If your cancer is diagnosed in an early stage, your doctor may give you the choice of a lumpectomy (surgery that removes only the tumor) or a mastectomy (surgery that removes the entire breast).
Which procedure is best for you? In many cases, it's entirely up to you.
In recent years studies have found there is very little difference in their ability to effectively treat breast cancer. The ten-year survival rate is the same for both procedures. There is a slightly higher risk of local recurrence (a new tumor in the breast) with lumpectomy, but a recurrence usually can be treated with a mastectomy, and usually does not affect the overall likelihood of survival. In many cases there is a valid medical reason to do a mastectomy, but in some cases, there is not. Studies have found significant differences in breast conserving rates around the country.
You may wish to approach your decision in one of several ways. You might imagine your life in several years and think about what will be important to you then. For example, having daily radiation treatments for five or six weeks may seem impossible based on work or other responsibilities, but this may be a small inconvenience if the loss of your breast will impact your feelings for the rest of your life. On the other hand, keeping the breast might not be worth the worry of even a small risk of local recurrence. And losing a breast may be less important than giving up your immediate lifestyle. Finally, reconstruction after mastectomy is an option for most women. Depending on the method of reconstruction, in clothes the new breast mound may look almost exactly like your other breast.
Lumpectomy
In a lumpectomy, also called breast conserving surgery, the surgeon removes only the cancerous tissue and a surrounding margin of normal tissue. The rest of the breast tissue is left behind. Depending on the size of the breast, some distortion in the breast might occur, but most women have good cosmetic results. The best results are achieved when the tumor is at most 4 to 5 cm in diameter. Sometimes, if the tumor is large, chemotherapy might be used to shrink it before surgery, thus making a lumpectomy possible.
Lumpectomy is not an option for women who have already had radiation to that breast, those who have two or more tumors in the same breast that must be removed separately, women with extensive ductal carcinoma in situ (DCIS), women with tumors that are large relative to the size of the breast, and women who cannot receive radiation because they are pregnant or have other conditions.
A lumpectomy is a surgical procedure requiring either a local anesthetic and sedation or general anesthesia. The surgeon will make a small cut in the skin and remove the cancerous tissue along with a surrounding margin of normal tissue that is ½ to ¾ of an inch thick. If the tumor is not easily felt, it may be necessary to have a tiny wire inserted before the surgery, guided by mammography or some imaging device, so the surgeon can find the tumor (needle localization). The surgeon may also leave in tiny metal clips so that radiation beams can be precisely pointed at the area later on.
The tissue removed will be examined under a microscope by a pathologist. If the margin of surrounding tissue is "clean," or free of cancer cells, no further surgery is necessary. If, however, the margin shows some cancer cells you may need a re-excision of tissue (another lumpectomy) or a mastectomy.
If the nearby lymph nodes are also being examined, the surgeon will make a separate incision under the arm. On occasion, if the tumor is close to the underarm, only one incision is made.
The surgery takes about an hour, and you probably won't stay in the hospital overnight.
How your breast will appear afterward depends on how much tissue is removed. In many cases there is little cosmetic difference. However, if you were small breasted you may need a special bra and prosthesis to match the size of the affected breast to the other one.
A similar "breast conserving" procedure is a partial (or segmental) mastectomy. More of the breast is removed than during a lumpectomy, but the breast is still conserved. This is sometimes called a quadrantectomy. If your doctor suggests any of these breast conserving procedures, be sure to ask exactly how much tissue will be removed.
Side Effects
Shoulder stiffness and loss of range of motion in the affected arm may occur after surgery if the arm is not exercised properly. Ask your doctor or nurse, or the physical therapist with whom they work, for directions on what exercises you should perform and how often to do them so that you can avoid these problems.
An infection, a seroma, and a hematoma are also possible. An infection would be treated with antibiotics. A seroma is a build-up of clear fluid in the wound. A seroma may cause a fullness or an uncomfortable feeling under your arm or at the surgical site. Eventually, the body will reroute the fluid, but in the meantime, you may need to have it drained several times over several weeks. This is painless, because the area remains numb for months to years after the surgery. A hematoma, which is a build-up of blood in the wound, will usually resolve over time without treatment.
Mastectomy
A mastectomy may be recommended under certain circumstances, such as: if the tumor is large, if there is more than one tumor in the breast, or if you have suspicious microcalcifications throughout the breast. Mastectomy might also be recommended if you are small-breasted and limited resection would produce a poor cosmetic result. How extensive the surgery is depends on the size of the tumor, whether or not it is attached to the chest wall, and if any lymph nodes are involved.
