Breast Cancer Surgery

Breast cancer is cancer that forms in the cells of breasts. Breast cancer is not common in men, with one in 400 men contracting the disease. It is most common in women, with the likelihood of 1 in 28 women in India developing breast cancer during their lifetime. The risk is higher in urban areas, being 1 in 22 women, compared to rural areas where this risk is relatively lower, being 1 in 60 women. In India, the average age of the high-risk group is 43-46 years unlike in the west where women aged 53-57 years are more prone to breast cancer.

The line of treatment for breast cancer is based on the type of breast cancer, its stage and grade, size, and whether the cancer cells are sensitive to hormones. Your overall health and preferences are also accounted for when deciding on the treatment. Your doctor will discuss the best treatment plan with you.

Surgery, chemotherapy, radiotherapy and hormone therapy are the four modalities of treatment of breast cancer.

Dr Rupa with Nishan Sashidhar and is answering queries related to Utility and Effectiveness of Tomosynthesis for Breast Cancer

 

Surgical options used to treat breast cancer include:

 

  • Lumpectomy (Breast conservation surgery) – In this procedure, the surgeon removes a tumour and a small margin of surrounding healthy tissue. A part of healthy breast tissue around the cancer is removed and tested for traces of cancer. If no traces are of cancer are found, then there’s less chance that cancer will reoccur. If cancer cells are found in the surrounding tissue, more tissue may need to be removed from your breast. After breast-conserving surgery, you will usually be offered radiotherapy to destroy any remaining cancer cells.
  • Mastectomy – In this procedure, the surgeon removes all the breast tissue, including the nipple. To determine whether cancer has spread to the lymph nodes, a sentinel lymph node biopsy may be carried out. The sentinel lymph nodes are the first lymph nodes that the cancer cells reach if they spread. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed. If cancer is found in the sentinel node, your surgeon will discuss with you the role of removing additional lymph nodes in your armpit.
  • Some patients choose to have breast reconstruction after surgery. Discuss your options and preferences with your surgeon. Reconstruction can be carried out either by inserting a breast implant or by using tissue from another part of your body to create a new breast. It can be done at the same time as your, or months to years later. Some women decide not to have reconstruction and opt for prosthesis instead.
  • Chemotherapy involves using anti-cancer (cytotoxic) medication to kill the cancer cells. It’s usually given after surgery to destroy any cancer cells that haven’t been removed. In some cases, you may have chemotherapy before surgery, which is often used to shrink a large tumour.
  • Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. If you need radiotherapy, your treatment will begin about a month after your surgery or chemotherapy, to give your body a chance to recover. The type of radiotherapy you have will depend on your cancer and surgery type.
  • Hormone therapy is used in cases where the breast cancer is sensitive to the hormonesoestrogen or progesterone, which are found naturally in your body. These types of cancer are known as hormone-receptor-positive cancers. Hormone therapy works by lowering the levels of hormones in your body or by stopping their effects. Your doctor will suggest the type of hormone therapy depending on the stage and grade of your cancer, which hormone it’s sensitive to, your age, whether you have had menopause and what other types of treatment you’re having. Hormone therapy is given after surgery and chemotherapy to decrease the chance of your cancer returning, but it’s sometimes given before surgery to shrink a tumour, making it easier to remove.

 

Symptoms of breast cancer

Most breast cancers show the following symptoms:

  • A breast lump that feels different from the surrounding tissue.
  • Change in the size, shape or appearance of a breast.
  • Changes to the skin over the breast.
  • Changes in skin such as peeling, scaling or flaking of the pigmented area of skin surrounding the nipple or skin of the breast.
  • A newly inverted nipple.
  • Bloody discharge from the nipple.
  • Redness of the skin over your breast.

Inflammatory breast cancer is characterized by diffuse inflammation and enlargement of the breast, often without a lump, and has a particularly aggressive course.

 

Diagnosis of breast cancer

If you have symptoms, your general physician (GP)will examine your breasts for any lumps or any other abnormality. If any abnormality is noticed, your GP may suggest you to get a mammogram or an ultrasound of your breasts done. A biopsy may be conducted if a suspicious lump is found during mammography or ultrasonography. In this, a sample of tissue cells is taken from your breast and tested to see if these are cancerous. MRI is useful to locate a suspicious mammographic lesion that cannot be located otherwise, particularly if the breasts are dense.

 

Staging breast cancer

Once you have been diagnosed with breast cancer, your doctor will give it a stage to determine your prognosis and the best treatment options.
You will undergo a number of tests, which may include:

  • Blood tests.
  • Additional mammogram of the other breast to look for signs of cancer.
  • Bone scan.
  • Computerized tomography (CT) scan.
  • Positron emission tomography (PET) scan.

Your doctor will inform you about the appropriate tests based on your overall health and the new symptoms you may be experiencing.

Breast cancer stages range from 0 to IV, with 0 indicating cancer that is non-invasive or contained within the milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body. This is a simplified guide. Each stage is divided into further categories: A, B and C. If you’re not sure what stage you have, ask your doctor.

