Mastectomy
Mastectomy is the surgical removal of all or part of the breast for the treatment or prevention of breast cancer. The size, location, and type of tumor are very important when choosing the best surgery to treat a woman's breast cancer. The size of the breast is also an important factor. A woman's psychological concerns, and her lifestyle choices should also be considered when decisions are made.
The severity of a cancer is evaluated according to a complex system called staging. This takes into account the size of the tumor, and whether it has spread to the lymph nodes, adjacent tissues, and/or distant parts of the body. Amastectomy is usually recommended for more advanced breast cancers. Women with earlier stage breast cancers, who could have breast conserving surgery, inwhich only the tumor and surrounding tissue are removed (called a lumpectomy), may decide to have a mastectomy.
There are many factors that make a mastectomy the treatment of choice. A large tumor is indicates a later stage of breast cancer, when the removal of theentire breast is recommended. In addition, large tumors are difficult to remove with good cosmetic results, especially if the woman has small breasts. Very rapidly growing breast cancers are usually treated with a mastectomy. Sometimes multiple areas of cancer are found in one breast, making removal of thewhole breast necessary. A cancer that has already attached itself to nearby tissues, such as the skin or chest wall, is most likely to be removed with a mastectomy. Breast conserving may also prove unsuccessful. The surgeon is sometimes unable to remove the tumor with a sufficient amount, or margin, of normal tissue surrounding it. The entire breast needs to be removed in this situation. Recurrence of breast cancer after a lumpectomy is another indication for mastectomy.
Radiation therapy is almost always recommended following a lumpectomy. If a woman is unable to have radiation, a mastectomy is the treatment of choice. Radiation therapy is not used in regnant women for fear of harming the fetus; women with certain collagen vascular diseases, such as systemic lupus erythematosus or scleroderma; and any woman who has had therapeutic radiation to thechest area for other reasons cannot tolerate additional exposure for breast cancer therapy.
The need for radiation therapy after breast conserving surgery may make mastectomy more appealing for nonmedical reasons. Some women fear radiation, and choose the more extensive surgery, so radiation treatment will not be required. The commitment of time, usually five days a week, for six weeks, may not beacceptable for other women.
Some women choose mastectomy because they strongly fear recurrence of the breast cancer, and lumpectomy seems too risky. The issue of prophylactic mastectomy, or removal of the breast to prevent future breast cancer, is controversial. Women with a strong family history of breast cancer and/or who test positive for a known cancer-causing gene may choose this option. Patients who havehad certain types of breast cancers that are more likely to recur may electto have the unaffected breast removed. Evidence suggests that this procedurecan decrease the chances of developing breast cancer, but it is not a guarantee that all breast tissue has been removed. Breast cancers have occurred after both breasts have been removed.
There are several types of mastectomies. The radical mastectomy, also calledthe Halsted mastectomy, is rarely performed today. It was developed in the late 1800s, when it was thought that more extensive surgery was most likely tocure cancer. A radical mastectomy involves removal of the breast, all surrounding lymph nodes up to the collarbone, and the underlying chest muscle. Womenwere often left disfigured and disabled, with a large defect in the chest wall and significantly decreased arm sensation and motion. Unfortunately, it isstill the operation many women inaccurately picture, when the word mastectomy is mentioned.
Surgery that removes breast tissue and some axillary or underarm lymph nodesand leaves the chest muscle intact is usually called a modified radical mastectomy. The most common type of mastectomy performed in the 1990s, the surgeryleaves a woman with a more normal chest shape than the older radical mastectomy procedure and a scar which is not visible in most clothing. It also allows for immediate or delayed breast reconstruction.
In a simple mastectomy, only the breast itself is removed. If a few of the axillary lymph nodes closest to the breast are also taken out, the surgery maybe called an extended simple mastectomy.
There are other variations on the term mastectomy. A skin-sparing mastectomyuses special techniques that preserve the patient's breast skin for use in reconstruction. Total mastectomy is a confusing expression, as it may be used to refer to a modified radical mastectomy or a simple mastectomy.
A mastectomy is typically performed in a hospital setting, but specialized outpatient facilities are sometimes used. The surgery is done under general anesthesia and may take from two to five hours. In the past, women often stayedin the hospital at least several days. Now many patients go home within a dayor two after their mastectomies.
Pain is usually well controlled with prescribed medication. Severe pain may be a sign of complications, and should be reported to the physician.
Exercises to maintain shoulder and arm mobility may be prescribed as early as24 hours after surgery. These help restore strength and promote good circulation.
Emotional care is another important aspect of recovery. Patients are often advised to seek counseling and/or support groups.
Additional treatment for breast cancer may be necessary after a mastectomy. Depending on the type of tumor, lymph node status, and other factors, chemotherapy, radiation therapy, and/or hormone therapy may be prescribed.
After mastectomy and axillary lymph node dissection, a number of complications are possible. A woman may experience decreased feeling in the back of her armpit, or other sensations including numbness, tingling, or increased skin sensitivity. Some women report phantom breast symptoms, experiencing itching, aching, or other sensations in the breast that has been removed. There may beinjury to the nerves controlling arm motion, resulting in decreased arm mobility.
Approximately 2-10% of patients develop lymphedema after axillary lymph noderemoval. This swelling of the arm, caused by faulty lymph drainage, can rangefrom mild to very severe. It can be treated with elevation, elastic bandages, and specialized physical therapy. A new technique called sentinel node biopsy, which may eliminate the need for removing many lymph nodes, is being tested.
Although mastectomy remains the definitive surgical treatment for breast cancer, research continues into non-surgical interventions, such as drug therapy.The most important research, however, may be the investigations into how toavoid or prevent breast cancer, which eliminates the need for a disfiguring mastectomy.
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