Types of Mastectomies
In the past, the most common procedure was a radical mastectomy. The entire breast was removed along with the lymph nodes and the chest wall muscle underlying the breast. This procedure is rarely done now, because a modified radical mastectomy was found to be just as effective but with fewer side effects and less disfigurement.
In a modified radical mastectomy, the surgeon removes the entire breast and some lymph nodes, but not the chest muscles. As much skin as possible is left behind. The modified radical mastectomy is the most common procedure done for women who need some type of mastectomy. It may also be called a total mastectomy with axillary node dissection.
Another option, a total mastectomy, entails removal of the entire breast, but no lymph nodes.
A variation of the total mastectomy is the skin-sparing mastectomy, which is possible for some women, but not all. In this procedure, the surgeon removes the breast tissue, but leaves nearly all of the skin intact. In women who are candidates for this procedure, it can often provide excellent aesthetic reconstruction results. The muscle tissue must still be stretched gradually, to accommodate an implant. The nipple and areola are removed, but they may be reconstructed later. The new nipple won't have any sensation, since the nerves were cut, and there will most likely be significant numbness in the rest of the breast.
A mastectomy is major surgery. You will have general anesthesia and the operation will take between one and three hours. Expect to stay in the hospital for two days after the procedure. Once the procedure is done, your doctor will place one or two small drainage tubes just under the skin at the site of your incision. Any fluid that collects at the site will flow out and collect in plastic sacks that you will need to clean out periodically. Your nurse will teach you how to do this before you are discharged from the hospital. The fluid may be tinged red at first, but within a few days it should change to a clear yellow. It should not be bright red - that would indicate internal bleeding and should be brought to your doctor's attention right away. The drains are removed when fluid accumulation tapers off, within a few weeks. You should also call if you develop a temperature of 101 F (38.3 C), shaking chill, and increased redness near the incision.
If you've decided to have immediate reconstruction, that procedure may be started while you are still under anesthesia. In that case, you will be under anesthesia for an additional one to one and a half hours for an implant or about six hours for tissue transfer and may stay in the hospital longer.
Side Effects
There are possible side effects after mastectomy and these include both those that can occur after any kind of surgery and those that are more specific to the breast.
Immediately after surgery, you may have pain or discomfort from the drains. If you are having breast reconstruction with a tissue expander, you will experience some discomfort when the expander is filled with fluid to stretch your skin. Following a lymph node dissection, you will be at risk for cellulitis, which causes the area to turn red and swell. Call your doctor right away if you have redness under your arm or on your mastectomy incision.
You will have numbness over the breast and under your arm for months to years; occasionally this is permanent. Another side effect after breast surgery is shoulder stiffness or loss of range of motion in the affected arm. A physical therapist, or your doctor or nurse may give you a list of exercises that you should do until you regain full range of motion. Common exercises include the shoulder roll, clasp, lift, and stretch, back climb, wall climb, and arm circles. You will be given instructions on the exercises your doctor advises and how often to do each. If you are having reconstruction, your doctor may want you to delay exercising until he or she thinks it is safe for you to begin.
An infection, a seroma, and a hematoma are also possible. An infection would be treated with antibiotics. A seroma is a build-up of clear fluid in the wound. One of the many functions of lymph nodes is to absorb fluid. If lymph nodes were removed during surgery, this fluid has no place to go. A seroma may cause a full sensation or an uncomfortable feeling under your arm or at the surgical site. Eventually, the body will reroute the fluid, but in the meantime, you may need to have it drained. This is painless, because the area remains numb for months to years after the surgery. A hematoma, which is a build-up of blood in the wound, will usually resolve over time without treatment. Another possible side effect, if you've had lymph nodes removed, is lymphedema. This is a buildup of lymph fluid in the arm. It is discussed elsewhere in this chapter.
Lymph Node Surgery
You may also be told that your surgery will include an axillary lymph node dissection - the removal of lymph nodes from under your arm so they can be checked under a microscope for cancer cells. The axillary lymph nodes are the most common place breast cancer will begin to spread.
Examination of the lymph nodes is an important step in determining the final diagnosis and treatment, since positive lymph nodes may require further treatment. One procedure to evaluate the presence or absence of breast cancer in the axillary nodes is called sentinel node biopsy. In this procedure, a blue dye and a very small amount of radioactive tracer are injected into the breast near the tumor or biopsy site. The surgeon tracks the path of these substances as they move out of the breast area and into the region of the lymph nodes. In this manner, the surgeon can determine which lymph node is first in the path of the cancer - and so would be first to show signs of cancer, if it has spread. This sentinel node is then removed and sent to pathology for detailed analysis. If it turns out to be free of cancer, it can be assumed that the rest of the lymph nodes are clear as well, and no further surgery is necessary. If the sentinel node does show signs of cancer, the other nodes are removed as they would be in a standard axillary dissection or lymphadenectomy.
