Surgical Treatment of Breast Cancer
The surgical treatment for breast cancer is best discussed in detail with your general surgeon. The type of breast cancer surgery that is most suitable for you will depend on a number of factors including the size, location, type, and stage of the cancer, as well as your lifestyle and personal preference. Below is a brief overview of breast cancer surgical treatment options but we encourage you to have a detailed discussion with your general surgeon.
A lumpectomy is considered a breast-conserving surgery. The procedure involves removing the cancerous area and some of the surrounding normal tissue. Surgery is typically followed by breast radiation therapy. This procedure is also known as a “partial mastectomy”.
A lumpectomy is the least invasive form of breast cancer surgery, but, depending on the size of the excision, can lead to breast deformity and asymmetry. In approximately 30% of lumpectomy patients, a reconstructive procedure may be needed to create better symmetry and improve the scar’s appearance.
Breast reconstruction can be performed after the lumpectomy or at the same time as the lumpectomy. Options for delayed reconstruction, or reconstruction performed after the lumpectomy, include fat grafting and natural tissue reconstruction, utilizing a flap. In some patients, reconstruction can be performed at the same time as the lumpectomy surgery. This is referred to as oncoplastic reconstruction and involves rearranging the breast tissue to camouflage the defect created from the lumpectomy. The decision regarding reconstruction timing is based on multiple factors and will be discussed with you during your consultation.
Women with a greater volume of breast tissue tend to make better candidates for lumpectomy and reconstruction. Women with smaller breasts may have a more significant breast distortion following a lumpectomy and therefore, may instead elect to undergo a mastectomy with flap or implant based reconstruction for improved cosmetic results.
It is important to remember that radiation changes can, and often do, occur over the course of three years. At the earliest, delayed reconstruction can be performed 6 months following the completion of radiation therapy. This allows time for the tissue to heal and for most breast and skin changes to settle, prior to operating. It is also important to consider that a lumpectomy defect, which may be small and acceptable initially, may change over time and create an undesirable deformity.
A mastectomy is a more invasive approach to breast cancer surgery that involves the removal of all of the breast tissue. There are several types of mastectomies. A unilateral mastectomy is the surgical removal of one breast, bilateral mastectomy is the removal of both breasts, and prophylactic mastectomy is the removal of a healthy breast to reduce a woman’s risk of developing breast cancer. Bilateral prophylactic mastectomy is the most effective means of reducing a woman’s risk of breast cancer, however the benefits of such surgery depend on the individual risks for each woman.
Mastectomy breast reconstruction may be performed at the same time as the mastectomy, immediate reconstruction, or at a later date, delayed reconstruction. The type of reconstruction performed depends upon multiple factors including the mastectomy technique, the patient’s medical history, and the patient’s reconstruction goals.
Techniques for mastectomy surgery have evolved over the years and there are now several variations of mastectomy surgery. Advances have led to three sophisticated variations of the simple mastectomy: skin-sparing, areola-sparing, and nipple-sparing.
Radical & Modified Radical Mastectomy
A radical mastectomy involves the removal of the breast, underlying chest muscle, and axillary lymph nodes. In the past, breast cancer was managed by radical mastectomy. This surgery is the most extensive type of mastectomy and is rarely performed today, unless the breast cancer has spread to the chest muscles under the breast. The modified radical mastectomy is an improved version of this surgery that spares the chest muscles. In these cases, breast reconstruction is performed at a later date and flap reconstruction is required to replace the entire breast skin and breast tissue that has been removed. Reconstruction may also include a lymph node transfer to improve lymphedema.
Simple (Total) Mastectomy
This is the most commonly performed type of mastectomy, which entails removal of the breast tissue, skin, areola, and nipple. Simple mastectomies are often combined with removal of one or more of the lymph nodes from the armpit for biopsy. Breast reconstruction is performed at a later date and flap reconstruction is required to replace the entire breast skin and breast tissue that has been removed. Reconstruction may also include a lymph node transfer to improve lymphedema.
Skin Sparing Mastectomy
A skin sparing mastectomy is a variation of the simple mastectomy and involves removing the breast tissue along with the overlying nipple and areola, while sparing the breast skin. Reconstruction involves replacing the breast volume, through either implant or flap based reconstruction, and typically involves nipple reconstruction.
Areola Sparing Mastectomy
An areola sparing mastectomy is a variation of the simple mastectomy and involves removing the breast tissue along with the overlying nipple, while sparing the breast skin and areola. Reconstruction involves replacing the breast volume, through either implant or flap based reconstruction, and typically involves nipple reconstruction.
Nipple Sparing Mastectomy
A nipple sparing mastectomy involves the removal of the breast tissue, while preserving the skin, areola, and nipple. This is the most advanced technique in breast cancer surgery.
If it is determined that leaving the nipple/areola complex intact will not compromise oncologic safety, then the patient will be eligible for a nipplesparing mastectomy. This mastectomy technique offers improved cosmetic results as the breast envelope is maintained and only the breast volume needs to be replaced. Breast reconstruction is performed at the same time as the mastectomy and can include natural tissue or implant based reconstruction.
Suitability for this procedure depends on a number of factors including the type, location, and amount of cancer in the breast, as well as the size of the breast and further treatment plans. Women with large tumors or tumors located near the nipple are not good candidates for this surgery.
Research regarding the safety of the nipple sparing mastectomy has been extensive and a recent study, which accounted for more than 20 years of previous research, showed no significant evidence of breast cancer developing after a nipple-sparing mastectomy for the treatment or prevention of breast cancer. With appropriate candidate selection, the nipple sparing mastectomy successfully maximizes breast tissue removal and cosmetic results.
Mastectomy vs Lumpectomy
There are many elements to consider when looking at lumpectomy vs mastectomy for treatment of breast cancer. Women may opt for a mastectomy out of fear that the cancer will return or because they do not want to undergo radiation therapy. Radiation therapy is almost always recommended after a lumpectomy procedure. Supplementing a lumpectomy with radiation has been shown to significantly reduce the risk of cancer returning in the breast (local recurrence). Radiation therapy may also be indicated after a mastectomy, depending upon the type of cancer and progression of the disease.
The choice between lumpectomy versus mastectomy is an immensely personal decision, but your surgeon will be able to counsel you on the comparative statistics and advise you on which procedure will benefit you best in the long term.
Whether you plan to undergo a lumpectomy or mastectomy, there are breast reconstruction options for you. Fortunately, as great medical advancements have been made in the area of breast cancer diagnosis and treatment, so too has the field of breast reconstruction grown. Newer and more sophisticated breast reconstruction techniques, such as the DIEP flap procedure and prepectoral implant reconstruction, are available and allow for a minimally invasive, natural, breast reconstruction. Please visit the Breast Reconstruction Overview page for further information on the options available to you.