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The majority of women with breast cancer will undergo surgery as part of their cancer treatment. The standard types of breast surgery include:  lumpectomy and mastectomy.   In some cases, women will receive adjuvant (additional) treatment to stop cancer growth, spread, or recurrence. Types of adjuvant therapies include: chemotherapy, radiation therapy,   and drug treatments. Occasionally women may be treated with chemotherapy, radiation, or drugs without having breast surgery.

Staging is the process physicians use to assess the size and location of a patient's cancer. Identifying the cancer stage is one of the most important factors in selecting treatment options. Several tests may be performed to help stage breast cancer including clinical breast exams and certain imaging tests such as a chest x-ray, mammogram, bone scan,  CT scan, and MRI scan.   The TMN classification system is the most common staging system used today. The TMN system categorizes a patient's  breast cancer by its tumor size, palpable lymph nodes, and metastasis (spread).

Pathologists (physicians who conduct laboratory studies of tissues and cells) often assign a histologic grade to a patient's cancerous breast tumor to identify the type of tumor present and help determine the patient's outcome. Three features are closely observed when determining a cancer's grade: the frequency of cell mitosis (rate of cell division), tubule formation (percentage of cancer composed of tubular structures), and nuclear pleomorphism (change in cell size and uniformity).

Lumpectomy  is the surgical removal of a breast lump and a surrounding margin of normal breast tissue. Lumpectomy usually does not significantly alter the physical appearance of the breast. Mastectomy is the surgical removal of an affected breast and often some or all of the axillary (underarm) lymph nodes and pectoral (chest) muscles. Breast reconstruction is possible in most cases after mastectomy.

Many women are faced with the choice between mastectomy or lumpectomy. Though both mastectomy and lumpectomy have equal survival rates, there are advantages and disadvantages to both procedures. Lumpectomy may preserve the physical appearance of the breast but usually requires six to seven weeks of radiation therapy. Mastectomy may reduce local recurrence of breast cancer, but additional decisions about breast reconstruction are introduced. Also, some women may be better candidates for mastectomy than lumpectomy or vice versa depending on their individual medical situation.

Axillary node dissection is the surgical removal of some or all of the lymph nodes under a woman's arm. Axillary node dissections are usually performed on women who undergo mastectomy or lumpectomy. After surgery, the axillary lymph nodes are examined under a microscope to determine whether the cancer has spread past the breast and to evaluate treatment options. The most common side effect of axillary node dissection is lymphedema, chronic swelling of the arm (though lymphedema occurs in less than 10% of breast cancer patients).

Sentinel node biopsy is a procedure in which only the sentinel lymph node (the first node in the lymphatic chain) is removed to evaluate breast cancer metastasis (spread). Sentinel node biopsy can eliminate the need to remove all of the underarm lymph nodes when staging breast cancer and results in less pain and complications versus traditional axillary lymph node dissection.

The side effects of breast surgery vary from woman to woman. In general, the recovery period for lumpectomy is shorter than for mastectomy. Lumpectomy patients usually spend one to two days in the hospital while mastectomy patients spend two to three days (although some may spend up to eight days in the hospital). Major soreness from breast surgery usually disappears after a few days.

Common side effects that may occur after lumpectomy include:

• temporary swelling of the breast
• breast tenderness
• hardness due to scar tissue that forms at the surgical site
• seroma (clear fluid trapped in the wound)

Common side effects that may occur after mastectomy include:

• hematoma (blood trapped in the wound)
• seroma (clear fluid trapped in the wound)
• temporary to permanent limitations of arm/shoulder movement (lymphedema) if lymph nodes are removed during the operation
• numbness in the upper-arm skin

Breast reconstruction is a surgical procedure to rebuild the contour of the breast, along with the nipple and areola (the pigmented area surrounding the nipple) if desired. Recent advances in reconstructive techniques have given patients more choices when it comes to breast reconstruction, including the option to have breast reconstruction during the same operation in which the breast is removed.

The two main types of breast reconstruction available to most mastectomy patients are saline breast implants and muscle flap reconstruction. Implant surgery usually requires placing a tissue expander in the intended breast area beneath the skin and chest muscle until the skin is sufficiently stretched before a permanent implant may be placed. Muscle flap reconstruction involves using a patient's own tissue to rebuild the contour of the breast. Tissue may be taken from the back, stomach, or buttocks.