Lymphedema
Post-mastectomy lymphedema is an abnormal swelling of the arm, hand, breast, or chest wall that may occur as a result of breast cancer or its treatment. Currently, there are no tests which predict whether or not lymphedema will develop following treatment for breast cancer. A number of studies indicate that lymphedema can develop in 6% to 30% of patients. One study demonstrates that 20 years after diagnosis nearly half of breast cancer survivors reported the subjective sensation of arm heaviness.
Lymphedema may develop when the arm's lymphatic system (vessels that are smaller and more fragile than veins) is no longer able to remove all the lymph that is normally filtered from the blood vessels. The major risk factors for the development of lymphedema include lymph node dissection and radiation therapy. Sentinel lymph node biopsy may pose a slight risk for developing lymphedema. Patients with breast cancer that require more extensive treatment (ie. radical mastectomy, extensive lymph node dissection, and radiation to the lymph nodes) are more likely to develop lymphedema than patients who have less extensive treatment. Recurrent breast cancer in the axillary lymph nodes can also cause lymphedema. The best way to manage lymphedema is with early treatment.
Lymphedema can occur immediately after surgery, months, or even years later. The development of lymphedema does not necessarily mean that there has been a recurrence of the breast cancer. Most often the development of lymphedema has no obvious cause other than the history of breast cancer treatment. If you do notice arm swelling or pain it is very important to consult your doctor so that infection, if present, can be treated. Additional testing such as a Doppler ultrasound of the arm's veins (to look for blood clots) and a contrast MRI of shoulder region (to make sure there is no recurrent cancer) may be necessary.
Symptoms of Lymphedema
Symptoms of lymphedema may include visible swelling in the arm or part of the arm, a sensation of heaviness, achiness, or tightness in the arm, easy fatigability of the arm, or pain in the arm. Patients often notice lymphedema for the first time during or immediately after an event that overloads the ability of the lymphatics to remove the lymph fluid. Such events include an injury, infection, burn, strenuous activity, a significant weight gain, and air travel (because of pressure changes). These events are probably not the cause of lymphedema but "the last straw" that causes the swelling to be noticed and thus symptomatic. This initial swelling may diminish or even resolve in a day or two but is still significant. Swelling that occurs immediately after surgery is common and usually resolves with time and does not necessarily mean that you either have or will develop lymphedema.
If you notice swelling or redness in the arm after mild or strenuous activity, a burn, an injury, or for any other reason, you should consult your doctor. These symptoms are important to discuss with your doctor even if they are transient. An infection in the affected arm is particularly serious as it may progress and lead to impairment in quality of life. Evaluation, education, and treatment may be essential in keeping it that way.
General Precautions to Minimize
the Risk of Developing Lymphedema
While there is no proof that avoidance of certain activities will prevent the development of lymphedema in at-risk patients, adherence to some basic precautions is recommended:
- Use a moisturizer daily to help protect the skin of your arm and hand.
- Avoid anything that might cause a break in the skin and lead to infection of the affected hand or arm. If you do get a cut, clean the area well and apply anti-bacterial ointment and a bandage.
- Manicure your nails carefully. Do not cut the cuticles.
- Wear gloves when gardening, cleaning, or washing dishes.
- Use care when removing hair under your arm. Do not use a straight razor or hair removal (depilatory) cream as they can cause skin breaks.
- Use insect repellent to avoid stings.
- Avoid tight jewelry, clothing, or anything that can cause a tourniquet effect along the arm.
- Take care not to get sunburned. Use a sunblock with an SPF of at least 15.
- Avoid local heating and hot-packs on the affected arm and shoulder.
- Use the other arm for injections, blood drawings, and blood pressure measurements. If both arms are involved, ask your doctor if your legs could be used for these procedures.
Activity
Some people want to resume all prior activities without limitations while others are most comfortable with a more cautious approach. Since it is unclear if any type of activity will increase your chance for developing lymphedema, both approaches are reasonable. Keep in mind that it is important to live your life and continue to participate in all the activities that give you pleasure and satisfaction. You may choose to modify some of these activities if you begin to notice swelling or symptoms in your arm. You should consult with your physician and a trained lymphedema therapist for help in making these decisions.
