About Breast Cancer and Treatment...

General Information

In the treatment of breast cancer there are two major considerations.  The first issue is treatment of the breast so that the cancer is removed, and there is little chance of recurrence in the breast.  The second main issue is to decide whether it is likely that the breast cancer will spread to other areas of the body. This is found out by taking lymph nodes from the armpit and seeing if they are involved.

After consideration of your individual situation, a recommendation for treatment will be discussed with you. If you have a cancer that is confirmed through biopsy, this recommendation will likely include one of the following surgeries.

Lumpectomy (also called Wide Local Excision)

Excision of only the cancerous breast lump (a lumpectomy) instead of all of the breast has been an important improvement in the care of breast cancer. This usually has to be combined with radiotherapy to the breast. The lymph nodes in the armpit (axilla) are removed at the same time, usually through a separate cosmetic incision. For most patients a lumpectomy with removal of lymph nodes from the armpit (axillary dissection) combined with x-ray treatments, has the same cure rate as when the entire breast is removed. The major advantage of this treatment is that the breast is retained. 

Modified Radical Mastectomy

Modified radical mastectomy is removal of the whole breast as well as the lymph nodes in the armpit (axilla). This is done when the cancer cannot be removed by a smaller operation such as a lumpectomy. If a modified radical mastectomy is performed, usually radiotherapy is not required.

Common Signs and Symptoms

• Early breast cancer often has no symptoms
• There may be mild discomfort near the tumor
• Often a breast lump is discovered by chance while taking a shower, dressing, or doing a breast self-examination, or by a physician during a routine examination
• A mammogram shows a suspicious abnormality, but nothing can be felt
• Any new breast lump deserves investigation. This is why it is so important for patients to perform breast self exam.

Diagnosis

Breast cancer diagnosis is confirmed by a pathologist looking at the tissue under the microscope. This tissue can be obtained in several ways:

• Needle aspiration, when a fine needle is used to take a tiny piece of tissue under local anesthesia. This can be done by palpation or under ultrasound guidance in the office
• An open biopsy is done under local anesthesia or under heavy sedation
• A mammogram technique is used to localize the lesion and take a sample of the tissue
• Rarely we perform a biopsy with a frozen section. If this shows cancer then a definitive surgical procedure can be performed at the same time. The entire operation can be done in one step while you are asleep under anesthesia. The biopsy is performed, and while you are kept asleep a quick examination is made of the tissue in the laboratory. If the diagnosis is cancer, the remainder of the operation is completed.

It may take one or two days to get results back from the pathologist.

Preparing for Surgery

• Most patients have blood tests, urine tests, an EKG, and a chest x-ray
• Under certain circumstances a bone scan is done to be certain there is no tumor in the bones
• It is important to fast for 8 hours before your operation, usually this means eating nothing after midnight the day before
• Regarding your usual medications the morning of surgery:
  ­ Definitely take any medicine to treat a heart condition, except blood thinners 
  ­ Do not take insulin or pills to lower your blood sugar.  If you are diabetic, your blood sugar will be checked on admission to the hospital and regulated at that time. 
  ­ Do not take Coumadin, or other blood thinners. This medication should be stopped three to five days prior to surgery. Be sure to ask us about this if you are taking it.
  ­ Other prescribed medications may be taken as directed.
  ­ Pills may be taken with sips of water.
• If you are a smoker, do not smoke the morning of the operation.
• You should shower on the morning of the operation.

The Operation

• The operation is done under general anesthesia. (You will be asleep).
• For a Lumpectomy (Wide Local Excision), there is generally an incision over the tumor and another one in the armpit. Sometimes these incisions can be combined. The guiding principle in making the incisions is to make them least visible while adequately removing the cancer.
• For a Modified Radical Mastectomy, there is generally one incision over the breast which goes up towards the armpit.
• The removed breast tissue and lymph nodes are sent to the laboratory to be examined by a pathologist.
• Surgery takes between one and two hours.
• It is rare to receive a blood transfusion.

Following Surgery

• You will wake up in the recovery room. When your blood pressure, pulse and breathing become stable, you will be taken to a regular hospital room.
• Pain is usually easily controlled with pills.
• Your stay in the hospital will only be overnight. Some patients can go home the same day if their surgery starts early enough in the morning.
• Usually a drain is placed in the armpit. It is easy to care for and you will be given instructions. It will be removed in the office several days after your surgery.
• You will have a visiting nurse if necessary.
• Do not start any arm exercises until you are shown how to do them by the surgeon.
• The need for any hormones or chemotherapy will be determined after all the laboratory tests on the removed tissue are completed.
• Serious complications are uncommon. Rarely patients have infection in the incision. More commonly there is a collection of fluid in the armpit which can be removed in the office with a needle. The major problem is swelling of the arm which occurs less than five percent of the time.
• The pathology report is important. It will be discussed with you in the office. Important factors in prognosis (whether the cancer is likely to recur) include whether the lymph nodes are involved, whether the tumor is estrogen and progesterone receptor positive, whether the tumor has a tendency to invade blood vessels, and whether there is a lot of abnormal breast tissue near the cancer. Some patients should have chemotherapy after surgery, depending upon the final pathology report.

At Home After Surgery

• You may walk about as you wish, even climb stairs.
• Unless instructed otherwise, you may shower as you wish, with any dressings on or off. There may be narrow strips of tape across the incision. It is all right if they get wet; they will be removed in the doctor's office. After you dry yourself, replace any dressings with clean, dry ones.
• Even though many of the lymph nodes were removed, enough of them remain in other parts of the axilla and above the collar bone to drain the arm. To preserve the remaining lymph nodes, try to protect the arm. Even dirty scratches, splinters, needle sticks to draw blood, or repeated hard work with the arm could cause infection or injury
• X-rays to the axilla: You will not receive any x-ray treatments to your armpit area.
• Occasionally there will be some swelling of the hand or forearm. There are treatments for this.
• Take medicine as prescribed for your pain.
• If you had a Lumpectomy, wearing a loose bra at bedtime may make you more comfortable, mostly by keeping your breasts from moving around too much as you shift during sleep.
• Driving a car with an automatic shift may not seem too demanding. However, you may have to slam on brakes or twist to turn the steering wheel and may strain your sutures or tear something. During your follow-up visit let's discuss when you can resume driving.
• You may resume sexual activity whenever you choose.

Call our office if...

• The incision on the breast or axilla becomes swollen or red, or there is drainage from it.
• You develop a temperature higher than 100.7 °F
• You have any questions.

Follow-up Treatments

If you had a lumpectomy, arrangements will be made for the routine x-ray treatments to your breast starting 4 to 6 weeks after the operation, after everything has healed satisfactorily.  The x-ray treatments will be given to you daily on an outpatient basis (five times per week) for 5 to 6 weeks.