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5. Surgery

Most breast cancers are treated with an operation, aren’t they?

Most people with breast cancer will be offered surgery as the first treatment. The aim is to remove the cancer completely from the breast. Broadly speaking, there are two main types of breast cancer operations, breast conserving surgery and mastectomy. With breast conserving surgery the cancer and a small area of tissue around it (called a margin) is removed. Depending on where the cancer is, and how big it is, this might mean a lumpectomy or the removal of a wider portion of tissue (called a wide local excision) where up to a quarter of the breast may be removed. A mastectomy means all the breast is removed including the nipple.

I have breast cancer and my surgeon says I don’t need to have my breast removed; but surely mastectomy is always safer, isn’t it?

Not necessarily. Research has shown that people who had operations that conserved the breast and then a course of radiotherapy did just as well as those having a mastectomy. Nowadays, more than half of primary breast cancers are treated with breast conserving surgery and surgeons will try to preserve the breast if at all possible. (A primary breast cancer is one that has started in the breast and is not thought to have spread anywhere else in the body.)

There are a few reasons why a mastectomy might be recommended, for example if the cancer is very large in relation to the size of the breast, or if there is more than one area of cancer in your breast. Your surgeon and breast care nurse will explain which type of operation is likely to be best for you and why.

Why do I need to have my lymph nodes removed?

Generally, everyone having breast conserving surgery or mastectomy will have some or all of their lymph nodes in the axilla (armpit) removed. This is called an axillary dissection. Breast cancer can spread to the lymph nodes and then from there into the rest of the body through the lymphatic system. It is important to remove the nodes to try to prevent further spread but also to help plan what treatment is best for you. If the lymph nodes contain breast cancer cells, you are more likely to have chemotherapy, which treats the whole body, because there is a risk that the cancer has spread to other parts of the body. We all have a different number of lymph nodes in the armpit and how many are removed depends on your surgeon as well as on your cancer; some surgeons remove more than others. Most people having an axillary dissection will have between two and twenty removed. An increasingly common technique used before your operation is called sentinel lymph node biopsy. This is a way of checking the lymph nodes to see if the breast cancer has reached them. In this test a doctor injects a small amount of radioactive material and some blue dye into the breast, some hours before the operation. The nodes that are radioactive, blue or both are called the sentinel nodes, and only these (between one and four nodes) are removed during surgery for testing. If they are free from cancer cells, the other nodes are assumed to be clear as well, and will not be removed unnecessarily. However, if there are cancer cells in the sentinel nodes, then more nodes will need to be removed, usually at a second operation. Sentinel node biopsy should be offered to all people with invasive breast cancer, unless it is already known from a biopsy that the lymph nodes are affected by disease. If breast cancer has spread to the nodes, it is called lymph node positive and if it hasn’t, it is called lymph node negative.

 Can having my lymph nodes removed do me any harm?

 People who have surgery to the lymph nodes in the axilla are at risk of developing lymphoedema on that side. Lymphoedema is swelling caused by a build-up of lymph fluid in the tissues. It can happen within weeks, months or even years of the surgery, and can affect the whole length of the arm and the breast/chest area. Your breast care team will advise you on care of your arm to reduce the risk of lymphoedema – things like looking after your skin and trying to avoid cuts, burns, infections, insect stings and injections on that arm.

I’ve heard that when you have an operation for breast cancer it increases the risk of the cancer spreading. Is this true?

Some people believe this can happen but it has never been proven by research, and breast cancer doctors do not believe it is true. Virtually everyone with breast cancer has surgery and in spite of this breast cancer does not spread in most cases.

If I have a mastectomy, can they rebuild my breast for me?

It is usually possible to rebuild the breast, in what is called a breast reconstruction. Sometimes this is done at the same time as the mastectomy, and is called an immediate reconstruction; if it’s done later it is known as delayed reconstruction. This might be a week, months or even years later. There are several different types of breast reconstruction. You may have an implant inserted on its own, or it may be possible to use muscle and tissue from elsewhere in your body. The two usual sites are the top of your back near the shoulder (LD flap) or from your abdomen (TRAM or DIEP flap) to replace the mound of the breast, with or without an implant.  Your surgeon and breast care nurse should explain the options you have for reconstruction. You can ask to see photographs of women who have had different types of reconstruction.

I am worried about having an implant. Is it safe?

Almost certainly. The Health Department of the major countries and many experts in the use of implants have considered the available evidence. They have stated publicly that there is no reason to stop using implants for breast reconstruction surgery. All implants sold within Europe have to pass strict safety checks but will only last an average of 15 years so they may need replacing over time. The Medicines and Healthcare Regulatory Agency (MHRA) in United Kingdom and similar institutions in other country, the government agency responsible for ensuring that medicines and medical devices are acceptably safe, have published. Any ‘foreign body’ implanted into the human body brings the risk of rejection or infection. If you are considering having an implant at the time of your breast surgery, or at a later date, discuss the procedure and its advantages and disadvantages with your surgeon.  If you already have an implant and are worried, speak to your surgeon or breast care nurse.

If I don’t want a breast reconstruction after my mastectomy, can I pad out my bra instead?