Lymphedema Guidelines
If you have developed lymphedema, you should follow all of the precautions listed above. In addition, the following recommendations may help prevent a worsening of the condition:
- Elevating the affected arm and hand may temporarily help to reduce the swelling, especially if the swelling is new. If you are sitting, you may rest the affected arm on a few pillows next to you or on the back of a couch, in order to raise the arm above the level of the heart. Avoid holding your arm over your head for extended periods of time as this may cause the muscles of your arm to fatigue. While sleeping on your back, you may rest your arm on one or two pillows at your side. If you are able to sleep on the opposite side of your surgery, you may place one or two pillows in front of you and rest your arm on those pillows. Over time, elevation may be less effective at reducing the swelling.
- Monitor your activities to determine if a particular activity causes the swelling to worsen, or symptoms such as fatigue, achiness or heaviness to develop. Notice if the swelling is worse in the morning after sleeping, or worse in the evening after using your arm for your daily activities. If a particular activity causes the swelling to worsen, try to take more frequent rest breaks during that activity. Keep in mind that both resistive activities (i.e. lifting heavy packages) as well as repetitive activities (i.e. typing on the computer or chopping vegetables) may cause an increase in swelling in some people. Other people find that exercise and activity help to reduce the swelling.
- Use compression garments or low-stretch lymphedema bandages (not ACE bandages) when you take an airplane flight. It is safer to use some form of hand compression on an airplane, even if you use a sleeve that ends at your wrist at other times. Make sure that you have properly fitting garments that are comfortable for you to keep on for the entire length of the flight. If you are using garments for the first time, you may want to test the garments before your flight to check that they do not cause any new swelling in your hand or arm. Low-stretch lymphedema bandages are an effective alternative to garments. Although bandages are more bulky than garments and more difficult to apply, they may be more comfortable for longer flights and they provide excellent support to the lymphatic system if they are applied properly.
Treatment
Lymphedema can range from mild to severe and a variety of treatments are available. Treatment may be provided by a physical or occupational therapist that is specially trained in the management of this condition or at a specialized lymphedema treatment center. Treatment options can range from a simple plan of instruction in a home program to an intensive program with daily treatments.
Treatment has three main components: compression, exercise, and a gentle form of massage. Compression helps prevent additional fluid from accumulating in the tissue and may be applied in the form of an elastic sleeve or low-stretch compression bandages. An exercise program can help stimulate the lymphatic system; however it is important to avoid fatiguing the muscles of the affected arm since that can encourage additional fluid accumulation in the arm. Gentle massage can also help stimulate the lymphatic system while vigorous massage may provoke fluid production and should be avoided.
Since the severity of lymphedema varies considerably from person to person, patients should work with a physician and therapist to determine an individualized treatment plan based on their medical history and the extent of the swelling. The treatment plan should take into account the patient's lifestyle and individual preferences, complications, as well as tolerance and response to the different treatment options.
Complications of Lymphedema
- Swelling of the arm and hand, even without other complications, can be a source of great emotional distress and decreased function for breast cancer survivors. Some common emotional responses include anger, frustration, and occasionally depression. If you are having trouble coping with your feelings, or your feelings are interfering with your ability to participate in your daily activities, you should discuss this with your doctor or therapist. One way to try to deal with these feelings is to know that you have choices in how you will manage your lymphedema. A lymphedema therapist can explain your treatment options and help you decide which of these options will fit into your lifestyle. Fortunately, the degree of swelling can usually be controlled with proper therapy.
- Infections tend to be more serious, harder to treat, and progress more quickly in patients with lymphedema. Infection in the affected arm can also cause a worsening of the lymphedema. Patients should have a very low threshold for contacting their doctor at the first sign of infection. These signs include fever, pain, redness, and increased swelling or warmth in the arm. Repeated episodes of infection may require advice from an infectious disease specialist.
- Pain or abnormal sensations in a limb treated for breast cancer can develop for many reasons. Not all of these reasons are the direct result of lymphedema. Lymphedema can increase your risk for many other disorders that cause pain. It is recommended that you consult your doctor so that the correct diagnosis can be made and proper treatment started.
Causes of arm pain include:
- Infection.
- The swelling itself.
- Deep Vein Thrombosis ("DVT" or a blood clot in the vein).
- Musculoskeletal disorders such as:
--Tendinitis of the shoulder
--"Golfer's" or "tennis" elbow
--"Frozen shoulder"
--Carpal tunnel syndrome
-- A pinched nerve in the neck
