You have been diagnosed with breast cancer. Do you need to have surgery? And, if so, which type of surgery is right for you?

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Surgery is the mainstay of treatment for people with breast cancer that hasn’t spread beyond the breast area and lymph nodes (or glands). For people with cancer that has spread to other parts of the body, surgery is done in special cases.

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1. Ductal Carcinoma in Situ (DCIS)

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If you have DCIS, also called Stage 0 or non-invasive breast cancer, surgery is the first type of treatment you will have. If you have an operation that keeps most of your breast, radiation therapy will most likely be recommended as well. Some people do not need to have radiation therapy.

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2. Invasive Breast Cancer, Stages I, II, and III

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If you have been diagnosed with Stage I (one), Stage II (two), or Stage III (three) breast cancer, surgery will typically be the first type of treatment that you will have. However, some people with large tumors or enlarged lymph nodes under the arm (called the axilla) may be offered chemotherapy first to try to shrink the size of the tumor before surgery. This may allow for a simpler operation. Even if the tumor appears to disappear completely after chemotherapy, surgery is still part of your treatment plan.

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Additional treatments are usually given after surgery. These treatments may include chemotherapy, radiation therapy, hormonal therapy, and targeted therapy.

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3. Invasive Breast Cancer, Stage IV

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If the cancer has spread to other parts of your body at the time you are diagnosed with breast cancer, the cancer is referred to as being Stage IV (four). Some people will refer to Stage IV cancer as “advanced breast cancer” or “metastatic breast cancer.” The cancer in other parts of your body started in the breast and then spread to other places.

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The most important part of your treatment will be directed at treating the cancer throughout your body. The vast majority of these treatments will also decrease the size of the tumor in your breast.

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If the cancer in the other parts of your body is shrinking as a result of treatment, you and your doctors may decide that you would benefit from having surgery on the breast itself. Not every person will need to have the breast tumor removed.

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Other types of surgery may be recommended in people with Stage IV breast cancer. Occasionally, surgery will be required to treat or prevent complications from cancer that has spread to other parts of the body. Examples might include surgery on the thigh bone to prevent a fracture or surgery on the spine to decrease or eliminate pain. It is not possible to know in advance if you will need one of these surgeries.

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Types of Surgery

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1. Lumpectomy

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Lumpectomy means removal of the breast lump or abnormal area on mammogram or ultrasound. Many patients have this type of surgery because it removes the least amount of breast tissue and keeps the shape of the breast. In addition to removing the cancer, the surgeon will also remove a surrounding area of normal tissue, or what is referred to as a “margin.” You could consider this a ”margin of safety.” This extra tissue can involve both breast tissue. Even though only a portion of the breast is removed, this type of surgery is highly effective. Lumpectomy followed by radiation treatment is the most common type of surgery for breast cancer.

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2. Mastectomy

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Mastectomy means removal of the breast.

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• Total mastectomy or simple mastectomy means what the name implies. It involves removal of the breast, including the nipple.

• ‍Modified radical mastectomy means a total mastectomy plus removal of the axillary (under your arm) lymph nodes.

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3. Lymph Node Removal

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What are lymph nodes? Lymph nodes are part of our immune system. Lymph vessels carry lymph through our body through nodes which are filters that help us fight infection, infection, or even abnormal cells such as in cancer. Lymph is a colorless fluid comprised of white blood cells. Breast cancer, like many other cancers, can spread first to the lymph nodes near the tumor. Therefore, in addition to removing the cancer by lumpectomy or mastectomy, it is vital to remove the local spread of the cancer to the lymph nodes as well. There are two main types of lymph node removal that you may have.

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• Sentinel node removal. These are the first lymph nodes to capture the abnormal cells closest to the tumor. These are the first line of defense for your body. If these lymph nodes do not have cancer in them, it is very unlikely that the other lymph nodes in your axilla are involved with cancer. Your surgeon will identify the sentinel lymph nodes by injecting a dye or radioactive substance into the tissue near the tumor. This allows the surgeon to be able to identify the sentinel lymph nodes and allow for immediate biopsy instead of removing too many of the surrounding lymph nodes.‍

• Axillary node dissection means some if not most of the lymph nodes are removed under the arm for testing for cancer. This procedure is more debilitating for some patients in that it can cause limitation of arm or shoulder movement. However, it provides not only a good way to remove cancer spread that is not readily seen by the surgeon or by preoperative testing, but it also allows for accurate cancer staging and subsequent treatment planning. Both sentinel lymph node removal and axillary node dissection usually requires two separate incisions for patients undergoing breast lumpectomy.

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4. Cryotherapy

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This is freezing the cancer cells and it remains experimental.

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Which Type of Surgery Should you Have?

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The type of surgery that is best for you depends on several factors. One of the first things we consider when helping you make a decision about surgery is the size of the tumor in relation to the size of your breast. For example, if you have a relatively large tumor but are large-breasted, you are more likely to be able to have a lumpectomy than if you are smaller-breasted, in which case mastectomy may be the best option to remove all the tumor.

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Other things that play a role in the type of surgery you have on your breast include whether or not you are able to have radiation therapy. Radiation therapy is recommended following surgery for the vast majority of people with invasive breast cancer. However, if radiation is not possible, you may be advised to have a mastectomy.

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If you undergo genetic counseling and testing and are found to have inherited a gene that increases your risk for another cancer in the same breast or the other breast, you may be advised to have a mastectomy.

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Finally, if the cancer has already spread to other parts of the body, surgery may be part of your treatment plan, but other treatments that control the cancer throughout your body usually take priority.

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While many people in your life may have opinions on which type of surgery you should have, the decision should be made by you and your medical team. If you are not comfortable with your doctor’s recommendation, do not feel bad about getting another medical opinion.

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Factors Affecting Type of Surgery on the Breast

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• The size of the tumor in relation to the size of your breast

• The amount of cancer in your breast (especially for non-invasive cancer, also called ductal carcinoma in situ, which will not decrease in size with chemotherapy or other treatment before surgery)

• Your willingness to have radiation therapy (needed after breast conserving surgery for most people) and whether or not you have another medical problem that increase the risk of radiation therapy.

• Whether or not you have inherited a gene that increases your risk for another breast cancer

• Whether or not cancer has spread to other parts of your body

• Your preferences

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Factors Affecting Type of Surgery on the Lymph Nodes

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• Whether or not the lymph nodes are positive by biopsy before you have breast surgery

• Whether or not your lymph nodes are abnormal by exam or on imaging (such as mammogram or ultrasound)

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Summary

The majority of people with breast cancer will undergo surgery at some point in their treatment. If your doctor tells you that you do not need to have surgery, make sure that you understand why surgery is not needed in your situation.

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References

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1. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Version 2.2020-February 5, 2020

2. Chustecka Z. New guideline on lumpectomy margins should reduce re-excision. Medscape Medical News. February 11, 2014