Many women choose to use breast prosthesis, which is an artificial breast. It fits in a bra cup or sticks to the chest and replaces all or part of the natural breast shape. While your operation wound heals, you can use a light, soft product temporarily. Then you can have a permanent prosthesis fitted, usually around six weeks later. The hospital where you have your operation in major EU countries will arrange this and give you the prosthesis free of charge. If you have had your surgery in the private sector you may need to pay for your prosthesis, but if you have health insurance, your insurance company may provide it. There are many different shapes and styles and some different colors to help you find a comfortable fit that closely matches your natural breast. The person fitting you (usually a surgical appliance officer or a breast care nurse) will advise you about caring for and replacing your prosthesis and about best styles of bras and swimming costumes.

If I have a mastectomy, will I look different afterwards?

When you have all your clothes on your appearance and shape shouldn’t look different. But when undressed you will see the scars from the mastectomy or the breast reconstruction. If you have a prosthesis, or a reconstructed breast, it will also not move as

naturally as the real thing: there will be less ‘bounce’ when you move and the breast will be more rigid when you lie down. It may also feel less natural to the touch and may not have a nipple. A realistic looking nipple can be created with an operation or by applying an artificial one which sticks onto the breast, but they won’t be sensitive to touch or changing temperatures as a natural nipple would. Everyone is different and for some women decisions about the type of reconstruction or whether to have a nipple, and if so what type, can take some time to make. If you are not sure, don’t rush to decide. Talk to women who have had similar operations or to a counselor, or your breast care nurse. Make sure that whatever you decide to do is right for you.

If my breasts don’t match after surgery, can anything be done?

Yes, you might be able to have an operation on the other side to make the other breast larger or smaller, or to lift it up.

How do I know that what I agree to have done is what will actually happen?

These matters are covered by law. Before your operation your surgeon should explain exactly what he or she proposes to do and why. You will then be asked to sign a consent form which shows that you agree to the operation. In law, the surgeon can only carry out the procedure to which you have consented, unless an emergency arises during the operation and an immediate change of plan is required. This is extremely rare with breast cancer surgery but if such a situation should arise, the surgeon must explain to you what happened and what needed to be done and why.

 What will happen before my operation for breast cancer?

This depends on the hospital where you have your operation and the type and extent of breast surgery you are having. You may go into hospital on the day of your operation or the day before. You will meet the doctors, nurses and others who will be caring for you and can ask them any questions you may have about your treatment. It is normal to be worried before an operation. You are bound to have concerns about what will happen and what the outcome will be. Your breast care nurse can talk with you about it. And there are other people, besides the medical staff, in the hospital who can support you. For example, there are representatives of many religions and faiths who work in or visit hospitals, who are there to listen, and social workers if you are worried about work or finances. Outside the hospital, there are cancer support organizations who give information and support, and you might like to see a counselor – sometimes just sharing your feelings helps, and talking through fears and concerns with a trained professional can help reduce stress.

What sort of care will I need after my operation?

Again, this depends on the extent of your breast surgery. As you come round from the operation, the nurses will be with you; they will check your pulse and blood pressure fairly often to see how well you are recovering from the anesthetic. You would expect there to be some pain or discomfort after an operation, but people experience pain or discomfort in different ways, and again it will depend on the operation you have had. If you feel too sore or uncomfortable you should tell your nurse straight away so you can have some analgesia (pain relief). Also tell the nurse if you are feeling sick, so that you can have an anti-emetic (anti-sickness) drug. When you wake up you may have an intravenous infusion (an i.v. or ‘drip’) in your arm which gives you liquid and any drugs you need into a vein. This will only be in place until you start drinking normally again in a day or two. You may also have tubes to drain the wound of the blood and liquid which result from the surgery. The wound drains remove this liquid from the operation site and help it to heal, and they will be removed after a few days. Sometimes you can go home with the drains still in, and come back to have them taken out at the hospital when you no

longer need them. It could take anything from a few days to a few weeks for your wound to fully heal. Sometimes there is a build-up of liquid near the wound, called a seroma, which may drain away naturally or need to be removed by the doctor or nurse with a needle and syringe while you are still in hospital or at a follow-up clinic visit.

Should I keep the arm on the side of the breast surgery still to rest the area?

No, some gentle exercise will actually help the area heal more quickly and get you moving normally again. There are specific exercises you can do, which your surgeon, breast care nurse or a physiotherapist will show you. Find out when to start them and how

many times a day you need to do them – it will vary according to the type of operation you have had.

If I have had an operation to cut out the breast cancer, why do I need other treatments as well?

Successful surgery will remove the breast cancer, but cells may have already broken off and travelled elsewhere in the body. Scans and other tests may not be able to detect these very small numbers of cancer cells. Chemotherapy, hormone therapy and targeted therapy reduce the chances of secondary breast cancer developing. The cancer

can re-grow back in the breast area. Radiotherapy treats the breast area to reduce the risk of this local recurrence. When additional treatments are given as well as surgery, they are called adjuvant therapies. Sometimes chemotherapy, hormone therapy or targeted therapies are used before surgery to begin treating the whole body immediately and to shrink the cancer down, making surgery easier. This is called neo-adjuvant therapy.

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