgeon might be able to rebuild your nipple using nearby tissue or tissue from another part of your body. 2
Whether you have breast reconstruction is completely your choice. Losing a breast mound can be very difficult for some people, as it is part of their identity as a woman and who they are. Breast reconstruction can help people feel more satisfied with how their breasts look after breast cancer surgery. But no one needs to have reconstruction if they do not want to have such surgery.
Women can have breast reconstruction at any age. A plastic surgeon may perform breast reconstruction surgery immediately after a mastectomy or lumpectomy (immediate reconstruction), or it can be done as a separate procedure at another time (delayed reconstruction). Reconstruction is often done in stages. 2
It’s important to note that having immediate reconstruction extends the length of your procedure and your recovery time. Talking with your medical team about any preexisting conditions can help you make an informed decision about whether or not to choose breast reconstruction. 2
Adjuvant radiation therapy
Radiation therapy that occurs after surgery is called adjuvant or postoperative radiation therapy. Most people who have a lumpectomy are advised to have radiation after. Adjuvant radiation therapy can treat any remaining cancer cells present after surgery, which helps to prevent the cancer from coming back in the breast or the lymph nodes. (2,9)
If you have a mastectomy, your medical team may recommend radiation if you have, for example, positive lymph nodes or a tumor bigger than five centimeters. Radiation after a mastectomy can reduce the chance that the cancer comes back in the chest wall, neighboring lymph nodes, or elsewhere in the body. 9
Which breast cancer surgery is right for me?
Your breast cancer surgery options depend on the size and location of your tumor and whether the cancer has spread to surrounding tissues. 2
Certain tumor characteristics can make mastectomy a better option for some patients. These include:
- having small breasts and a large tumor
- having multiple tumors in different areas of the breast
Some people opt for a mastectomy because they believe it will give them better odds of survival. However, if a surgeon can remove all of the tumor and get a negative margin, a lumpectomy with radiation has the same survival rate as a mastectomy. Having a lumpectomy does not compromise survival.
A mastectomy is more likely to prevent local recurrence. This means it’s more likely to prevent the cancer from coming back in the breast. However, a 2018 study showed local recurrence rates after lumpectomy were declining, likely due to improvements in technology and individualized care. 10
Ultimately, it’s your body, and the choice is yours. Talking with your medical team can help you make an informed decision about which type of breast cancer surgery is best suited to you and your needs. If a mastectomy is recommended to you, make sure you understand the reasons for this recommendation.
What are the potential complications?
As with any medical procedure, breast cancer surgery has its risks. Learning about potential complications before having breast cancer surgery can prepare you to manage them if they occur.
Decreased shoulder mobility
During surgery, you’ll lie on your back with your arm raised overhead in a cradle so that the surgeon can get to the lymph nodes under your arm. Depending on the extent of the surgery you have, your arm may be in this position for one to two hours.
After the surgery, you may feel discomfort and have decreased range of motion in your shoulder. Some people avoid moving their shoulder after surgery because of the pain, which can lead to further stiffness.
If you have discomfort in your shoulder, let your medical team know. They can give you some range of motion exercises to try at home or refer you to physical therapy if necessary. Once your medical team has given you the OK, you can practice raising your arm to increase your mobility.
Tenderness or swelling near the surgical site
When tissue is removed from the breast or under the arm, our bodies may fill in these areas with fluid and blood. This is a natural reaction to the surgery, but it can cause discomfort. You may get tenderness, swelling, or a feeling of fullness in the breast or under the arm. If this happens, you can contact your medical team to set up an appointment to have the fluid drained. A surgeon, nurse practitioner, or physician’s assistant can remove the fluid using a small needle and syringe. This can give you relief from the pain or swelling.
Pain near the surgical site
Surgery can cause disturbance to the nerves, leading to pain. After breast cancer surgery, you will most likely not need to take strong pain relievers. The exception is if you’ve had reconstruction using tissue from another part of your body. To help with pain, you can apply ice to the area. Be sure to use a barrier between the ice and your skin, like a washcloth or dish towel, and use a timer so you don’t leave it on too long. Some people find that alternating ice with heat can also help.
Lymphedema
Some people have swelling in the arm after lymph node surgery. This is more common in people who have a more extensive surgery on the axilla. Lymphedema is a condition that occurs when lymph fluid can’t get back through the normal channels to go back into the bloodstream. If fluid can’t get back into the bloodstream, it can accumulate in your hands, arms, or breast area. This can cause swelling or a feeling of fullness.
