Everything you need to know about breast cancer surgery

Leading consultant oncoplastic breast surgeon Mr Sumohan Chatterjee explains what's involved in breast cancer surgery, as well as the different types and what the most suitable type of surgery for patients is, in expert detail.

What type of breast cancer surgeries are there?

Breast cancer surgery, interestingly, has increased in its whole gamut. If you go back 25 years, all of the operations were lumpectomies or mastectomies. From there, we moved on and we pushed for more lumpectomies. However, the lumpectomies resulted in patients being unhappy with the cosmetic outcome because they were done with just cancer in mind, not the overall look of the breast after the cancer is removed.

This resulted in a lot of dissatisfaction among patients after lumpectomy. Although we managed to save the breast, we didn't save it in a way which was meaningful for the patient. This is where modern breast cancer surgery came into play.

Discussing the possibility of reconstruction

When we do the mastectomy, now it's absolutely essential we speak to the patients about the possibility of reconstruction. This can be done with biological mesh, with an implant which is the most common way of doing it - I wouldn't say the simplest way, but the most common. However, there are other options using free flaps, like from the tummy or the back.

The reconstruction can be done at the time of the surgery, or in a delayed manner if the patient chooses to do so. There are risk factors, so patients who have other health issues, other conditions like diabetes; high BMI, or patients who smoke, can be at risk. It's a high-risk operation so, we have to be mindful of that.

Lumpectomy combined with oncoplastic technique

The second part is the lumpectomy. Now, we don't look at lumpectomy as a whole, we see it as a lumpectomy combined with oncoplastic technique so that the breast retains its shape and cosmesis. It could be simple, like removing the lump when it's small and considering the proportion affect to the breast; we don't go by the size of the lump, we go by the size of the lump in proportion to the breast. So, if it's a lump which is only 10 per cent of the breast, you can simply remodel the breast and get a good outcome.

Therapeutic mammoplasty

If it gets bigger, then we have to put in techniques where we can do what is called a breast reduction technique called a therapeutic mammoplasty where the cancer is taken out and a breast reduction is done on one side, or both sides to match it. 

Filler flap technique

The other technique is what we called a filler flap where we create the cavity to take out the cancer with the margin, and then we fill that cavity with what we call a local perforator flap which could be borrowed from the side of the chest wall, which is called the LICAP, or it could be borrowed from below the breast which is called an ICAP or MICAP.

All is dictated by the position of the cancer in the breast. This has made breast cancer surgery much more acceptable, and we're doing more lumpectomies more than ever before. This is for the benefit of our patients, because if you can successfully do a lumpectomy then we know that psychologically, patients deal with this whole episode much better when the dust settles in six, twelve months when they've finished their treatment. They can look back and start to get on with life, and what we call 'move forward.'. So, this is breast side of things.

Moving from complete lymph node removal to sentinel biopsy

The armpit side, what we call the axilla - where we have the lymph nodes; 25 years ago, the only operation acceptable was complete removal of the lymph nodes even if they were normal. We've moved on from that for patients who, on assessment, have normal lymph nodes, they have what's called a sentinel biopsy where only two or three lymph nodes are removed.

If they're all clear of cancer, then no further surgery is required. If they have cancer in the lymph nodes confirmed on biopsy, then they can have full removal of the lymph nodes. This is called axillary node clearance. Again, there are improvements from there, because if you remove the lymph nodes completely then there's a high risk of swelling of the arm and lymphoedema, shoulder stiffness and real problems that patients can face long term.

Targeted axillary dissection

So, we're now in an era where we have to remove the affected cancerous lymph nodes. We're adopting a new technique called targeted axillary dissection, where we put localiser in the lymph node in itself. This helps us find the lymph nodes, we can remove the affected lymph nodes and leave behind normal lymph nodes because taking them doesn’t add to the cancer outcome. However, it adds to the comorbidities the patient will face after their operation.

New localisation methods

So, things are moving, and one of most helpful things in doing breast conservation surgery, or lumpectomy, as its commonly known as, is previously for impalpable, or small cancers. We used to use what we call 'guide wire'. This wasn't very precise and also it has to be done on the day of surgery which increases the anxiety of the patient. Now, we're using localisation methods like Magseed and other similar ones where these seeds can be put in before the surgery so, on the day of surgery there's no disruption to the operating time. The patients can have a much better, smoother journey.

Restrictions on mastectomies

All in all, things are moving forward and we have a whole range of surgery. Sometimes we have to do surgery on the other breast, to make it look symmetrical, so, there may be an operation done on a normal breast. Mastectomies, nowadays, are restricted to patients who absolutely need it. There's a group of patients who've inherited gene mutations like the BRCA gene. They need mastectomy as a part of their treatment. Not only on the affected side but also on the normal side.

Heat treatment with chemotherapy

There are some cases where the patient has disease which is so extensive that we can't preserve the breast. However, nowadays we are using what is called heat treatment with chemotherapy, or even tablets to see if we can reduce the size of the cancer so we can convert what could have been a mastectomy up front, but the patient may get away with breast conservation. 

What is the best type of surgery for my breast cancer?

The best type of surgery is what is right for your cancer, because breast cancer isn't one entity. It's a big basket of different types of cancer, considering biology, size and how it presents. The best surgery is different people.

Overall, we try and aim for breast conservation and there are many merits in considering breast conservation if it's possible.

Number one; the whole mantra is 'less is better'. So, we're in the era of what's called de-escalation. We offer to give people a personalised treatment, so what is right for patient A may not be right for patient B. It may not be right for patient C. So, there's no single answer. Everybody's an individual and has to be dealt with.

