London, September 28, (Pal Telegraph) - This information tells you about an operation to remove your breast cancer. It explains how the operation is done, how it can help you, what the risks are and what to expect afterwards.

The benefits and risks described here are based on research studies and might be di fferent in your hospital. You may want to talk about this with the doctors and nurses treating you.

What is breast-conserving surgery?

Breast-conserving surgery is an operation for breast cancer that lets you keep your breast. Your surgeon will remove only the part of your breast that has cancer. The aim is to get rid of your breast cancer while changing the appearance of your breast as little as possible.

 

Is this operation suitable for me?

You may be able to have breast-conserving surgery if:[1]

You ha ve early breast cancer. This means the cancer hasn't spread outside your breast, or has only spread as far as the nearest lymph nodes. Lymph nodes are small, round or oval lumps. They help fight infections in your body. Breast cancer usually spreads to the lymph nodes in your armpit before it spreads anywhere else You have just one lump in your breast. If you have more than one lump, or lots of small patches of cancer cells, breast-conserving surgery may not be suitable. It's hard to remove all the cancer cells without changing the way your breast looks. And if you have lots of small patches of cancer, it's more likely to come back than it is if you have a single lump. Removing your breast can help stop this[2] [3] Your lump is small compared with the size of your breast. If you have a small lump, you'll only have a small scar, and maybe a small dent in your breast You can have rad iotherapy. You may need radiotherapy after breast-conserving surgery. Doctors try to avoid giving radiotherapy to the same area twice, so you may not be able to have breast-conserving surgery if you've had radiotherapy before. If you are pregnant, you may want to avoid radiotherapy as it can harm your baby.

Up to 80 percent of women with early breast cancer are able to have breast-conserving surgery. And there's good evidence from lots of studies that women who only have their lump removed live just as long as women who have a mastectomy.[4] [5]

But breast-conserving surgery isn't suitable for everyone. If you have a large lump and a small breast, or if you have cancer under your nipple, it can be difficult to remove the cancer without changing the way your breast looks. You may get a better result with a mastectomy and breast reconstruction. There are several kinds of breast reconstruction available, including surgery to put in implants.

If you have a family history of cancer, or tests show you have a high risk of breast cancer, there is a bigger chance that the cancer will come back in the same place.[6] In this case, some women choose to have a mastectomy rather than risk needing more surgery later.

Guidelines from the National Institute for Health and Clinical Excellence (NICE), the government body that advises doctors about treatments, say that:[1]

You should start treatment within four weeks of being diagnosed with breast cancer You should be treated in a hospital by a team of specialists who are experienced in breast surgery. You can ask your doctor to refer you to a hospital with a specialist breast-surgery unit. Each year, a specialist unit treats at least 100 women who are newly diagnosed with cancer.

 

What happens during breast-conserving surgery?

Your surgeon will remove the cancer from your breast. He or she will probably also remove some or all of the lymph nodes from your armpit.

The breast tissue and lymph nodes the surgeon has removed will be checked to see if they contain cancer.

You'll also have radiotherapy to kill any stray cancer cells that were left behind.

Removing cancer from your breast

You may have chemotherapy or hormone therapy before your operation to shrink the cancer. It can make your lump easier to remove, but it has side effects. You may wish to ask your doctor about these.

Your surgeon may be able to feel the cancer in your breast. But if he or she can't feel your lump, you may need a mammogram so that your doctor can see inside your breast. During a mammogram, a thin wire is threaded through your skin to mark the cancer. The wire is left in place during surgery to show the surgeon which part of your breast to remove.

Most women have a general anaesthetic to make them sleep during surgery. If your overall health isn't good, you may just have a local anaesthetic to numb your breast. Either way, you shouldn't feel any pain during the operation.

If you have a general anaesthetic, you won't be able to eat anything for eight hours before the operation or drink anything for up to two hours before. Breast-conserving surgery usually takes between 15 minutes and 40 minutes. You should be able to go home the same day, although some women stay in hospital overnight.

Here's what happens.

