Breast Mastectomy

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Breast Mastectomy

The condition

The breast is a glandular tissue (can secrete substances). Around the breast are lymph nodes. These are part of the lymphatic system.

Lymphatic vessels run from the limbs towards the heart, usually beside veins. They carry fluid called lymph, which is a collection of dead cells, waste material and leakage from ordinary blood vessels.

At various points along a lymphatic vessel lie lymph nodes. These are usually small – 5mm or less in most places. Lymph nodes are scattered at various points around the body, but the most important ones for breast disease are in the armpit.

Cancer cells travel along lymphatic vessels and collect in lymph nodes. In breast cancer, the lymph nodes of the armpit are usually the first site of spread.

What is breast surgery?

It is important to understand that breast surgery for cancer is not cosmetic surgery. The appearance of the breast after surgery will be different from that before surgery.
The survival rates for women who have mastectomy (all of the breast removed) are the same as for women who have breast-conserving surgery accompanied by radiotherapy, and each form of treatment has its advantages.

Wide local excision

The removal of a lump in the breast and the tissue around it. The lymph nodes under the arm on the same side as the tumor may also be removed and tested for cancer. If the lump cannot be felt, a marking wire may need to be placed before surgery. This is usually done in the X-ray department using ultrasound or mammogram.

Partial or segmental mastectomy

The removal of the tumor as well as some of the breast tissue around it and the lining over the chest muscles below. Usually some of the lymph nodes under the arm are taken out and tested for possible spread of cancer.

Total or simple mastectomy

The removal of the whole breast. Sometimes lymph nodes under the arm are also taken out and tested for possible spread of cancer.

Modified radical mastectomy

The removal of the breast, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes part of the chest wall muscles.

Radical mastectomy

The removal of the breast, chest muscles, and all of the lymph nodes under the arm. It is used only when the tumor has spread to the chest muscles and the wound may burst open.

Reconstruction

Breast reconstruction involves the use of prosthesis (artificial breast tissue) or tissue from other parts of the body. The type of prosthesis can be either silicone filled but are usually saline filled implants. Soft tissue may be taken from the other breast, the back or abdomen depending on body shape and size.

What are the risks of this specific procedure?

The aim of the surgery is to get rid of the tumor so it cannot spread. It is generally considered that surgery is effective for early breast cancer. For cancer that has spread outside of the breast and lymph nodes, the benefits of surgery are unclear. You need to discuss your options very carefully with your doctor so that you can make the best decision for your situation.

What if I don’t have this procedure?

If you choose not to have surgery, may be shortening your life expectancy. The tumor may also grow outside the breast and spread to other parts of the body. This can cause significant pain and discomfort.

Comparison between breast conserving treatment and mastectomy

	Breast Conserving Treatment that includes radiation therapy	Mastectomy
Effectiveness	Breast conserving treatment with radiation therapy is as effective as mastectomy.	Mastectomy is as effective as breast conserving treatment that includes radiation therapy.
Tumour size and position	If the tumour is small then your surgeon will probably recommend that you choose between breast conserving treatment and mastectomy.	If the tumour is large or involves the nipple or there is more than one tumour your surgeon will probably recommend mastectomy.
Radiation therapy	Radiation therapy is necessary each weekday for about six weeks.	Usually no radiation therapy is necessary.
Changes to your body appearance	A small amount of your breast will be removed.nPartial prostheses are available.	Your whole breast will be removed.nProstheses and/or reconstruction are available.
Fear of the cancer returning	Some women feel concerned about getting cancer in the remaining part of the breast and in other parts of their body.nBreast conserving treatment that includes radiation therapy is as effective as mastectomy in treating early breast cancer.	It is very unlikely that the cancer will come back in the breast area after a mastectomy.nIt is no u2018saferu2019 to have a mastectomy than breast conserving treatment.

