“What are my surgical treatment options if my breast cancer is found early?”
For any woman with a new diagnosis of breast cancer curing the cancer is our primary goal. For most women, surgery is the first step in treatment. Surgery is the most effective treatment that we have for breast cancer. It gives us valuable information about the size of the cancer, helps determine whether the cancer has spread outside of the breast, and decreases your risk of cancer recurrence.
The surgical treatment options for early stage breast cancer generally fall into two categories, lumpectomy with radiation, or mastectomy. A lumpectomy, which is also known as breast conserving surgery, involves removing the breast cancer as well as a rim or margin of normal breast tissue surrounding the lump. The goal is to maintain as much of the normal breast tissue and contours as possible. In most cases the nipple can be preserved. Removing all of the cancer and having a “margin” or free space removed around the tumor site is important. Some women will have to go back for a second surgery if this margin is not obtained in the first surgery. When lumpectomy is chosen it is followed by radiation therapy which consists of treatments every weekday for approximately 6 weeks. If chemotherapy is needed it is usually given first and radiation therapy would follow.
A mastectomy involves removing all of the breast tissue including the nipple. A mastectomy can be combined with breast reconstruction either at the time of the mastectomy or later once all treatments are completed. There are many reconstructive options which provide women with a natural and satisfying cosmetic result. Some women who have a mastectomy will also need chemotherapy and radiation treatments following their surgery.
Whether a woman chooses lumpectomy or mastectomy, she also needs evaluation of her lymph nodes. This procedure is discussed in the next section.
The survival and long term outcome of women who have a lumpectomy and radiation compared to those who have a mastectomy are equal. Most women are free to choose the surgery which they decide is best for them. In some cases however, other considerations such as the size or location of the cancer might take precedence. Choosing which type of surgery you will have is one of the first and most difficult decisions you need to make when you are diagnosed with breast cancer. We will discuss your options at length and together will make a treatment decision.
“Why are lymph nodes important in breast cancer and how are they evaluated?”
Lymph nodes are small collections of glands that are part of our immune system. When we refer to lymph nodes in breast cancer we are referring to a cluster of lymph nodes in the axilla (armpit). These are important because they are the first place that cancer goes when it spreads. Knowing whether cancer has spread to the lymph nodes is one of the most important factors we look at to plan further treatments and estimate the chances that a woman will remain free of her cancer after treatment. If the lymph nodes have cancer in them removing them helps prevent recurrence of the cancer. At the time of your initial surgery the lymph nodes will be sampled in one of two ways. Either with a complete axillary node dissection or a sentinel lymph node biopsy.
A complete axillary lymph node dissection means all of your axillary lymph nodes will be removed on the side of the cancer.
A sentinel lymph node biopsy involves isolating and removing the 1-3 lymph nodes in the axilla that are most likely to be positive if cancer has spread to the lymph nodes. The sentinel node is the first lymph node to receive drainage from the breast and would also be the first lymph node to have cancer in it if the cancer had spread to the lymph nodes. With this procedure a radioactive dye is injected around the nipple the morning of the surgery. During the surgery, the surgeon may also inject a blue colored dye into the breast. Both of these dyes or “markers” travel along the lymph pathways in the breast to the sentinel node. If the sentinel nodes are negative for cancer we can safely assume that all of the other lymph nodes in the axilla are also negative. If any of the sentinel nodes are positive a second surgery is required to remove the remainder of the axillary lymph nodes.
Side effects from removal of lymph nodes are directly related to the number of lymph nodes removed. The sentinel lymph node biopsy decreases the total number of lymph nodes removed and thus decreases the risk of side effects. The most common side effects are numbness and discomfort in the arm, armpit, and along the chest wall, and heavy swelling in the arm, known as lymphedema.
“What other factors should I consider to help me make a decision on surgery?”
Some women choose to have the breast on the opposite side of their cancer removed either at the time of their cancer surgery or later. Generally these are women who have a very high risk for cancer recurrence. Other reasons to choose this would be to enable a woman to have bilateral breast reconstruction or to maintain breast symmetry. Women with very large breasts may feel “off-balance” after mastectomy and may choose to meet with a plastic surgeon for consideration of a procedure to make the breasts more symmetrical.
All women want to be cured of their cancer, but other issues such as quality of life, self image, sexuality, and anxiety over recurrence should also be factored into your decision.
“What is involved with radiation treatment?”
Radiation therapy uses high-energy electromagnetic waves to kill cancer cells. If radiation may be a benefit to you, you will meet with a radiation oncologist who will discuss the treatment with you in detail. Treatments usually start 2-4 weeks after surgery and chemotherapy is completed and will consist of treatments each weekday for 6 weeks. At your initial visit your breast and the treatment area will be carefully outlined. After this first visit treatments generally last only a few minutes and are painless. The most common side effect for woman undergoing radiation treatments is fatigue. Many women find that they can continue to work and do their usual activities with minor adjustments. Other common side effects are irritation, itching or increased sensitivity of their skin. After the radiation is completed some women will have permanent changes in the breast skin such as swelling, discoloration or thickening.
“Will I need chemotherapy and if so what is involved?”
Chemotherapy involves the use of medications either intravenously or by mouth to treat any cancer cells that have traveled away from the breast. Whether or not you will need chemotherapy is determined by many factors such as your age, the size and type of tumor you have, and whether it has spread to the lymph nodes. Once you have completed your surgical treatment you will meet with a medical oncologist who specializes in chemotherapy and will discuss the benefits and risks of chemotherapy for you. The type of medications that are used and the length of time that chemotherapy is given vary from person to person. Generally treatments are given in cycles where each course of treatment is followed by a rest period. The treatments will last for 3-6 months.
Usually chemotherapy follows surgery, but a small percentage of women will get chemotherapy first. These may be women with large cancers, cancers involving the skin, or women with a type of breast cancer known as inflammatory. Some women who have larger tumors and want a lumpectomy may decide to have chemotherapy before surgery to shrink the tumor so that a lumpectomy can be performed.
The side effects of chemotherapy vary depending on which drugs are given and whether they are given in the veins or by mouth. Possible side effects include fatigue, nausea, hair loss, and changes in your blood counts such as a drop in your white or red blood cells or platelets. Before you start chemotherapy your medical oncologists will explain what side effects you may experience. There are many effective medications to decrease your symptoms.
“What things are important to know about my breast cancer?”
After you have had your surgery and the pathologist has examined all of the tissue that the surgeon removed we can determine the stage of the cancer. This enables us to estimate the chances that the cancer has spread beyond the breast and the chances of the cancer coming back. The stage is determined by the final size of the tumor and the number of lymph nodes which were positive for cancer. We may also want to find out whether the cancer has spread outside of the breast and axilla. We do this by performing blood work and a combination of radiology studies such as CT scans and bone scans. The type of breast cancer, the tumor grade, and other “markers” such as Her2Neu also give us clues about how the tumor will act. We test all breast cancers to see if they respond to estrogen and progesterone. Knowing whether your tumor is estrogen receptor and progesterone receptor positive or negative helps guide your treatment after surgery.