Your surgeon makes a small cut across your breast above the cancer. He or she will try to make the cut as small as possible. Your surgeon shouldn't need to cut away any skin unless the cancer is just under the skin's surface.[7] The surgeon cuts away the cancer along with a small amount (about 2 millimetres, or 1/12 of an inch) of healthy-looking tissue.[8] Removing tissue around the cancer or lump is called taking a margin. It's done to reduce the risk that any cancer cells are left behind. Your surgeon will move the layers of breast tissue around to fill the hole left by the cancer and keep your breast as close to its original shape as possible. The cut on your skin is usually sewn up with one long stitch that dissolves later.

Occasionally, if your surgeon had to remove more of your breast, the hole left behind can be filled with a piece of muscle from your back.[9] You can talk to your surgeon about whether this might happen to you.

Removing your lymph nodes

For some types of breast cancer, your surgeon will probably remove some or all of the lymph nodes in your armpit. This is because these nodes are usually the first place breast cancer spreads to. If you have a type of early breast cancer called ductal carcinoma in situ (DCIS), you won't need any lymph nodes removed.

If your breast cancer is in the upper part of your breast near your armpit, your surgeon may be able to reach your lymph nodes through the same cut he or she made in your breast. But if your cancer is somewhere else, the surgeon will need to make another cut under your arm to reach the lymph nodes.

You may have all 20 or so lymph nodes removed from your armpit. This is called an axillary clearance. The aim is to remove any cancer that might have spread there by removing all of the lymph nodes. Or your surgeon may remove between four and 10 lymph nodes to see if they contain cancer cells. This is called axillary sampling. If the nodes in the lowest part of your armpit are clear of cancer, it's unlikely that any of the nodes higher up will have cancer in them. A newer treatment called a sentinel node biopsy uses a blue dye and a radioactive injection to find the lymph node, or nodes, that fluid from your breast drains into first. The dye is injected into your breast and colours the nearest nodes. The nodes that the fluid from your breast drains into first are called the sentinel node s. The sentinel nodes are then tested for cancer. If there are no cancer cells in these nodes, it's likely that the other lymph nodes are free from cancer as well.

You will have fewer side effects if fewer nodes are removed.[10] You're likely to have less pain after sentinel node biopsy than if you have more nodes removed. And you'll probably be able to move your arm more easily.[11] But this treatment is still being tested to see how well it works.[12] Doctors who use this test need to be specially trained. Ask your doctor about this.

Testing the breast tissue and lymph nodes

After surgery, the lump and lymph nodes are checked under a microscope. If no cancer cells are found in the surrounding tissue, your surgeon might say you had a healthy or clear margin. A clear margin reduces the risk of your cancer coming back in that part of your breast.[13]

Radiotherapy

Radiotherapy is used after surgery to kill any cancer cells that may have been left behind. It uses X-rays to destroy cancer cells in your breast. You'll need to have radiotherapy five days a week for between four weeks and six weeks. Each session only takes a few minutes. Radiotherapy doesn't hurt, but it has side effects.

If there's a high risk that your cancer will come back in your breast, or you haven't had all your lymph nodes removed, you may need radiotherapy to the lymph nodes in your armpit.[4]

How can breast-conserving surgery help me?

If you have early breast cancer, breast-conserving surgery can stop your cancer spreading and help you live longer.

Breast-conserving surgery with radiotherapy works just as well as having your whole breast removed. This is true for women of all ages. Studies involving thousands of women have found that women are just as likely to be alive 10 years or 20 years after breast-conserving surgery as after a mastectomy.[4] [5] [14] [15] [16] In one study, a quarter of the women who'd had either operation died of breast cancer within 20 years. Some women had died of other things in the same time.[14]

Breast-conserving surgery also has some advantages over a mastectomy.

You'll be able to keep your breast, although it won't look the same as it did before. Your scar will be small compared with a mastectomy scar. The exact size of your scar will depend on how much tissue is taken away. You won't need to wear a false breast or have surgery to reconstruct your breast. You are likely to feel better about the way your body looks.[17] [18] Between 6 and 9 out of 10 women say their breast looks "good" or "excellent" after breast-conserving surgery.[19] You can wear the same clothes, and you may find it easier to get back to your life, go to the gym and have sex.

 

Will the cancer come back?

