Surgery for Breast Cancer – Cindy Matsen, MD

Hello, my name is Cindy Matsen.
I am a breast cancer surgeon at Huntsman Cancer Institute at the University of
Utah. In this video I will be discussing surgical options for breast cancers. Almost all patients with breast cancer that has not spread to other parts of
their body will have surgery as part of their treatment. Sometimes surgery is the
first phase of treatment. Sometimes we do surgery after chemotherapy. You and your surgeon will discuss your specific situation when you come for your
appointment. Your surgeon will let you know what your cancer care team
recommends for you. Whether or not you get chemotherapy is not based on the
kind of surgery you have. The decision for chemotherapy is based on the type of
cancer you have and how far it has spread. It has nothing to do with the kind of
surgery you choose. Surgery for breast cancer is done to remove the disease and
to get more information about your cancer. There is no right or wrong choice.
Every woman feels differently about her breasts. My goal is to give you enough
information that you choose the best option for you. For many women, there are two options for breast cancer surgery. Mastectomy removes the entire breast.
Breast conservation, also called lumpectomy followed by radiation, removes the tissue
where the cancer is and leaves the rest of the breast. As I said, lumpectomy is
almost always followed by radiation. Not every woman has the choice, but the
majority do. You and your surgeon will discuss your specific situation when you
come in for your appointment. Many women think it seems odd that there is a choice. Shouldn’t there be simply one best way to treat breast cancer? But
we know from data going back many decades that the chance you will live a
long time after your cancer, also called survival, is the same with either
procedure. Survival is the thing we care about most, but there are other
considerations and differences between the two surgeries. Let’s go over some of
those now. Mastectomy removes the entire breast. There are reconstruction options to recreate a breast shape. It is a bigger
surgery and you will stay in the hospital, usually for just one night. You
will have drains in place after surgery and these typically stay in for one to
two weeks. Lumpectomy removes the tumor and a ram of normal tissue around it. There will be a scar on your breast and there may be some change in the shape of your breast. This is an outpatient surgery, so you
come in and go home the same day. Most women do not need drains after lumpectomy. There is a chance you will need a second surgery if there are microscopic cancer
cells at the edges of the tissue, which are called the margins. This happens with about 15 in 100 lumpectomy surgeries. This type of surgery is almost always
followed by radiation, which kills any cancer cells that might remain in your
breast. The remaining difference between the two is what we call the risk of recurrence, or the chance that the cancer will come
back in your breast or chest wall. The exact numbers for this vary by study, but
everyone agrees that the chances are low with either option as long as you get
all the treatments you need. What I tell my patients is that about one to three
percent of women who have a mastectomy will have cancer come back in their
chest wall at ten to fifteen years after surgery. With lumpectomy followed by
radiation the chance that the cancer will come back in the breast is about
five to seven percent at ten to fifteen years after surgery, which is also low.
These numbers are generalities based on large populations of women. They may not apply to your specific case. The medications that you’re recommended and radiation will also play a role in how likely it is that the cancer will come
back. It should be noted that these numbers are the lowest possible
estimates that are based on a very favorable breast cancer. You should know
that the risk of recurrence depends much more on the stage and type of cancer
that you have than the type of surgery that you have, and that in either case
there’s a small chance that the cancer can come back. Surgery for breast cancer often includes surgery for the lymph nodes under your arm, as well. This is
also called your axilla. We remove lymph nodes from under your
arm so that we can look at them under the microscope. We need to know if there
are cancer cells in the lymph node to know what other treatments you might
need. Some women only need a few nodes removed with what’s called a sentinel lymph node biopsy. Some women need all of the lymph nodes removed, which is called an axillary dissection. Let’s talk briefly
about how that decision is made. If your surgeon can’t feel any abnormal nodes on
your physical exam he or she will perform a sentinel lymph node biopsy
during your breast cancer surgery. The sentinel lymph nodes are the first lymph
nodes that drain the part of your breast where the cancer is located. To identify
these nodes, a radioactive tracer and a blue dye are injected into your breast
on the day of surgery. These travel through the drainage system of your
breast, which is called the lymphatic, to the very first nodes. Your surgeon can
see the nodes that took up the tracer in the operating room and remove them. The pathologist would sit them under the microscope. If they show no or very few
cancer cells, the surgeon won’t take out any more lymph nodes. Every woman has a different number of sentinel nodes. It has nothing to do with the cancer, it has
to do with individual anatomy. The average number of nodes removed is two.
Some women need to have all the lymph nodes under the arm removed and this is
called an axillary dissection. Women who need all of the lymph nodes removed
include: those who have abnormal nodes on physical exam, women who are getting a
mastectomy and have cancer in any sentinel lymph nodes, and women who are getting a lumpectomy with radiation who have cancer in more than two sentinel
lymph nodes. We know from an important trial published several years ago that
if a woman is getting lumpectomy with radiation and has cancer in two or
fewer lymph nodes, that is a very little bit of cancer, then leaving the other
lymph nodes behind is not dangerous, even if they contain some cancer cells,
because the radiation and other medications will help take care of it. Since most women who get mastectomy don’t get radiation, we currently don’t
know if it is safe to leave some cancer behind with this procedure. Your surgeon
will talk with you about your specific needs. The reason we want to remove fewer nodes, if possible, is because there is a difference in the chances of developing
lymphedema, or arm swelling, after surgery. About 5% of women who have a sentinel
lymph node biopsy get lymphedema, and about 15 to 20% of women who have an axillary dissection get it. Again, these are estimates and different
studies report slightly different results. There are many other things
women consider when choosing what type of surgery to have, including
reconstruction options, mastectomy for the other breast, which is called a
contralateral prophylactic mastectomy, and nipple-sparing options. Some of these topics are quite controversial. We can discuss all of these options when you
come in for your appointment, and we look forward to seeing you.

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