Once a doctor determines that a breast tumor must be removed, one of the first decisions the person you're caring for will have to make -- with the help of her medical team -- is how much breast tissue to remove. In some cases, doctors will recommend removing the entire breast, known as a mastectomy .
But women with early-stage tumors that haven't spread may choose breast-conserving surgery. Research shows that for stage I and II tumors, the long-term outcome from lumpectomy plus radiation or from mastectomy is the same, so doctors are likely to say the choice is yours. There are two breast-conserving options: lumpectomy or partial mastectomy.
In a lumpectomy, the surgeon removes only the breast tumor and a small margin of surrounding tissue. The goal is to make sure the tumor comes out with "clean margins," which means that the biopsied tissue shows no cancer calls remaining. (If the pathology report does not show clean margins, a re-excision or mastectomy may be necessary.)
A lumpectomy is almost always followed by five to six weeks of radiation therapy to catch any stray cancer cells.
Chemotherapy may also be recommended following surgery; this is known as adjuvant chemotherapy . Nowadays, though, based on encouraging results from recent studies, oncologists and surgeons are increasingly likely to recommend neoadjuvant chemo , which means that chemotherapy is given first to shrink the tumor before removing it surgically.
After lumpectomy or partial mastectomy
Like any surgery, lumpectomy or partial mastectomy has some risks, side effects, and recovery issues
Pain medication. You'll want to make sure the person you're caring for goes home with adequate pain medication. Ask her doctor to explain clearly what to expect in terms of pain and other possible reactions. Although lumpectomy is now often performed as outpatient surgery, it's still a major medical procedure and the patient is likely to be exhausted and uncomfortable for several days afterward
Surgical dressing and drains. The dressing over the wound may need to be changed, or there may be a drain in the breast area or armpit that requires care. Make sure you understand the procedure for emptying the drain, if the patient you're caring for is given one. And watch for signs of infection such as redness, swelling, and fever.
Physical therapy. Her doctor may recommend simple physical therapy exercises to prevent stiffness in the arm and shoulder on the side where the tumor was removed. These are important after a lumpectomy or partial mastectomy, so ask for written instructions and make sure the patient understands the exercises -- it can help to run through them together.
Removal of a larger amount of breast tissue is called a segmental mastectomy , partial mastectomy , or quadrantectomy , because typically about a quarter of the breast tissue is removed. (The terms get confusing, because a lumpectomy is also sometimes called a partial mastectomy.) In this procedure, the surgeon removes the tumor and some of the surrounding tissue and may also remove a portion of the chest wall behind the tumor.
Depending on the amount and location of the tissue being removed and the patient's preferences, a plastic surgeon can perform reconstruction to preserve the shape of the breast. The most common procedure is called breast remodeling and involves rounding the breast out into a smaller one that preserves the natural shape. (The opposite breast may then be sized down to match.)
Another technique involves using tissue from another part of the body to augment the area of the breast where tissue was removed.
Depending on the type of reconstruction and other factors, reconstruction can be done either at the same time as the quadrantectomy or in a separate procedure. If reconstruction is done separately, it's advisable to do that before radiation, since surgery will be more successful on tissue that hasn't been exposed to radiation.
Reasons to choose lumpectomy or partial mastectomy over mastectomy:
- The tumor is less than 5 centimeters across.
- The tumor is small in proportion to overall breast size.
- The tumor is not directly behind the nipple, so the nipple can be saved.
- The woman wishes to keep as much of her natural breast as possible for cosmetic reasons.
- The patient or her partner feels strongly about keeping the breast for sexual reasons.
- The woman doesn't have a family or genetic history of breast cancer .
Reasons not to choose lumpectomy:
- Anxiety over whether the cancer is completely gone can persist.
- If the lump is large or the breast is small, the cosmetic result may not be desirable.
- There are multiple small tumors.
- In most cases, radiation must follow and can have side effects.
- Radiation therapy requires daily appointments for five to six weeks, posing scheduling challenges.
- The patient has had radiation previously to the same breast.
Radiation and Older Women
In some cases, experts don't consider radiation after lumpectomy necessary for women over 70, in whom cancer grows more slowly. This takes the radiation issue out of the decision about whether to have a lumpectomy or quadrantectomy.