There is a chance that your cancer could come back in the same place. This chance is bigger for younger women.[20] And some women get a new breast cancer somewhere else in their breast. Each year, less than 1 percent of women who have had this operation get a new breast cancer.[21]

Radiotherapy can help stop your cancer coming back.[22] Women who don't have radiotherapy are three times more likely to get their cancer back in the same place than women who have radiotherapy.[22]

Only 7 in 100 women who have radiotherapy have cancer again within five years. But 26 in 100 women who don't have radiotherapy have their cancer come back within five years.

Radiotherapy also reduces the chance that you'll need to have your breast removed later.[23]

If you have ductal carcinoma in situ, having radiotherapy after breast-conserving surgery reduces the risk that your breast cancer will come back by about half.[24] [25]

Radiotherapy after breast-conserving surgery may also help women live longer.[22] But radiotherapy has side effects. So researchers are looking at whether some women (such as older women or those with less aggressive cancers) will do just as well without it.[26]

Researchers are also looking at whether having radiotherapy to the breast during surgery (intra operative radiotherapy) works as well as having radiotherapy after surgery.[27] [28]

We don't know whether radiotherapy just around the part of your breast being removed is better and safer than radiotherapy to a wider area.[29] More research is needed to be sure.

If the cancer does come back, you'll usually need to have the rest of your breast removed.

What are the risks of breast-conserving surgery?

All operations have risks, and your surgeon should talk to you about the risks of surgery to remove cancer in your breast. If you have a medical condition such as a heart problem or have had a blood clot, surgery may be more risky for you.

Anaesthetics can have side effects. These are more likely with a general anaesthetic. You may have an allergic reaction to the anaesthetic or get breathing or heart problems. These problems are serious but very rare. If you have any allergies, you must tell your doctor.

It's hard to say exactly how often other problems happen because the research isn't very good. You can use the figures we give below as a guide, but it's important to discuss with your doctor how often problems happen in your hospital.

Risks of removing your breast cancer

Sometimes, not enough tissue is removed from around the lump. This may happen if the cancer has spread further than your surgeon thought. The tissue that has been removed during the operation will be checked, and if your surgeon thinks some cancer could be left behind, you may need a second operation. About 1 in 10 women need another operation. You may either have more of your breast removed or have a mastectomy. Some women who need more surgery say they wish they had chosen to have a mastectomy in the first place.[19] [30]

You may be unhappy with your breast shape. Between 1 and 3 out of 10 women are disappointed with how their breast looks after surgery.[19] Your scar may be bigger than you expected, your breast may look distorted and your breasts may be uneven sizes. But you can have more surgery to improve the way your breast looks.

An infection can make your wound hurt, and the surrounding skin may be hot and red. The risk of infection after breast-conserving surgery is around 1 in 50.[4] Occasionally, the infection causes pus to collect around the scar. You may need antibiotics for this.

A clear fluid, called serous fluid, can collect under the scar. This is called a seroma. It is part of the normal healing process. About 1 in 5 women get a seroma after their breast cancer is removed.[31] The fluid can be drained with a needle by a doctor or nurse.

You may get bleeding under the cut in your skin after the operation. If the blood builds up and clots, you will get a big bruise called a haematoma. The area will be swollen and feel tender. If this happens, you may need surgery to remove the blood clot or stop any bleeding.

Risks of removing lymph nodes

The pain and discomfort under your arm can last for a few weeks.[10] Your arm may feel bruised and heavy.

Shoulder stiffness can start because your upper arm is painful after surgery. In one study, about 1 in 4 women had this problem.[10] You need to take painkillers and do gentle arm exercises.[32] Don't let your shoulder stiffen up because it hurts to move it. Six months after surgery, stiffness is more common in women who have all, rather than a few, of their lymph nodes removed.[33] Very few women who have sentinel node biopsy get shoulder problems.[34]

You may get numbness or tingling in your arm, shoulder or breast. This happens if the surgeon accidentally stretches or damages the nerves that run close to your lymph nodes. Women who've had a few of their lymph nodes removed and get this problem tend to recover within a few months. About 2 to 4 out of 10 women who have all their nodes removed get this problem.[10]

Swelling of the arm and armpit (lymphoedema) can start straight away or years later. It may last a few weeks or become an ongoing problem. It can be very unpleasant. Your arm may feel heavy and painful.

