Breast Cancer Surgery: When Mastectomy Is Best

Surgery is the treatment of choice for virtually all women with breast cancer. One of the first choices anyone diagnosed with breast cancer will need to make is whether to have a lumpectomy and radiation or a mastectomy.

Whether to have a mastectomy

The choice is often an either-or, with similar risk factors and cure rates. But a mastectomy is the only option if the person you're caring for:

  • Has a tumor bigger than 5 centimeters.
  • Has tumors in more than one quarter of the breast.

Mastectomy is also preferable for women who don't want to have radiation because:

  • They're pregnant.
  • They're concerned about side effects.

They don't have time for the multiple treatments. In addition, some doctors and patients select mastectomy simply to make sure all cancerous and potentially cancerous tissue is removed, even if tests indicate a lumpectomy would be fine.

What is a mastectomy?

A mastectomy entails the removal of the entire breast. There are numerous types of mastectomy, distinguished by how much tissue is removed, the type of incision, and other factors.The oncologist and surgeon will work with other members of the medical team to decide which type is most appropriate. In addition, if the patient you're caring for wants to have the breast reconstructed, a plastic surgeo n's input will also be important.

Type of mastectomy

  • Simple or total mastectomy. In a simple mastectomy, the entire breast is removed. Doctors typically recommend simple mastectomy when a biopsy of the sentinel lymph node doesn't show any cancer in the lymph nodes.
  • Radical mastectomy. When the pectoral muscles, underlying chest wall, and all underarm lymph nodes are removed along with the breast tissue, it's called a radical mastectomy. This used to be the standard treatment for breast cancer , but more recently doctors have concluded that it's only necessary when cancer has spread to the chest muscles.
  • Modified radical mastectomy. This is the most common type of mastectomy used today. The difference between this procedure and a radical mastectomy is that with the modified version, the surgeon removes the lymph nodes but preserves the muscles of the chest wall. Along with the benefit of keeping the muscles themselves, it allows for breast reconstruction for those who want it.
  • Skin-sparing mastectomy. A new technique that's gaining in popularity, skin-sparing mastectomy uses an incision that circles the nipple and areola, instead of a traditional incision across the breast. This technique minimizes scarring and leaves the plastic surgeon more flexible options for reconstruction. Skin-sparing mastectomies are usually performed only for women who definitely plan to have reconstructive surgery. A skin-sparing mastectomy is only safe when doctors are sure cancer cells have not spread within the skin.
  • Subcutaneous or total skin-sparing mastectomy. The entire breast tissue is removed, but the nipple and areola remain. (This is also called nipple-sparing mastectomy .) Total skin-sparing mastectomy can't be done if cancer is located in or close to the nipple, which is a common location for breast tumors. Usually the requirement is that the tumor be smaller than 2 centimeters and located more than 2 centimeters away from the nipple. The surgeon makes an incision around the nipple, leaving the areola intact.

What to expect when having a mastectomy

  • Type of surgery. Mastectomies are surgeries performed under general anesthetic, whereas lumpectomies may be outpatient procedures.
  • Length of surgery. A mastectomy typically takes two to three hours. If reconstruction is done at the same time, surgery will probably take longer.
  • Hospital stay. Most women stay in the hospital from one to three nights.
  • Aftereffects. It's normal to feel a little nauseated after having general anesthesia, and the hospital staff monitors this.

Going home after a mastectomy

Aside from providing emotional support, the main things you'll be concerned with when caring for someone who's had a mastectomy are managing pain, monitoring for infection, and dealing with bandages and drains.

  • Pain medication. The doctor will send you home with a prescription for pain medication, and it's a good idea to get it filled immediately, as pain medication is most effective if started proactively. If you notice, in the first few days following surgery, that the pain medication isn't working or doesn't seem strong enough, it's important to call the doctor and tell her this. She may be able to prescribe a different drug. Dealing with pain is one area where your role as the caregiver -- and advocate -- is very important.
  • Possible infection. In the days following a mastectomy, be sure to watch for signs of infection, such as redness, swelling, and fever. Call the doctor immediately if the person you're caring for complains of any of these symptoms, or if you notice them in her.
  • Bandages and drains. When you leave the hospital, the wound will have a bandage or dressing over it. Sometimes the instructions are to leave the bandages on until the next doctor visit. In other cases, the doctor may tell you how to check or change it. Dissolving stitches are the norm now, so there's usually no need to go back and have them removed. Occasionally, though, one sticks up like a "whisker" and you'll need to ask the doctor to remove it. If surgical staples were used instead, the doctor will remove them during the first office visit.

Most women have a surgical drain to remove fluid from the breast area. There's usually a detachable bulb that you'll need to empty a few times a day. Make sure the staff gives you careful instruction on how to do this; it can help to practice a couple of times with a nurse watching before you and the person you're caring for leave the hospital.

Watch out for lymphedema

After a mastectomy that has included removal of the axillary lymph nodes, some women experience a side effect called lymphedema, in which lymph fluid doesn't drain properly and builds up in the arms, hands, or torso. The symptoms to watch for are:

  • Stiffness
  • Swelling
  • A feeling of tightness in the arms or upper body
  • Rings that suddenly fit fingers too tightly
  • Inability to flex the wrists or hands

Lymphedema can develop very gradually, which makes it hard to spot quickly. As the caregiver, you can be alert for any signs of swelling, stiffness, or pain. Call the doctor right away if you're concerned about lymphedema after a mastectomy, in order to get a jump on treating it.

Melanie Haiken

Melanie Haiken discovered how important it is to provide accurate, targeted, usable health information to people facing difficult decisions when she was health editor of Parenting magazine. See full bio