 

Risks of the procedures

  • Complications of breast cancer surgery depend on the procedures you choose. Surgery carries a risk of bleeding; infection; formation of hard scar tissue at the surgical site; shoulder pain and stiffness; numbness; particularly under your arm; from lymph node removal; and build-up of blood in the surgical site (hematoma).
  • Side effects of radiation therapy include fatigue, irritation and darkening of the breast skin – a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. You may experience lymphoedema (excess fluid build-up in your arm caused by blockage of the lymph nodes under your arm). More-serious problems, such as damage to the heart or lungs, are rare and very rarely second cancers are seen in the treated area.
  • The side effects of chemotherapy depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of developing an infection. Rare side effects can include premature menopause, infertility (if premenopausal), damage to the heart and kidneys, nerve damage, and, very rarely, blood cell cancer.
  • In case of hormone therapy, you may experience hot flashes, night sweats and vaginal dryness. More-significant risks include blood clots, stroke, uterine cancer and cataracts.

 

Before the procedure

  • Your doctor will explain the surgical procedure to you. Ask any questions that you might have about the procedure.Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward. If you are thinking about breast reconstruction, it is a good time to discuss this with your surgeon.
  • If you’re planning to have radiation therapy after surgery, meet with a radiation oncologist before surgery to discuss benefits and risks.
  • You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
  • Ask your doctor if you will possibly need a blood transfusion. If the doctors think a transfusion might be needed, you might be asked to donate blood beforehand.
  • Your doctor will go through your full medical history and additionally may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
  • Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
  • Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
  • Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
  • Notify your doctor if you are pregnant or suspect pregnancy.
  • You will be asked to fast for eight hours before the procedure, generally after midnight.
  • You may receive a sedative prior to the procedure to help you relax.
  • You may meet with a physical therapist prior to your surgery to discuss rehabilitation.
  • Stop smoking, as smoking can delay wound healing and slow down the recovery period.

Based on your medical condition, your doctor may request other specific tests or examinations.

 

During the procedure

Lumpectomy/Mastectomy usually takes about one to three hours. A mastectomy followed by breast reconstruction or double mastectomy (involving both breasts) takes a longer time to perform. Procedures may vary depending on your condition and your doctor’s practices.
Generally, a lumpectomy/mastectomy follows this process:

  • You will be asked to remove clothing and put on a hospital gown.
  • An intravenous (IV) line may be started in your arm or hand.
  • You will be positioned on the operating table.
  • A urinary catheter may be inserted (after you are asleep).
  • The surgery will be performed while you are asleep under general anaesthesia. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  • The skin over the surgical site will be cleansed with an antiseptic solution.
  • Your surgeon will make an elliptical incision around your breast. The breast tissue is removed and, depending on your procedure, other parts of the breast also may be removed.
  • Regardless of the type of procedure you have, some breast tissue and lymph nodes will be sent to a laboratory for analysis.
  • If you’re having breast reconstruction following the mastectomy, a plastic surgeon will coordinate with the breast surgeon to be available at the time of surgery.
  • The incision will be closed with stitches or surgical staples.
  • A drain may be placed in the incision site to remove fluid.
  • A sterile bandage or dressing will be applied.

 

After the procedure

In the hospital

 you have had outpatient surgery — usually lumpectomy and sentinel node biopsy — you will be released when your condition is stable. However, you should get someone to drive you home. Driving should be resumed according to your doctor’s advice.
Mastectomy requires a one-day stay in the hospital. Mastectomy followed by breast reconstruction or double mastectomy (involving both breasts) requires a longer stay in the hospital.
After
thesurgery ,you will be taken to the recovery room for observation. The staff will monitor your blood pressure, pulse, alertness, pain or comfort level, and your need for medications and give you medicine for pain. When they are sure that you are stable, you will be transferred to a room in the hospital.
Most doctors will want you to start moving your arm soon after surgery so that it won’t get stiff. You will given pain medication to manage pain in your underarm and surgical areas.
 

 

At home

Once you are home, it is important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up hospital visit.
You may feel some pain, numbness and a pinching sensation in your underarm area. You will be given prescriptions for pain medication and possibly an antibiotic. Be sure to take only recommended medications.
Notify your doctor to report any of the following: Fever; redness, swelling, bleeding, or other drainages from the incision; increased pain near the incision; and numbness and/or tingling sensation in the breast.
Your dietician will advise you on the diet if there are any changes.
Your doctor will inform you about some activity restrictions. Talk to your doctor about when to resume wearing a bra or wearing a breast prosthesis. Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

 

Recovery

How long it takes to recover from breast cancer surgery depends on the type of procedure performed. Most women can return to their regular activities within 2 weeks after a lumpectomy. It can take up to 4 weeks after a mastectomy. Recovery time is longer if reconstruction was done as well, and it can take months to return to full activity after some procedures. Still, these times can vary from person to person. Your doctor will give you a better idea of what you can expect.

You will probably have a follow-up with your surgeon about 7 to 14 days after the surgery to go over the results of your pathology report and talk about any further treatment. If you need more treatment, your doctor may refer you to:

  • A radiation oncologist to discuss radiation treatments, which may be recommended if there was a large tumour, or traces of cancer were found in other areas after mastectomy.
  • A medical oncologist to discuss other forms of treatment after the operation, such as chemotherapy or hormone therapy or both.
  • A plastic surgeon, if you’re considering breast reconstruction.
  • A counsellor or support group to help you cope with having breast cancer.