The risk of getting lymphoedema is greater if you have radiotherapy to your armpit or if all the lymph nodes in your armpit are removed. It's hard to say how common the problem is because studies vary. About 2 or 3 out of 10 women get lymphoedema after all their lymph nodes are removed. Some studies show that there's no risk of lymphoedema if only a few nodes are removed. But other studies show that up to 2 in 10 women get this problem after a few nodes are removed.[35]

Wearing a close-fitting elastic sleeve can help prevent the swelling. Gentle massage may also help.

Fluid can collect under the scar in your armpit. This is part of the normal healing process. It happens to between a quarter and a half of women who have all their lymph nodes removed.[36]

Risks of radiotherapy

There aren't many studies on the side effects of radiotherapy.[37] Different women have different experiences, but many women cope well with the side effects.

Your skin may itch or change colour after radiotherapy, and your breast may feel tender.[38] In one study, about 1 in 3 women who had radiotherapy after surgery had breast pain six months later. This compared with 1 in 5 women who only had surgery. About 1 in 3 women who had radiotherapy had skin irritation three months later. This compared with 1 in 10 women who only had surgery.[39]

Some women feel more tired than usual. These problems are usually mild and go away after a few weeks.

If your doctor thinks that there's a high risk of your breast cancer coming back, you may have an extra boost of radiotherapy to your breast. This can make your breast feel hard and change shape. This problem is called fibrosis.[40]

Side effects that happen some time after your treatment include nerve damage and inflammation in the lungs.[41] These may sound serious, but they are rare and can be treated. You may also find that hair stops growing in your armpit.

What will happen if I choose not to have surgery?

Although some women have surgery within a few days of being diagnosed, don't feel you have to rush into a decision. Take the time you need to talk to your doctor and consider your options. Taking a week or two to make up your mind won't do you any harm.

If you need more time to decide, you can have chemotherapy or hormone therapy to stop the cancer spreading.

If you decide not to have your breast cancer removed, it may spread through your breast tissue into your skin, chest and the muscles below your breast. It will then spread to other parts of your body. No one can say for certain how long you will live if you don't have the cancer removed. There aren't any good studies to tell us, as most women have treatment.

What other treatments are available?

Some women choose a mastectomy instead of breast-conserving surgery. It's a bigger operation and your whole breast is removed. If you have a mastectomy, you may wish to have breast reconstruction surgery as well.

You can have breast reconstruction surgery at the same time as the mastectomy or later. Your surgeon may be able to remove your breast but keep the skin in place. The breast tissue is replaced with an implant or a piece of muscle from your back. This is called a skin-sparing mastectomy.[42]

If you have a mastectomy:

You aren't likely to live any longer than a woman who's had breast-conserving surgery[4] [5] [14] [15] [16] There is still a small risk that breast cancer will come back in the scar, so removing all the breast tissue can't guarantee that your breast is free of cancer cells. The chances of your cancer coming back are the same as a woman who has had breast-conserving surgery and radiotherapy[4] You are likely to get more serious side effects than someone who has had breast-conserving surgery. There's a bigger chance that you'll get pain and swelling under your arm and in your wound You may miss your breast, and some women say they feel mutilated by losing a breast. You may find it hard to look at your scar. You may also find it difficult to be intimate and have sex. Breast reconstruction can help.

Every woman's situation is different. You may decide that removing your breast gives you more peace of mind. You may want to consider a mastectomy if you have a large cancer and a small breast. In this case, your breast may look very different after breast-conserving surgery, and a mastectomy with reconstruction might give you a better result.

You may choose a mastectomy if, for some reason, you can't have radiotherapy. But some women need radiotherapy even after they've had a mastectomy.

What can I expect after breast-conserving surgery?

 

Immediately after your operation

When you leave the operating theatre, you'll go to the recovery area until you are fully awake. You'll probably have a thin tube in the vein in the back of your hand where you were given the anaesthetic. If you had a local anaesthetic, the parts of your breast and armpit where the cuts were made will feel numb for several hours.

