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COMMON QUESTIONS ABOUT BREAST CANCER: WHAT KINDS OF SURGERIES ARE AVAILABLE?

At one time most women with breast cancer were given few choices about the extent of surgery that could be performed to remove a breast cancer. Today there are many choices, and they are not always easy. Although the doctor may make recommendations, the final decision is often left to the patient. She therefore needs to be well informed on what types of surgery are available and the advantages and disadvantages of each. She should ask her doctor for a definition of each type of surgery, the amount of tissue that will be removed, the potential for reconstructive breast surgery, the additional therapy that may be necessary, and the risk of cancer recurrence following the surgery. In actuality, the surgical cure rate is strongly dependent on the stage of breast cancer diagnosed in the patient. At stage I, the cure rate is 90 to 100 percent; at stage II, 60 to 90 percent; at stage III, 20 to 30 percent; and at stage IV, it is O.

There are two types of surgery, a lumpectomy and a partial mastectomy, that do not remove large portions of the breast. In a lumpectomy, only the cancerous lump is excised—although the doctor may also remove a number of axillary lymph nodes (in the armpit on the same side as the breast lump) to check for the spread of cancer. In a partial mastectomy, the cancerous lump and some of the normal tissues surrounding it are removed. Again, several lymph nodes in the armpit are removed and checked for cancer. Both surgeries tend to be good options for large-breasted women with small tumors; they avoid total breast amputation, reduce the pain and discomfort associated with the more extensive operations, cause less destruction of muscle tissue, and induce less swelling subsequent to surgery. For smaller-breasted women these procedures are not always a satisfactory option, in that removal of a portion of the breast may significantly change its size or shape. This type of surgery is also inappropriate for women with multiple cancerous lumps or women whose tumors involve the underlying muscle.

If your doctor recommends either of these operations, ask how many of them he or she has performed. Will the doctor be removing any lymph nodes to check for the spread of cancer; if not, how can he or she be sure that the cancer has not spread to the lymph nodes? How disfiguring will the surgery be? Is the risk that the cancer will spread any greater with the chosen procedure?

Typically, both of these surgeries are followed by radiation therapy, a treatment that helps reduce the likelihood of cancer recurrence and is considered necessary postsurgical follow-up. The initial radiation treatment is given over a 30-minute period daily for four to six weeks. A subsequent treatment, a few weeks later, consists of daily dosages for approximately a week. If you will undergo radiation therapy, be aware of the added time and expense, and discuss these matters with your doctor when considering your options.

The doctor may suggest a mastectomy instead of these less invasive procedures. In this surgery the entire cancerous breast is removed. The doctor's selection of this alternative will be based on several factors: the size of the tumor, its location, the type of tumor, the size of your breasts, and whether the cancer has spread to the lymph nodes or elsewhere. If your doctor recommends a mastectomy, several further options must be considered. They differ primarily in the amount of other normal tissue (muscle, lymph nodes, fat) that is removed in addition to the breast itself. The most common variants are simple mastectomy, modified radical mastectomy, and radical mastectomy.

A simple mastectomy removes the entire breast but leaves the underlying muscle tissue intact. Typically, a number of lymph nodes are removed to check for the spread of cancer.

A modified radical mastectomy is a common procedure that removes the entire breast including the tissue lining over the muscles of the chest, and sometimes the muscle itself. The lymph nodes of the armpit are taken out, which may lead to some swelling after surgery. A modified radical mastectomy is frequently used to treat women with early-stage breast cancer, particularly those whose breasts are medium to small in size.

A radical mastectomy is by far the most disfiguring surgery and is performed much less frequently than the other two operations. This surgery removes the breast, the muscles of the chest that support the breast, the fatty tissue of the chest and armpit, and all the lymph nodes of the armpit. The patient is left with reduced muscle strength in the arm, significant pain and swelling, and major disfigurement of the chest.

Should your doctor suggest any of these procedures, ask about the degree of disfigurement that may result, and about the potential for reconstructive surgery later on. In general, the more tissue that remains, the easier the reconstructive surgery will be. Therefore, reconstructive surgery following a radical mastectomy can be rather difficult. If your doctor has recommended a radical mastectomy, ask if it is absolutely necessary. Consider getting a second opinion, preferably from a surgical oncologist associated with a large medical center. Most physicians today believe they can achieve equivalent results by performing a much less extensive modified radical mastectomy.

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