FAQs about Surgery

This content has been reviewed and approved by

William J. Gradishar, MD FACP
Director, Breast Medical Oncology, Professor of Medicine
Robert H. Lurie Comprehensive Cancer Center
Northwestern University Feinberg School of Medicine

Is there a way to avoid a mastectomy? 

A mastectomy or complete removal of the breast is not necessary in all women with breast cancer. It used to be the standard in every woman many decades ago. It was believed then that breast cancer spread directly from the tumor, and that if we could remove enough tissue around the tumor, we could cure this type of cancer.

It is now understood that in most cases, any spread of cancer occurs at a relatively early stage through the lymphatic channels and bloodstream rather than by direct extension from the tumor. Multiple studies after that realization have shown that complete removal of the lump and irradiating the remaining breast tissue produces equivalent survival time compared with a complete mastectomy.

Whether or not you are a candidate for a mastectomy depends not only on the size and location of the tumor, but also the ratio of the tumor size to the breast. Only your surgeon can determine whether or not a mastectomy can be avoided. Additional considerations may apply if you are not a good candidate for receiving radiation after only a partial breast removal.

It has been shown in large randomized clinical trials that standard chemotherapy given before surgery or after surgery results in the same survival outcome. However, some women who receive chemotherapy before surgery are more likely to conserve their breast by virtue of having a smaller operation after initial shrinkage of the tumor.

Therefore, many doctors now prefer to shrink the tumor before surgery. This has an additional advantage. Shrinkage of the tumor can be seen, showing the effectiveness of the treatment. If we give chemotherapy after surgery, we have no way of knowing whether it is working or not because there is nothing left to measure.

Preoperative chemotherapy also gives us an opportunity to look at the surgical specimen under the microscope and see if all of the cancer cells were killed by chemotherapy, which would be very good news for patients because such patients have been shown to have much better survival time than those who still have disease present after all of the chemotherapy has been given.

This latter situation, however, does pose a dilemma for the doctor and the patient as to what to do after surgery if the initial chemotherapy was not completely effective. Currently, this is a subject of considerable debate, and if you do not want to be in that dilemma and do not have the need to shrink the tumor before surgery (by virtue of having a small tumor to begin with), you can choose not to receive preoperative chemotherapy.

Physicians are definitely encouraging preoperative chemotherapy more and more because it is an excellent way to test new drugs and improve therapies for breast cancer. You may want to play your part to contribute to that improvement. Some patients have a concern that the tumor might grow while they receive chemotherapy first. That concern is not well founded. Only about 1 percent to 2 percent of patients will actually have growth of the tumor while receiving chemotherapy. That group of patients is not likely to derive much benefit from chemotherapy even if it was given after an operation.

The body fluid that bathes the breast tissue is normally drained to the armpit on the same side and filtered through small glands called lymph nodes before it is then circulated. The number of lymph nodes in the armpit that are involved with cancer cells is an important clue to gauge the aggressiveness of the disease, assess prognosis, and assign therapy. This is because these nodes trap cancer cells draining from the tumor into this first line of defense.

It has, however, been realized that this drainage follows the pattern of going to a first-station lymph node (sentinel lymph node) before the cancer spreads to other lymph nodes. This "sentinel node" is therefore an excellent target for sampling for cancer cells.

If the sentinel node is free of tumor cells, there is only about a 4 percent to 5 percent chance that cancer cells will be found in other lymph nodes. This saves the patient from a more extensive procedure (complete axillary dissection) and removal of additional lymph nodes, which could lead to subsequent swelling of the arm due to impaired lymphatic drainage. The risk of swelling of the arm is particularly enhanced in those patients who receive radiation afterwards and can be as high as 8 percent to 10 percent. The sentinel lymph node sampling is increasingly becoming the standard in patients with operable breast cancer.

If your sentinel lymph nodes are positive, the standard practice is still to complete the axillary dissection and sample additional nodes because the number of lymph nodes involved is linked to the stage of your tumor, its prognosis, and choice of therapy.

The skin-sparing mastectomy allows you to have your breast tissue removed while still saving the overlying skin to use for reconstruction. This operation is done by removing the nipple areolar complex and using that opening to remove the rest of the breast tissue. The remaining skin is then filled with an implant and the nipple areolar complex is reconstructed by a plastic surgeon, borrowing skin from other parts of the body and using various techniques to make it look pigmented and natural. You should have a more detailed discussion about this technique, and its advantages and disadvantages, with your surgeon and the plastic surgeon.

This is a complex decision that you should make after discussing it with your surgeon, plastic surgeon, and the radiation oncologist. The factors going into this decision may have to do with the type of surgery, timing of surgery, likelihood of additional surgery, and timing of radiation. There is no single best time that applies to all patients; therefore, it is important that you individualize your timing after discussing it with your specialist.

The usual window of starting chemotherapy after surgery is about 3 to 6 weeks. We want to allow the surgical wound to heal before we start. The decision to begin chemotherapy is made jointly by your surgeon and your medical oncologist.

After the wound is healed, you do not want to wait too long before starting chemotherapy because that will allow time for potentially present microscopic disease (the prime target for chemotherapy) to grow untreated.

However, in certain situations, the delay may be longer than 6 weeks, which is acceptable. For example, certain clinical trials allow up to 84 days from primary surgery to start chemotherapy. However, the sooner the better is the rule after you heal from your operation.

After you develop a second cancer in the same breast, a complete mastectomy is the preferred treatment unless some very special circumstances exist. You should discuss this in more detail with your surgeon.