You'll have a bandage over your wound. You may have a plastic tube running from your wounds to drain away the blood and lymph fluid that builds up during the healing process. But most women don't need this.[43]

Your breast, arm and shoulder will feel sore after the operation. Your nurse will give you painkillers if you need them. If the first ones you try don't work, tell your nurse or doctor. You may need a stronger dose or another type of drug. Don't try to put up with pain, as this can slow your recovery.

You'll be left with a scar on your breast, and usually a separate scar in your armpit if your lymph nodes were removed.

You'll be able to get up and move about after surgery. The sooner you start to move, the better you'll feel. You will be shown arm exercises you can do to stop your arm getting stiff. Ask your doctor or nurse for a leaflet explaining the exercises.

Going home

Many women feel anxious about seeing their breast for the first time after the operation. Take your time and remember that it takes a while for your breast to settle down after surgery. You scar will also fade over the next few months.

You can wash your breast after a few days, but dry it carefully. Wear a comfortable bra as soon as you can. It will help support your breasts.

Avoid strenuous activities such as lifting or sport until your wounds have healed and there's no swelling in your arm. You can go back to work as soon as you feel ready.

It's important to avoid getting an infection in your arm if you have lymphoedema. Protect your arm by wearing gloves if you are gardening or doing something that might injure your hand or arm. Don't have your blood pressure taken on the arm that has lymphoedema.

Your breast will have changed in shape and size, depending on how much tissue was removed. This can affect how attractive you feel. Many women say that it affects how they feel about sex. Give yourself time to adjust. You can talk through your feelings and worries with those close to you or your breast cancer nurse.

Further treatment

If tests show that surgery may not have removed all the cancer, you might need a second operation. This is usually a mastectomy.

If your doctor thinks there's a risk that your cancer has spread, you may have further treatment such as chemotherapy or hormone therapy. These treat your whole body. They help prevent the cancer coming back and may help some women live longer, but they have side effects. Talk to your doctor about whether you will benefit from these treatments.

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The effects of radiation therapy on quality for life of women with breast carcinoma: results of a randomized trial. Cancer. 2000; 88: 2260-2266. Kurtz JM. Impact of radiotherapy on breast cosmesis. Breast. 1995; 3: 163-169. Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. A Canadian consensus document. Canadian Medical Association Journal. 1998; 158 (supplement 3): 1-84. Sotheran WJ, Rainsbury RM. Skin-sparing mastectomy in the UK: a review of current practice. Annals of the Royal College of Surgeons of England. 2004; 86: 82-86. Purushotham AD, McLatchie E, Young D, et al. Randomized clinical trial of no wound drains and early discharge in the treatment of women with breast cancer. British Journal of Surgery. 2002; 89: 286-292. Glossary mastectomy A mastectomy is an operation that removes all of the breast tissue, including skin and the nipple, from the side of the chest that has cancer. lymph nodes Lymph nodes (also called glands) are small, bean-shaped lumps that you cannot usually see or easily feel. They are located in various parts of the body, such as the neck, armpit and groin. Lymph nodes filter and remove unwanted things, such as bacteria and cancer cells. general anaesthetic You may have a type of medicine called a general anaesthetic when you have surgery. It is given to make you unconscious so you don't feel pain when you have surgery. local anaesthetic Local anaesthetic is a painkiller for one area of the body. You usually get it as an injection. It makes that area numb. An example is the lidocaine you may get when your dentist fills a cavity. X-ray X-rays are pictures taken of the inside of the body. They are made by passing small amounts of radiation through the body and onto film. Larger amounts of radiation are used to treat some kinds of cancer. allergic reaction You have an allergic reaction when your overreacts to a substance that is normally harmless. You can be allergic to particles in the air you are breathing, like pollen (which causes hay fever) or to chemicals on your skin, like detergents (which can cause a rash). People can also have an allergic reaction to drugs, like penicillin. antibiotics These medicines are used to help the fight infection. There are a number of different types of antibiotics that work in different ways to get rid of bacteria, parasites and other infectious agents. Antibiotics do not work against viruses. haematoma A haematoma is a collection of blood in any part of your body. The blood has usually clotted or dried.

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