The aim of surgery for primary breast cancer is to eradicate the primary tumour and any local extension in the hope of achieving total disease control.13
The type of surgical intervention offered to a woman depends on clinical and pathological aspects of the cancer. Irrespective of the eventual procedure selected, the diagnostic biopsy and surgical procedure that will be used as primary treatment should be performed as two separate procedures.35
The axilla is assessed to determine if the cancer has spread to surrounding lymph nodes (usually in the axilla) and to determine treatment options and prognosis.35
Sentinel node biopsy is a minimally invasive surgical technique used to assess the axilla, that may offer less arm morbidity for the patient (for example, less risk of lymphoedema).35 Dye or radioactive isotopes are injected around the cancer to locate the lymph node/s which will be removed for testing to determine whether they are positive for cancer cells. If cancer cells are found (a positive sentinel node), further surgery to remove more lymph nodes, and/or radiotherapy to the area may be required.35
Clinical practice guidelines recommend that sentinel node biopsy should be offered as a suitable alternative to axillary dissection for women with unifocal tumours equal to or less than three centimeters in diameter and clinically negative nodes.35
Treatment of early breast cancer involves surgery to remove the tumour (a lumpectomy or mastectomy) and management of the axilla.35
Many women opt to have breast conserving surgery (lumpectomy) when diagnosed with breast cancer. Breast conserving surgery may be suitable when:13
- single lesions are 4cm or less in diameter
- there are no signs of local advancement
- there is extensive involvement of lymph nodes or metastases and surgery is for local control only.
A total mastectomy includes complete excision of the breast parenchyma with preservation of the underlying pectoral muscles. Mastectomy is usually recommended if the breast cancer is large compared to the size of the breast or there is more than one cancer in the breast (multifocal disease). It may be also recommended after breast conserving surgery if:37
- there are cancer cells in the surgical margin around the breast cancer that was removed
- breast cancer comes back in the same breast
- the woman has previously had radiotherapy to the area.
- Describe the rationale for this procedure.
- Compare indications for sentinel node biopsy and axillary dissection.
- Discuss the adverse effects of sentinel node biopsy.
- Outline how you would explain the procedure to women.
Women should be clearly informed of potential side effects when surgical options are being discussed, so they may make an informed decision.
People undergoing surgery are at risk of the standard post-operative complications. Specific acute post-operative complications relevant to surgery for breast cancer include:13
- post-operative wound infection
- deep venous thrombosis.
Following breast conserving surgery, mastectomy and/or axillary dissection, a woman may also experience:13
- seroma of the axilla (following axillary dissection) or skin flap
- altered body image and self-esteem
- lymphoedema of the arm (following axillary dissection) - which can occur at any stage, even years after treatment
- chest wall discomfort - which should settle within six months
- breast pain and/or chest wall pain - which may last from three months to up to several years in some cases
- breast oedema
- limitation of shoulder movement (particularly abduction and elevation) usually during the first few weeks
- sensory loss in the chest wall below or posterior to the axilla and in some cases on the medial and posterior aspect of the upper arm.
Breast reconstruction may improve a woman's psychological and social wellbeing and improve their body image. Adverse effects following breast reconstruction may include:13
- partial necrosis of a soft tissue reconstruction
- infection and delayed healing
- infection and rejection of a prosthesis (in prosthetic breast reconstruction)
- a second primary tumour in retained breast tissue
- weakness of the abdominal wall (where tissue is in the rectus flap method of reconstruction).
For women undergoing breast conserving surgery and mastectomy, discuss the following:
- Pre-operative preparation
- Potential post-operative complications.
Access the Cancer Australia webpage – Breast reconstruction. Describe how you would respond to the following questions:
- What would be the advantages of reconstruction for me?
- Will my breasts look and feel the same?
- When should I have the procedure?
- What complications might occur?
- Will it make it more difficult to detect another breast cancer?
- Is it available in public hospitals?