Mastectomy is a surgical procedure which involves the removal of either the entire breast or a segment of the breast. Usually performed for cancer of the breast, it can also be used for prophylactic removal of the breast for women who are at high risk of developing breast cancer.
Breast cancer begins as a local disease in the breast and if not treated spreads (metastasizes) to other parts of the body. The idea of removing the breast or a part of it goes as far back as Vesalius in the 16th century. Currently the type of surgery performed is determined by the extent or “stage” of the cancer.
STAGES OF BREAST CANCER
- Stage 0 (in situ). This includes ductal or lobular carcinoma in situ (CiS), which is noninvasive cancer, and Paget’s disease, which is a local cancer of the nipple. There are two types of in situ: (a) intraductal (DCiS) which is noninvasive ductal carcinoma and (b) lobular CiS which is precancerous, more often multicentric (found throughout the breast), more often in both breasts.
- Stage I. Early cancer, the tumor is 2 cm (3/4 of an inch) or smaller with no evidence of tumor in the axillary lymph nodes (under the arm) and no distant metastasis.
- Stage II. Tumor size is 2-5 cm (3/4-2 in.), lymph nodes may be positive or not; but if the nodes are positive in a tumor less than 2 cm in size, this would qualify as Stage ii.
- Stage III. III A: The tumor is smaller than 5 cm (2 in.); axillary nodes are positive and it has spread to other lymph nodes; or the tumor is larger than 5 cm and has spread to the lymph nodes under the arm. III B: The cancer has spread outside the breast to the chest wall, muscles, and skin, or the cancer has spread to lymph nodes inside the chest wall near the breast.
- Stage IV. There is evidence of distant metastasis to other organs usually the bones, lungs, liver, or brain regardless of size.
TYPES OF SURGICAL PROCEDURES
The surgical technique that was used for the greater part of the 20th century was the radical mastectomy described by Dr. William Halstead in 1894 in the Johns Hopkins Hospital Report. This surgery involved removing the entire breast, skin and chest wall (pectoralis major) muscles, the contents of the axilla (under the arm), and skin, and required an extensive skin graft. Results with this form of surgery resulted in an immediate and drastic decrease in chest wall recurrences. Research in the 1970s and 1980s showed that there was no advantage to removing the chest wall muscles and a new surgical technique, the “modified radical mastectomy,” virtually replaced the radical mastectomy. By 1990, only 0.4% of all surgeries for breast cancer were of the radical mastectomy type. Modified radical mastectomy involves a total mastectomy, removing the breast, nipple, and areola with removal of 10-20 lymph nodes under the arm, called an axillary lymph node dissection, without removing the major chest wall muscles. The surgery takes approximately 2-3 hr and breast reconstruction can be performed immediately. It became the most popular surgery for early stage cancers, if the tumor is 5 cm or greater, if the skin or muscle is involved, or four or more axillary lymph nodes are positive for cancer cells.
Total mastectomy without removing the axillary lymph nodes is used for extensive ductal CIS or in invasive cancer when the sentinel lymph node (see below) is negative.
BREAST CONSERVATION THERAPY
More recently, breast conservation therapy (BCT) is being used. This involves combining two modalities: breast conserving surgery, also known as lumpectomy, with 5-7 weeks of postoperative irradiation.
The goal of breast conservation therapy is local control of the cancer and maintenance of a cosmetically normal appearance of the breast. It was demonstrated in the 1980s to have equal risks of recurrence compared to mastectomy. In 1990, a Consensus Development Statement by the National Institutes of Health recommended lumpectomy for as many as 50-75% of women with early breast cancer.
Breast conserving surgery, the first phase of breast conservation therapy, also called wide local excision or lumpectomy, leaves a safety margin of healthy breast tissue. It can be done under local or general anesthesia in a standard operating room or an outpatient surgery center and takes approximately 1 hr. The specimen is sent to pathology to assess that the margins of the specimen are without tumor (“clear”).
Contraindications to lumpectomy are: (a) the presence of more than one tumor, or if there are suspicious areas of calcifications, small specks of calcium demonstrated on mammography, elsewhere in the breast, (b) if the tumor is so large or the breast so small that cosmetic results following surgery would not be satisfactory, (c) if the tumor is found to extend beyond the margins of the tissue that was removed, (d) if the woman is not willing to have radiation therapy after surgery or has had prior irradiation to the breast or chest wall, or if there is no access to radiation treatment in the community. Collagen vascular disease such as scleroderma poses a risk to irradiation. It cannot be performed for women if they are pregnant. However, if a woman is pregnant in the 2nd or 3rd trimester, she may have surgery and chemotherapy and postpone irradiation until after delivery. Finally, if a woman would prefer to have a mastectomy rather than breast conservation therapy, she should be given that choice.
SENTINEL LYMPH NODE BIOPSY
This procedure, which has been added to the armamentarium of breast cancer treatment within the past decade, involves obtaining a tissue sample from the sentinel node, the “first lymph node,” which drains lymphatic fluid from the breast. It is performed only if there is a single tumor less than 5 cm, the woman has not had prior chemotherapy or hormone therapy, and the lymph nodes feel normal. The surgeon injects either a blue dye or a radioactive substance into the area around the tumor. The lymphatic vessels carry the dye to the first lymph node which is then examined microscopically for the presence of cancer cells. If the node is positive for malignant cells, the surgeon will then proceed with an axillary lymph node dissection.
Potential side effects of axillary lymph node dissection include lymphedema, which is a painful swelling of the involved arm caused by scarring around the lymph duct with resulting limitation of movement and function. The advantage of performing a sentinel node biopsy is that if it is free of cancer there is no need for further axillary lymph node removal.
PSYCHOLOGICAL EFFECTS OF MASTECTOMY
All women diagnosed with breast cancer will experience some degree of emotional distress. It was previously thought that the emotional trauma from breast cancer was the result of the physical disfigurement of amputating the breast. However, with the advent of breast conservation therapy, it has been shown that despite a better body image, the psychological trauma comes from having a potentially fatal disease.
Women faced with the decision of whether to choose breast conserving surgery versus a mastectomy also carry the psychological burden of having to make the “right choice.” The fear of leaving behind cancer cells in a breast or the fear of undergoing irradiation therapy with its side effects of fatigue and vulnerability to depression may prompt a woman to choose a mastectomy. Availability of support groups and individual counseling can help a woman through this very difficult time.
Sexual difficulties may be anticipated in women regardless of whether they have had breast conserving surgery with irradiation or mastectomy with reconstruction. Pain or numbness in the breast or chest wall after surgery with reconstruction will decrease sexual interest. Some women who choose mastectomy without reconstruction may be embarrassed for their partners to see their scar and avoid intimacy. Women should be encouraged to discuss these issues with their partner and health care providers so that referrals to specialty consultants can be made.
A woman’s style of coping, which includes attitudes of optimism or pessimism, the availability of social and family support, a woman’s ability to discuss emotional issues with her physician, and the way she felt about her body prior to the diagnosis of cancer, all determine her psychological response to breast cancer regardless of whether she has conservative surgery or mastectomy.