A woman’s breasts are an integral part of her femininity and identity. The breasts are symbolic of female fertility: they nourish, nurture and comfort a woman’s children and they contribute to her sexuality and femininity. In fact, a woman’s breasts are so interwoven into the fabric of her very existence that she simply cannot imagine herself without them. The discovery of a suspicious lump is therefore a most traumatic experience for any woman. There are two aspects to surgery: one involves what to do to the breast, the other involves what to do with the glands in the armpit (axilla).
The psychological impact of losing a breast varies, but for most women it means some form of grieving. Breast reconstruction can alleviate the sense of deformity that may develop after a mastectomy. It is considered an integral part of the management of patients with breast cancer. You can have breast-conserving surgery in many cases, as well as reconstructions. You don’t have to be disfigured for life. The reconstructive process should be discussed with you prior to the initial surgery.
Breast reconstruction can be done immediately after the mastectomy or it may be delayed for a few months. The benefits of having reconstructive surgery at the time of the mastectomy are obvious in that it helps to preserve body image. 75% of patients overseas either have breast conserving surgery or mastectomies with immediate reconstruction, so get a second opinion if your doctor suggests a mastectomy only and doesn’t present any other options.
Surgery can be either breast conserving or a mastectomy with reconstruction. Surgical margins must always be well clear of tumour by at least 1cm. The outcomes are equal whether a woman chooses to have part of her breast or the whole breast (including her nipple) removed – as long as the cancer is cut out with 1 cm clear margins and all other cancer treatment principles are adhered to.
Breast conserving surgery involves the removal of the cancer and a small area of surrounding breast tissue. Whether this can be done depends on the size of the breast, the size of the tumour and what you want! A mammogram MUST be done prior to surgery to make sure that there are no other hidden cancers.
Another important aspect is that the result must be cosmetically acceptable whilst still being a successful cancer operation (no cancer left behind or close to the margins). Breast conservation must ALWAYS be followed by radiation therapy (DXT). All patients having breast conserving surgery should have the tumour bed clipped to guide the radiation specialist.
A mastectomy is done if the cancer appears to be multicentred (may be in other parts of the breast) or is difficult to detect on the mammogram (lobular cancers). A mastectomy is also required when the position of the tumour or the tumour to breast ratio is such that conservation cannot be done. The mastectomy must always be planned in conjunction with either immediate or delayed reconstruction.
Surgery to the Axilla (armpit)
Traditionally, at least 8-10 lymph nodes should be removed from the axilla in all patients with an invading breast cancer. This can be done through the same incision as the mastectomy or through a separate incision.
A recent development in breast cancer surgery is sentinel lymph node dissection. This is where a dye or radioactive isotope (or a combination of both) is injected into the area surrounding the cancer. The sentinel lymph node is the first lymph node to receive lymphatic drainage from the area of the breast containing the tumour – and is most likely to harbour cancer cells if the tumour has spread.
Sentinel lymph node dissection enables the surgeon to identify the sentinel lymph node and remove it to see if it contains any cancer cells. If there is no cancer in this node then further axillary dissection is not required.
NB: Sentinel lymph node dissection should only be offered by surgeons trained in this technique, who have done at least 20 combined procedures (breast surgery and axillary clearance) and have had their results audited.
Written by Dr Carol-Ann Benn