If you have these symptoms, contact your medical team. They can provide you with arm exercises or a referral to physical therapy to help reduce your swelling. They may also recommend wearing compression garments like a gauntlet, arm sleeves, or gloves.
Increased risk of blood clots
Extensive surgery may cause an increased risk of blood clots. If you have a longer procedure or other risk factors, such as a history of blood clots or smoking, you may be put on a short-term blood thinner to avoid clotting. If you’re concerned about clotting, you can ask your doctor to learn more.
Infection
After your surgery, your medical team will tell you what symptoms you can expect at the surgical site. If you have swelling, redness, pain, or more drainage than you’ve been told to expect, contact your doctor or send them a photo through your patient portal. These could be signs of an infection.
What do I need to bring to surgery?
What you’ll need to bring to your surgery appointment differs depending on whether you have inpatient or outpatient surgery. Ask your surgeon whether you’ll stay overnight and for how many days.
If you’re going to be staying one or more nights, you might like to bring:
- a hair tie to keep your hair out of the wound area during recovery
- eye drops to keep your eyes moist, as hospital air can be dry
- lozenges or hard candies, as some people get an unpleasant taste when the IV is flushed with saline
- a toothbrush (a toothbrush and toothpaste are provided, but you might like to bring your own)
- mouthwash that does not contain alcohol
- a scarf, sweater, or hoodie to keep warm (choose something that opens to the front so you don’t have to raise your arms up)
- undergarments (if you want to wear a bra, choose one that is soft and opens in the front)
- deodorant wipes (avoid use on the side of your body where you’ve had surgery)
- a fanny pack or cross-body bag to hold a drain
- warm socks
- pen and paper to take notes and write down the names of the nurses and doctors you interact with
- something that makes you feel more at home, such as a blanket, headphones, or eye mask
- snacks
- your cell phone
You won’t need to bring your own medications, as your nurse will administer your medications to you from the hospital pharmacy.
If you are not staying overnight, bring as few items as possible. We suggest bringing a pen and paper, warm clothes, and your cell phone.
Summary
The two main types of breast cancer surgery are mastectomy, which is the removal of all breast tissue, and lumpectomy, which removes the tumor while conserving some of the breast tissue. Some women choose to have reconstructive surgery performed by a plastic surgeon to rebuild the breast mound after the cancer is removed. Learning about your options and potential complications can help you feel more informed and prepared. You and your surgeon will discuss your medical history, tumor characteristics, and other factors to come to a shared decision about what kind of breast cancer surgery is right for you.
References
- Lymphatic system: Parts & Common Problems. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/21199-lymphatic-system. Published February 23, 2020. Accessed September 7, 2022
- NCNN Guidelines for Patients: Invasive Breast Cancer. National Comprehensive Cancer Network. https://www.nccn.org/patients/guidelines/content/PDF/breast-invasive-patient.pdf. Published 2022. Accessed August 29, 2022
- Surgery for breast cancer. American Cancer Society. https://www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer. Published January 11, 2023. Accessed February 1, 2023.
- Selli C, Sims AH. Neoadjuvant therapy for breast cancer as a model for translational research. Breast Cancer: Basic and Clinical Research. 2019;13:117822341982907. doi:10.1177/1178223419829072
- Finding a qualified plastic surgeon. Breastcancer.org. https://www.breastcancer.org/treatment/surgery/breast-reconstruction/finding-a-plastic-surgeon. Published February 9, 2022. Accessed February 1, 2023.
- Types of mastectomy. https://www.breastcancer.org/treatment/surgery/mastectomy/types. Published August 25, 2022. Accessed February 1, 2023.
- Surgical margins after breast surgery. Susan G. Komen. https://www.komen.org/breast-cancer/diagnosis/biopsies/assessing-margins/. Published December 20, 2022. Accessed February 1, 2023.
- Sentinel lymph node biopsy. UCLA Health System. https://www.uclahealth.org/medical-services/cancer-services/breast-cancer/breast-health-services/breast-surgery/sentinel-lymph-node-biopsy. Accessed February 1, 2023.
- Radiation for Breast Cancer. American Cancer Society. https://www.cancer.org/cancer/breast-cancer/treatment/radiation-for-breast-cancer. Published October 27, 2021. Accessed August 29, 2022.
- Doyle C. Recurrence rates after lumpectomy significantly improved in patients receiving ‘modern-era’ therapy. The ASCO Post. https://ascopost.com/issues/june-10-2018/recurrence-rates-after-lumpectomy-significantly-improved-with-modern-era-therapy. Published June 10, 2018. Accessed February 1, 2023.
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