Know the key aspects of this important mode of treatment.

Worldwide, female breast cancer has now surpassed lung cancer as the most commonly diagnosed cancer. An estimated 2,261,419 new cases were diagnosed in women across the world in 2020.

Breast cancer is the most common cancer in women in the United States, except for skin cancers. It accounts for 30% of all new female cancers each year. The management of breast cancer is constantly evolving; however, for most women, surgery has been a cornerstone of breast cancer treatment and is often the sole treatment in the management of early-stage breast cancer. The decision to proceed with mastectomy or breast conservation surgery remains both patient and disease-driven.

Depending on the type of breast cancer, including stage, grade, and hormone receptor status, as well as other factors including personal medical and surgical history and body shape, breast surgery can be of different types:

A. Lumpectomy, or breast-conserving surgery, removes the cancer as well as a small rim of healthy breast tissue around it called the margin. This type of surgery is also referred to as breast-sparing surgery, quadrantectomy, wide excision, segmental mastectomy, or partial mastectomy.

Breast-conserving surgery allows a woman to keep most of her breasts but makes it likely she will also need radiation therapy. Other treatments, such as chemotherapy, immunotherapy, or hormone therapy, may be part of the treatment protocol. Side effects of breast conserving surgery may include pain, a scar and/or dimple where the tumor was removed, a firm or hard surgical scar, and sometimes lymphedema, a type of swelling, in the arm.

After surgery, the tissue that was removed is examined under a microscope. If no invasive cancer cells at any of the edges of the removed tissue are found, it is said to have negative or clear margins. If cancer cells are found near the edges of the tissue (within 2mm), it is said to have a close margin. If cancer cells are found at the edge of the tissue, it is said to have a positive margin. Having a positive margin means that some cancer cells may still be in the breast after surgery, so the surgeon often needs to go back and remove more tissue. This surgery is called a re-excision. If cancer cells are still found at the edges of the removed tissue after the second surgery, a mastectomy might be needed.

B. Mastectomy, is the removal of the entire breast to treat cancer. There are several different types of mastectomies, depending on how the surgery is done and how much tissue is removed.

1. In a simple mastectomy, the surgeon removes the entire breast, including the nipple, areola (dark skin around the nipple), fascia (covering) of the pectoralis major muscle (main chest muscle), and skin. If the cancer is near or touching the pectoralis major muscle, a small area of muscle may be removed. A few underarm lymph nodes might be removed as part of a sentinel lymph node biopsy, depending on the situation.
2. A modified radical mastectomy combines a simple mastectomy with the removal of the lymph nodes under the arm, called an axillary lymph node dissection.
3. A skin-sparing mastectomy is a type of surgery where most of the skin over the breast is left in place. Only the breast tissue, nipple, and areola are removed. The amount of breast tissue removed is the same as with a simple mastectomy. A skin-sparing mastectomy may be preferred because it offers the advantage of less scar tissue and a reconstructed breast that seems more natural; however, it may not be suitable for larger tumors or those that are close to the surface of the skin.
4. A nipple-sparing mastectomy is similar to a skin-sparing mastectomy in that the breast tissue is removed and the breast skin is saved. But in this procedure, the nipple and areola are left in place. This can be followed by breast reconstruction. The surgeon often removes the breast tissue under the nipple and areola during the procedure to check for cancer cells. If cancer is found in this tissue, the nipple and areola must be removed. This type of mastectomy is more often an option for women who have a small, early-stage cancer, away (more than 2cm) from the nipple and areola, with no signs of cancer in the skin or the nipple.
5. In a bilateral mastectomy, both breasts are removed. Double mastectomy is sometimes done as a risk-reducing (or preventive) surgery for women at very high risk of getting breast cancer, such as those with a BRCA gene mutation. Most of these mastectomies are simple mastectomies, but some may be nipple-sparing. There are other situations where a double mastectomy might be done as part of a women's breast cancer treatment plan.

C. Surgery is also performed to determine whether the cancer has spread to the lymph nodes in the armpit or axilla, called sentinel lymph node biopsy or axillary lymph node dissection.

D. Breast reconstruction after the cancer is removed is done either by using an implant (saline or silicone-based) or a tissue or muscle flap from another area of the body. This is discussed in detail in the next upcoming blog.

There are a lot of misconceptions and false information on the internet about breast cancer surgery. It is important not to let those common misconceptions influence you and stand in the way of getting the best treatment available. 

Here are some of the more common myths about breast cancer surgery:

• Surgery opens up the cancer to the air and makes it spread.
  No. If there is cancer in other parts of your body after surgery, it is because the cancer had already spread to other parts of the body before surgery. There are several treatment options after surgery, including radiation, chemotherapy, immunotherapy, etc., that may be part of your treatment protocol depending on your type and stage of breast cancer.

• If you have a strong history of breast cancer in your family, lumpectomy plus radiation is not for you.
  No. Having breast cancer in your family does not mean that your cancer has a poorer prognosis than that of another breast cancer patient. It doesn't mean that breast-conserving therapy is not an option for you. Your cancer care team will decide on the best treatment protocol for you based on many factors.

• If your lymph nodes are removed, your arm will be swollen for the rest of your life.
  No. Lymph node surgery can lead to some side effects, including on-and-off  discomfort, numbness, and swelling called lymphedema, but this usually happens in only 5–10% of cases.

A diagnosis of breast cancer can be distressing and create a lot of anxiety. In this setting, getting the right information and available options that meet the standard of care in the US is important. Speak to your doctor and cancer care team in detail, and take your time to make an informed decision about breast cancer surgery should you need it.