Lumpectomies and their advantages

Overall, the majority of our patients now have a lumpectomy. The advantage of a lumpectomy is that it's a lesser operation. We can preserve the breast. Psychologically patients do better long term, and more importantly now: data coming through, and these isn't high level data because they aren't from trials, and isn't randomised.

However, this is real-world data collected in various countries such as in Scandinavian countries and Australia, where population data has been published that shows patients which have lumpectomies with radiotherapy, especially node-negative patients, have better survival compared to mastectomy for the similar kind of cancer. We don't exactly know why this is the case. There's some guesswork going on, and I guess we'll never find out because you can't ethically do a trial to look into this. And even if we do a trial that will take 10 years to get an answer. So, we have to be mindful of the data.

In the past when patients would come with small cancers and say 'no, I want the mastectomy.' We used to say 'okay, patient choice, let's get on with it.' However, now, we take on extra effort to explain to the patient that this may not be the right option for them. We're now more careful in helping them choose the right option, and the right option, the majority of the time is lumpectomy. Mastectomy has now become, not the option we'd go to every time. We'll try and see if we can save the breast before we go down that route. In my practice, I'm doing less and less mastectomies nowadays.

What are the risks and benefits of different types of breast surgery?

Risks and benefits are all individual to patients, and we won't offer an operation that increases the risk of the cancer coming back. That's the whole point; that you get a treatment which is lasting longer. So, we have to be honest with patients and sometimes we have to make that difficult choice or decision to know that this is their only choice. Mastectomy is the only choice. However, we have to have that honest conversation with the patient, so it's very personalised.

Lumpectomy being right for a patient, or a mastectomy being right for a patient, and it all depends of the extent of the disease, presence or absence of genetic mutation and all those things. The emphasis is always that mastectomy isn't the default option. It's only an option when we've exhausted the choices of not to do a lumpectomy, or it isn't safe to do a lumpectomy. We won't offer a choice which will compromise the overall safety of the cancer treatment. 

What are the long-term risks of breast cancer surgery?

There's always a long-term risk to breast cancer surgery. These include:

• The cancer coming back

Statistically, 5 to 7 in 100 women who have breast cancer surgery, whether it's mastectomy or lumpectomy, it can come back in the same breast.

Anybody who has cancer can develop cancer in the opposite breast, and that's why we have regular mammograms even if the patient has a mastectomy on one side, to check the other side.

• The risk of cancer coming back elsewhere in the body.

The common places are the lung, liver and bones. So, we have an honest discussion with the patient. We tell them what we would class as a red flag sign; what to look out for. For example, if someone has had a lumpectomy and then a new lump is then found, or any new change which concerns them. If it's a mastectomy, we teach them how to look after the scar and if there are any lumps and bumps in the scar then they should ask for immediate review.

In the general body, there are some specific and non-specific symptoms that we teach them to look out for. For example, unexplained weight loss, unexplained symptoms like shortness of breath, headaches, abdominal pain, pain in the back or hips. Anything which is out of the ordinary which isn't treated by a simple paracetamol and goes away after a couple of days, needs to be brought to the attention of the clinician or the breast care nurses. So that, the right tests have begun. Hopefully, they make sure it isn't anything to worry about, but if there's anything that's coming up, we need to know and intervene as early as possible.

• Physical side effects

These are the physical side effects. However, we don't look at the physical side of the symptoms. There's also the mental health aspect to look for. It's equally important as physical health, and it could include wellbeing within the family, or a breakdown of the relationship which can happen. So, it's very important that if the patient does develop mental health issues, which could be dealing with aftermath of the treatment for example you can have chronic pain from surgery which can affect mental health.

You can have problems which come from long-term chemotherapy where patients can lose feeling in their hands and feet. Or, chronic fatigue. All of these things need to be evaluated.

There could be hair loss which can be from chemotherapy or hormone-blocking tablets. The biggest group of problems which women face is when they have tablets to block oestrogen in the body. That might aggravate symptoms of menopause, which can affect their mental and physical wellbeing, including their relationships. So, it's very important that patients are made aware that these are the possible things which may happen.

Radiotherapy is generally well tolerated, but there can be change in how the breast feels. It may feel more fibrous and firmer. Very rarely, there can be a secondary cancer which can develop called angiosarcoma. So, we have to tell patients to be on the lookout for those kinds of changes.

Because most patients end up having systemic treatment, the treatment affects not only locally in the breast but also the entire body and the mind.

Will I need reconstruction surgery after my breast surgery?

The word reconstruction has been used with mastectomy. As I said, we should as a default, offer all women undergoing mastectomy reconstruction. Reconstruction can be at the time of surgery, or it can be done in a delayed manner. Now, a lot of our patients are now taking up the offer of having reconstruction surgery immediately. This has some benefits, and also problems.

The benefit is that the patient doesn't go through a period without the breast mound and doesn't feel the loss of the breast.

However, in certain cases this may not be the best option for the patient. If the patient needs radiotherapy, and not all patients have a mastectomy with radiotherapy, then a reconstruction that may look and feel good to start with, may be affected by radiotherapy. Either they can choose to have a reconstruction without an implant using the tummy flap, or they can delay the reconstruction after they've had the radiotherapy. Then, it can start again.

Other areas where we find it difficult for patients to undergo reconstruction, is it's a big decision to make at the time when a cancer diagnosis has been made. Therefore, the patient may not feel it's the right time for them to make the decision.     

If you require breast cancer surgery, you can consult with Dr Chatterjee via his Top Doctors profile.