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Surgery is usually the first treatment for breast cancer, although in some cases chemotherapy or hormone therapy may be offered first to begin treating the whole body or to shrink the tumour so that surgery can be less extensive, or even avoided altogether.
One of the first decisions you may have to make is which type of operation you'll have. You may be offered a choice of breast conserving surgery or a total mastectomy.
Breast conserving surgery ranges from lumpectomy or wide local excision (in which the tumour is removed with a small amount of surrounding tissue, sometimes referred to as a margin), to quadrantectomy in which about a quarter of the breast is removed.
Total mastectomy means all breast tissue is removed, including the nipple. This can either be simple mastectomy, which removes the breast tissue alone, or modified radical mastectomy where your whole breast is removed and, occasionally, part of the muscle on the chest wall.
More than half of early stage breast cancers can now be treated with breast conserving surgery, usually followed by radiotherapy.
Studies show that in the long-term, breast conserving surgery, followed by radiotherapy, is as successful as total mastectomy.
The type of breast conserving surgery you have will be based on the type of cancer, the size of the tumour, where it is in your breast and how much surrounding tissue needs to be removed. It will also depend on how large your breasts are.
The surgeon will want to give you the best cosmetic result possible as well as the most effective surgery. That means keeping as much as possible of your breast without increasing the risk of the cancer coming back.
Your surgeon may recommend the removal of the whole breast. Total mastectomy can be the better option when:
For invasive breast cancer, it's recommended that some or all of the lymph nodes in the axilla (armpit) be removed to see whether or not they contain any cancer cells. Knowing whether lymph nodes are affected is important in helping your specialist team decide on any additional treatments to surgery.
On average there are between 20 and 30 lymph nodes in the armpit. Between four and ten of them will usually be removed to check whether they are involved but this figure varies.
Occasionally your surgeon may advise you that you don’t need to have any lymph nodes removed when you have the tumour removed from your breast.
Sentinel node biopsy is a diagnostic procedure to find out if the breast cancer has spread to the lymph nodes in the axilla. It involves injecting a small amount of radioactive material and a dye into the body to identify the first – or ‘sentinel’ – node (or nodes) to receive lymph fluid from the tumour. If the sentinel node is clear of cancer cells it usually means that the other nodes are clear too so no more will need to be removed. However, sentinel node biopsy is not appropriate for everyone and your surgeon will discuss whether or not this procedure is an option for you.
This technique is rapidly becoming the standard of care for patients with small cancers when the surgeon can't feel any enlarged lymph nodes in the armpit. This means that removal of all the lymph nodes under the arm could be avoided for those patients whose nodes are clear. However, it will be a few years before all surgeons are trained in this technique and it's not a suitable procedure for everyone.