Specific risks of breast cancer surgery

The risk	What happens	What can be done about it
Infection	Infection in the operation site causing pain, swelling, redness and discharge in 1 in 25 to 1 in 58 people. The wound may break down.	Treatment may be wound dressings, drainage and antibiotics.
Collection of fluid under the skin	The operation site under the arm continues to ooze fluid, which collects beneath the cut.	The collection may need to be drained with a needle and syringe. This may need to be repeated several times until the oozing stops.
Poor healing	The edges of the wound may lose blood supply and change colour.	Further surgery may be needed to cut out the affected areas along the wound.
Numbness and weakness to arms and chest	Weakness and numbness of the arms and chest may happen due to certain nerves being cut during the operation.	This may be temporary or permanent.
Shoulder stiffness	Difficulty with arm movement after the operation.	This is usually temporary when treated with physiotherapy and/ or exercises.
Poor wound healing	The layers of the wound may not heal well and the wound may burst open.	This may need long term wound care with dressings and antibiotics.
The wound may not heal normally	The scar can be thickened and red and may be painful.	This is permanent and can be disfiguring.
Swelling of the arm (lymphodoema)	The arm on the side of the operation may swell in 1 in 4 women. This may be caused by removal of the lymph nodes in the armpit. The risks are increased by damage to the arm, taking of blood specimens, infection and weight gain.	The average time between treatment and development of lymphodoema is 20 months but can occur years later.nIt can be treated with a special type of garment, which squeezes the arm to reduce the fluid build-up. Regular massage is also used.
The cancernre-grows	Recurrence of tumour in or around the scar can occur.	Further treatment to remove or to destroy the tumours. This may be surgery, chemotherapy or radiotherapy or a combination of all three.
Pain after mastectomy	After mastectomy, there may be chronic pain in the area of the surgery. This may happen in 2 out of 3 women in the 30-49 year age group decreasing to 1 in 4 women over the age of 70 years.	The level of pain varies between people. It is usually managed with drugs prescribed by pain specialist

Anxiety and/ or depression after lumpectomy	Feelings of anxiety and depression due to the disease and possible recurrence for every 2 out of 5 women.	Professional counselling both before and after the surgery
Anxiety and depression after mastectomy	Feelings of anxiety and depression due to losing a breast for 1 in 3 cases.	Professional counselling both before and after the surgery
Loss of interest in sexuality.	Distress at the change in body image or depression due to the disease causes loss of sexuality for 1 in 1:3 women.	Professional counselling both before and after the surgery
Increased risk in obese patients		An increased risk of wound infection, chest infection, heart and lung complications and thrombosis.
Increased risk in smokers	An increased risk of wound infection, chest infection, heart and lung complications and thrombosis.	Giving up smoking before the operation will help reduce the risk.

What are the general risks of the procedures?

General risks:

Infection can occur, requiring antibiotics and further treatment.
Bleeding could occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin).
Small areas of the lung can collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis.
Heart attack or stroke could occur due to the strain on the heart.
Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may break off and go to the lungs.
Death as a result of this procedure is possible.

Are there any alternative treatments?

As with most solid tumours, removing the tumour surgically is considered the first part of treatment in almost all cases.

Are there any additional treatments?

Also known as adjuvant therapy, they are used in some women in addition to surgery. The treatment may be local (radiation) or systemic (whole body e.g. chemotherapy, hormone therapy). The aim is to treat undetectable tumours before surgery. The treatment of breast cancer depends very much on the type of tumour, the size and stage of the tumour and your age and health. You need to carefully discuss with your doctor, treatments that are best for you.

The following treatments are all used either separately or together in the treatment of breast cancer.

Radiotherapy

Radiotherapy after breast conserving surgery reduces the risk of the cancer coming back in the same breast by 1 to 2% per year.
Radiation is used to damage or kill cancer cells. Most women have radiotherapy to the breast find their health is not greatly affected by it. Tiredness is a most common problem.

