Breast Cancer Surgery options?

There are two main components of Breast cancer surgery. Surgical treatment involves:

1. Surgery on the breast

2. Surgery on the lymph nodes

Specifically in regards to the breast there are two main types of breast surgery:

1. Breast conservation surgery (Lumpectomy or Wide Local Excision)

2. Mastectomy

The surgery you need depends on various factors. The type of surgery does not determine if you will need chemotherapy. Some believe that having a mastectomy lowers the chances of needing chemotherapy, but this is incorrect. The tumour type will guide this decision.

What factors influence the ability to have Breast Conservation Surgery?

• Breast and tumour size

Removing over 10% of breast tissue can cause shape changes. Oncoplastic methods help maintain breast shape even if 20-30% is removed. Smaller breasts are more prone to shape changes and may need these methods. If a tumor takes up more than 30-40% of the breast, a mastectomy is often needed. Chemotherapy may be given before surgery to shrink the tumour, making oncoplastic surgery possible instead of a mastectomy.

• Number of tumours

If you have multiple tumours in the breast, called multifocal breast cancer, a mastectomy is needed. If there are more than two tumours, an MRI is usually done to see if there are indeed multiple tumours or just one larger tumour that wasn't clearly seen in the initial mammogram and ultrasound.

• Gene mutation

Younger patients with a confirmed BRCA 1 or 2 gene mutation may benefit from a mastectomy, even for small tumours. This option will be discussed with all patients under 40 who have a strong family history or a confirmed genetic mutation.

• Ability to have radiation

Breast conservation surgery includes removing the tumour and some healthy tissue (lumpectomy) followed by radiation therapy. If radiation isn't an option or you choose to skip it, you will need a mastectomy instead. A lumpectomy without radiation raises the chances of cancer coming back by 5 to 6 times in 5 years compared to those who have radiation. If you wish to avoid radiation, a mastectomy is advised.

What is breast conservation surgery?

Breast conservation surgery, also known as a lumpectomy, removes small cancers found early in the breast, often through Breastscreen. This procedure takes out the cancer with a little surrounding normal tissue, keeping most of the breast intact. The breast may appear similar afterward, although it might be slightly smaller and have a scar. Women who undergo a lumpectomy typically require radiotherapy on the remaining breast tissue to reduce the risk of cancer returning. About 70-80% of women are eligible for this type of surgery.

Why is breast radiation needed?

Breast radiotherapy (XRT) uses x-rays to treat breast tissue after breast-conserving surgery (BCS). This treatment usually lasts 3-6 weeks, Monday to Friday, at a radiation center. BCS removes cancer and some nearby tissue, helping avoid a full mastectomy for small cancers. However, leftover breast tissue has a high risk of cancer returning without treatment. XRT reduces this risk and offers results similar to a mastectomy while keeping a good appearance. If you select BCS, be ready for XRT to lower the chance of cancer coming back. 

5-year recurrence rates for Mastectomy and BCS

Mastectomy = 2 - 5%. (0.5 - 1% per year)

BCS + XRT = 5 - 7.5%. (1 - 1.5% per year)

BCS alone = 20-30%. (5 - 6% per year)

Why might I need more surgery to get a bigger margin?

Breast Conserving Surgery (BCS) seeks to remove breast cancer while keeping some healthy tissue. We aim to take out the least amount of healthy tissue to preserve appearance. The pathology report shows how well we removed the cancer and whether the edges (margins) are clear, close, or involved. An involved margin means cancer is at the edge, often needing a follow-up surgery called 'Cavity Re-excision' to remove more tissue. A close margin, found in about 20% of BCS cases, can be worrisome, as small margins may lead to cancer returning. However, effective radiotherapy has made smaller margins more acceptable. I will review your margins and discuss the need for more surgery. Typically, a margin larger than 1mm for breast cancer and 2mm for pre-cancerous DCIS is seen as acceptable, but each case is different.

Will I definitely avoid a mastectomy?

Choosing breast-conserving surgery (BCS) does not guarantee that a mastectomy won’t be needed later. While it's uncommon for BCS patients to require a mastectomy, it can occur if the cancer turns out to be larger than seen in your mammogram or ultrasound. This could mean more surgery is needed if not all the cancer is removed. In cases of smaller breast size, removing extra tissue might affect appearance and lead to a mastectomy and possible reconstruction. If this is necessary, Dr. Green will explain your options thoroughly.

What is Oncoplastic Breast Surgery?

Oncoplastic breast surgery is now the standard for breast cancer treatment. It involves removing cancer while applying plastic surgery techniques. The aim is to remove cancer and maintain or improve breast shape, even after significant tissue removal. Traditional surgery often resulted in noticeable scars and changes in appearance, reducing satisfaction and body image. Oncoplastic surgery aims to prevent these problems and may improve the overall experience of breast cancer treatment.

When should Oncoplastic Breast Surgery be done?

Oncoplastic breast surgery should be available to all patients and is standard practice in many parts of Australia. Dr. Green has years of experience with this technique due to its benefits. This type of surgery removes the cancer with some nearby healthy tissue, but studies show that taking out more than 7-10% of the breast can cause deformities. Oncoplastic surgery reduces this risk by preserving breast shape.

Even small amounts of tissue removal can change breast appearance, highlighting the importance of this approach. In the past, many surgeons only took out the tumor without reshaping the breast, which could lead to fluid buildup. This buildup might seem fine initially but can cause deformities later, especially after radiation, and is often wrongly blamed on radiation instead of the surgical method.

Oncoplastic Breast Conservation

Therapeutic breast reduction ; removal of the breast cancer using a breast reduction technique.

How are small cancers found at surgery?

If breast cancer is not detectable, a method is required to find it for surgery. Traditionally, a Hookwire is used, which is common for locating small cancers. Dr. Green now uses a radar reflector (SCOUT locator) at St Andrew’s War Memorial Hospital for improved accuracy. The SCOUT reflector, about the size of a grain of rice, is placed in the tumor through imaging a few days before surgery. During the procedure, a radar probe identifies the reflector, giving Dr. Green real-time information about the tumor’s location and distance. This tool is precise to 1mm, allowing for exact tumor removal with minimal additional tissue, reducing deformity and further surgeries. SCOUT localization is exclusive to St Andrew’s; elsewhere, Dr. Green uses Hookwire localization. If needed, after completing hospital paperwork, a Hookwire is placed in the radiology suite to help Dr. Green locate the tumor. After removal, the specimen is x-rayed to ensure the lesion was extracted.

Hookwire localisation

SCOUT Radar Localisation

What happens after my operation?

You will typically stay in the hospital for one night following your breast conservation surgery. The operation is usually not painful, thanks to the advanced techniques and attentive care provided by our team. Throughout your recovery, you will need to wear a special supportive bra both day and night until your follow-up appointment. Detailed information regarding the appropriate bras will be provided during your initial appointment. Once you have had sufficient time to recover, you will return in about a week to discuss your test results, any additional treatments that may be necessary, and to have your dressings removed in a comfortable and supportive environment.