The most common complication with breast implants is capsular contracture the scar or capsule around the implant begins to tighten and squeezes down on the soft implant, causing the breast to feel hard. Capsular contracture may be treated with additional surgery to remove the scar tissue. Other less common complications from general surgery that may also occur during breast reconstruction include: bleeding, fluid collection, excessive scar tissue, infection, and problems with anesthesia.

Radiation therapy uses high-energy rays to stop breast cancer cells from growing and dividing. Ionizing radiation deposits energy in the area being treated that injures cancer cells by damaging genetic material and inhibiting growth. Although radiation damages both cancer cells and normal cells, normal cells are usually able to repair themselves and function properly after radiation.

Radiation is usually started several weeks after lumpectomy, allowing ample time for the breast to heal. If the woman is also having chemotherapy as part of treatment, the physician will sometimes begin chemotherapy prior to starting radiation therapy.

Common side effects of radiation therapy such as breast soreness, swelling, reddening of the breast skin, a feeling of heaviness in the breast, fatigue, and loss of appetite usually go away within four to six weeks after radiation begins. Other less common side effects of radiation such as slight darkening of the breast skin, enlargement of the breast skin pores, increased or decreased sensitivity of the breast skin, a thickening of the breast skin or tissue, or a change in size of the breast tend to last several months.

Chemotherapy is treatment with anticancer drugs and is normally administered intravenously (through the vein) or orally in the form of pills or liquid. Chemotherapy may be used alone or in conjunction with lumpectomy or mastectomy to treat breast cancer patients. Chemotherapy is a systemic form of treatment; it flows through the bloodstream, affecting the entire body. Its purpose is to interfere with the DNA synthesis of cancer cells. The appropriate combination of drugs used during chemotherapy will be determined by the patient's cancer treatment team, based on the individual medical situation and cancer tumor characteristics.

The most common side effects of chemotherapy are nausea and vomiting, hair loss (alopecia), and fatigue. Additional side effects that may occur in some women include: infection, anemia, increased blood clotting, mouth sores, nervous system problems, skin and nail problems, kidney and bladder infections, flu-like symptoms, fluid retention, or irregular menstrual periods. It is important to remember that side effects vary greatly from individual to individual. Some patients experience few if any adverse effects from drug treatment. Generally, most side effects go away after chemotherapy has ended.

Tamoxifen is a drug commonly used to help treat (and in some case instances, prevent) breast cancer. By blocking estrogen in the breast, tamoxifen helps slow the growth and reproduction of breast cancer cells. For decades, tamoxifen has been used to help treat advanced breast cancer. More recently, it has been used to treat early stage breast cancer after breast surgery (lumpectomy or mastectomy). Common side effects of tamoxifen include hot flashes, irregular menstrual cycles, unusual vaginal discharge or bleeding, and irritation of skin around vagina.

The prescribed length of time women should take tamoxifen varies depending on the specific medical situation. Most women take tamoxifen for two to five years. Click here for more information about tamoxifen.

Other than tamoxifen, physicians use several other drugs to help treat breast cancer. These drugs include:

• Herceptin:  used to treat breast cancer patients who show an excess of the HER2 receptor
• Ellence:  used in conjunction with chemotherapy (cyclophosphamide and fluorouracil) to treat early stage breast cancer
• Taxol:  used to treat early and advanced stages of breast cancer
• Docetaxel:  used in conjunction with chemotherapy to treat advanced breast cancer
• Aromasin:  used in post-menopausal breast cancer patients with advanced breast cancer
• Arimidex:  used in post-menopausal breast cancer patients with advanced breast cancer

Click here for more information on these and other drugs used to treat breast cancer.

The signs of a breast cancer recurrence are often that same as the initial warning signs for breast cancer. These signs include breast lumps, thickenings, discoloration, and swollen lymph glands. Women who notice any breast abnormalities should notify their physician as soon as possible.

If cancer recurs after lumpectomy, patients may often be treated by mastectomy. If cancer recurs after mastectomy, additional surgery may be necessary to remove tumors near the mastectomy site. Radiation therapy will usually follow any additional surgery. Chemotherapy and/or hormonal therapy (drugs) may also be administered.

• To learn more about breast cancer treatment, please visit the main menu on breast cancer treatment at http://www.imaginis.com/breasthealth/menu-treatment.asp

Updated: October 18, 2009

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