Chemotherapy and hormone therapy

Chemotherapy is most effective if more than one drug is used and is more effective in women under the age of 50 years. The main side effects are nausea, vomiting, hair loss, marked tiredness and mood changes. They do not last for long periods and most can be controlled with good medical care. There are other side effects from chemotherapy, which you need to discuss with your doctor.

High dose chemotherapy

The theory is that high doses will kill off more cancer cells than normal doses of chemotherapy. However, it is experimental, very toxic and can be fatal.

Tamoxifen

Tamoxifen is a drug that works by blocking the effects of oestrogen on cells. It is thought that oestrogen may be causing the cancer to grow. In most cases, the cancer stops growing although it does not kill cancer cells.

Ovarian treatment

The purpose of ovarian treatment is to reduce the amount of oestrogen produced by the ovary. It is only useful in women who have not yet reached menopause. Ovarian treatment is performed using either implants under the skin, surgical removal of the ovaries or radiation to the ovaries.

Combined treatments

Overall, the evidence of benefits from using one or more treatments at the same time does not suggest that there is any large benefit to be gained, but there may be some benefit if the cancer cells are hormone sensitive.

Recovering from your procedure?

After the operation, you will go back to the ward when you have recovered from the anaesthetic, until you are well enough to go home, about 2 days after wide local excision and 2 – 4 days after mastectomy. If you have any side effects from the anaesthetic, such as headache, nausea, vomiting, tell the nurse looking after you, who will be able to give you some medication to help.

Pain

You can expect to have pain in the operation site. There are a number of ways in managing your pain.

You may have:

a drip with painkillers into the vein
a drip with painkillers that you can give yourself when you feel pain
injections.

It is important that you tell the nursing staff if you are having pain. Your pain should wear off within 7 – 10 days. If it does not, you must tell your doctor.

Diet

You will have a drip in your arm when you come back from surgery. This will be removed when you are able to take food and fluids by mouth and you are no longer feeling sick. To begin with, you can have small sips of water then slowly take more until you are eating normally.

Wounds

You may have clips, stitches and/or stitches that are dissolvable or a combination of both.
Your wound may have a dressing and you will also have a wound drain, which is removed after 3 – 4 days or as soon as the drainage has stopped. Continue to keep your wound clean and protected until healed and no seepage is present.

Your lungs and blood supply

It is very important after surgery that you start moving as soon as possible. This is to prevent blood clots forming in your legs and possibly traveling to your lungs. This can be fatal. To help prevent against clots forming in your legs, you may have support stockings (TEDS) on before you go to surgery and these will stay on until you are walking on your own. You may also be put on drugs to thin your blood.
Also, you need to do your deep breathing exercises, ten deep breaths every hour, to get the secretions in your lungs moving and help prevent a chest infection. Avoid smoking after surgery as this increases your risk of chest infection which causes coughing – a painful experience after surgery.

Exercise

You will feel tired for some time after surgery. (You need to take things easy and gradually return to normal duties, as you feel able to.) You should not drive during the first 1-2 weeks and until you have a reasonable range of movement in your shoulder. You will be taught how to do arm exercises. It is important that you follow these to help you return to a normal range of shoulder movements.
If you have had surgery and/ or radiotherapy to the armpit
The arm on the same side of the surgery and/ or radiotherapy needs care to help in the prevention of lymphodoema (swelling in the armpit). You should avoid the following with that arm:

Blood taking or blood pressure measurement
Carrying anything heavy
Tight clothing or jewelry
Cuts, burns and insect bites

And use:

Skin cream to keep the arm moist
Cooling devices during the hot summer
Gloves to wash up
Gloves and long sleeved shirt when gardening.

Sexuality and self-esteem

Many women may have problems with their sexuality and selfesteem after breast cancer surgery. Your doctor may refer you for psychological counselling before and after your surgery so that you and your partner can work through these problems.

Tell your doctor if you have:

Fever and chills.
Pain that is not relieved by prescribed pain killers.
Swelling, tenderness, redness at or around the cut.
Swelling of the arm.
A cut or infection to the arm on the same side as your treatment.