Breast cancer surgery: Understanding your options

By Jessica Saenz

Most people diagnosed with breast cancer require surgery. New and better therapies are increasing surgical options in breast cancer treatment — in some cases, making more room for patients' preferences.

Judy C. Boughey, M.D., a surgical oncologist at Mayo Clinic, wants people to know they have options when it comes to breast cancer surgery. Here's what you need to know:

Initial staging and diagnosis of your breast cancer can help guide surgery and treatment.

Before making a surgery recommendation, your care team will try to learn as much about your breast cancer as possible to help them determine what kind of surgery and what sequence of treatment would be most effective.

"Prior to surgery, all patients will have breast imaging. Usually, they'll have a diagnostic mammogram, breast ultrasound and ultrasound of the lymph nodes underneath the arm, and they may have a breast MRI that examines the extent of disease in the breast and also examines the axillary lymph nodes," says Dr. Boughey. This imaging can help your care team see the extent of disease in the breast and if your tumor has spread to the lymph nodes  under your arm.

Some types of breast cancer surgery may fit your needs better than others.

Your surgeon will discuss  options for breast cancer surgery based on the cancer’s location, tumor size and characteristics, and breast size. "For most patients, if they have a smaller tumor, they have the choice between breast-conserving surgery, called a lumpectomy, followed by radiation, or a mastectomy to remove all breast tissue" says Dr. Boughey.

If imaging shows lymph node spread, your surgeon might recommend removal of the majority of lymph nodes under your arm, a procedure called axillary lymph node dissection.

Your reasons for selecting one surgery over another are very personal, but each is valid. And it's important to discuss these reasons with your health care professional.

"It really becomes a patient and physician discussion with shared decision-making in terms of what will provide the best long-term outcome for their personal preferences and goals,” says Dr. Boughey. "The majority of our patients have a very good long-term survival, so we want to consider, not only the best treatment for right now, but the treatment that the patient will be most comfortable with in five, 10 and 15 years."

If you have a high risk of breast cancer and have considered risk-reducing surgery, clinical trials are making more options possible. "For patients interested in surgery to decrease their risk of breast cancer due to a strong family history or genetic mutation, one of the trials we're offering uses a robotic approach to nipple sparing mastectomy with immediate reconstruction" says Dr. Boughey. Ask your care team what clinical trial options might be right for you.

Breast cancer surgery has risks, but pain, discomfort and numbness are most common effects.

Dr. Boughey says that while breast surgery has fewer complications than many other surgical procedures, no surgery is without risk. But if you undergo mastectomy or axillary lymph node dissection, pain and discomfort from your incision and drainage tubes are most common and to be expected.

Some less-common complications you should be aware of are bleeding or infection, so you should alert your health care professional of any concerning changes as soon as possible. "This is particularly important for patients that have breast reconstruction and have a tissue expander or implant because an infection around that foreign body may occur, and can sometimes require removal of the implant or expander," says Dr. Boughey.

After a mastectomy, as you begin to heal, Dr. Boughey says that numbness or loss of sensation in the chest is expected. "You lose a lot of the sensation, not only to the nipple areola — if you are able to preserve a nipple areola — but also to the whole chest wall."

In addition to physical changes in your body after breast cancer surgery, it's important not to overlook emotional concerns that may arise after your surgery, as these are also important to your quality of life. Talk to your care team about what you’re feeling — they can connect you with other breast cancer survivors and health professionals who can help support you.

Improved surgical techniques offer better breast preservation and reconstruction, address complications.

Techniques for breast cancer surgery and immediate reconstruction have come a long way, and there are now more options to consider as you decide on the best surgery for you.

Newer mastectomy techniques can preserve the nipple and areola along with breast skin to allow for a more natural breast appearance after breast reconstruction. This approach might not be appropriate for all breast cancer cases, however, especially if you have a large tumor that involves or extends close to the nipple. Breast and plastic surgeons also are working on ways to preserve and restore nerve(s) to the nipple with the goal of preserving sensation in the nipple and areola.

If your tumor has spread to the lymph nodes and requires lymph node removal, lymphedema — swelling caused by an accumulation of fluid that's usually drained through the body's lymphatic system — is a possible complication of breast cancer surgery. Treatment for lymphedema has typically focused on reducing the discomfort of swelling with bandaging and compression garments, but new surgical techniques, including lymph node transplant, the creation of new drainage paths or surgery to remove hardened tissue, can provide relief from pain and swelling.

Find a surgeon you trust who has expertise in breast cancer surgery.

Dr. Boughey says you can and should ask questions to confirm that your health care professionals have the right expertise in breast cancer surgery. "It's reasonable to ask them what proportion of their practice breast cancer surgery is or how many of these types of surgery they perform on average in a year," she says.

 You should place emphasis on finding an expert you trust. "Having a good relationship with your breast surgeon is most important. You really need to sit down with them and make sure this is someone you trust to perform your surgery,” says Dr. Boughey.

Managing your breast cancer will require a team of experts from other areas of cancer care. "For the vast majority of breast cancers, you really need to have a multidisciplinary team working with you," says Dr. Boughey. "Make sure you have a medical oncologist and a radiation oncologist in addition to your breast surgeon. You also want to make sure you have a good plastic surgeon dedicated to breast reconstruction involved in your care."

If your breast cancer has spread beyond the breast and lymph nodes to other parts of your body, Dr. Boughey says surgery is unlikely to be the main treatment approach. "For patients with stage 4 breast cancer, surgery may not provide an advantage," she says. Instead, a combined treatment approach with drug therapy or radiation will likely be recommended. In some cases, surgery may follow.

Watch Dr. Boughey discuss the different types of breast cancer surgery in this "Mayo Clinic Q&A" podcast video:

Learn more

Learn more about breast cancer and find a breast cancer clinical trial at Mayo Clinic.

Join the Breast Cancer Group on Mayo Clinic Connect.

Also read:

• "4 things you can do to improve your quality of life after breast cancer"
• "Preparing for your breast biopsy"
• "Breast cancer radiotherapy and treatment innovations"