Mastectomy is the surgical removal of the breast for the treatment or prevention of breast cancer.
Purpose
Mastectomy is performed as a surgical treatment for breast cancer. The severity of a breast 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. A mastectomy is usually the recommended surgery for more advanced breast cancers. Women with earlier stage breast cancers, who might also have breast-conserving surgery (lumpectomy), may choose to have a mastectomy. In the United States, approximately 50, 000 women a year undergo mastectomy.
The size, location, and type of tumor are important considerations when choosing the best surgery to treat breast cancer. The size of the breast is also an important factor. A woman's psychological concerns and lifestyle choices should also be considered when making a decision.
There are many factors that make a mastectomy the treatment of choice for a patient. Large tumors are difficult to remove with good cosmetic results. This is especially true if the woman has small breasts. Sometimes multiple areas of cancer are found in one breast, making removal of the whole breast necessary. The surgeon is sometimes unable to remove the tumor with a sufficient amount, or margin, of normal tissue surrounding it. In this situation, the entire breast needs to be removed. 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. Pregnant women cannot have radiation therapy for fear of harming the fetus. A woman with certain collagen vascular diseases, such as systemic lupus erythematosus or scleroderma, would experience unacceptable scarring and damage to her connective tissue from radiation exposure. Any woman who has had therapeutic radiation to the chest 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 be acceptable for other women. This may be due to financial, personal, or job-related factors. In geographically isolated areas, a course of radiation therapy may require lengthy travel and perhaps unacceptable amounts of time away from family or other responsibilities.
Some women choose mastectomy because they strongly fear recurrence of the breast cancer, and lumpectomy seems too risky. Keeping a breast that has contained cancer may feel uncomfortable for some patients. They prefer mastectomy, so the entire breast will be removed.
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 to have both breasts removed. Patients who have had certain types of breast cancers that are more likely to recur may elect to have the unaffected breast removed. Although there is some evidence that this procedure can decrease the chances of developing breast cancer, it is not a guarantee. It is not possible to be certain that all breast tissue has been removed. There have been cases where breast cancers have occurred after both breasts have been removed. However, a 1999 survey of over 500 women found that 70% of women who chose prophylactic mastectomy were satisfied with the procedure.
Precautions
The decision to have mastectomy or lumpectomy should be carefully considered. It is important that the woman be fully informed of all the potential risks and benefits of each surgical treatment before making a choice.
Description
There are several types of mastectomies. The radical mastectomy, also called the Halsted mastectomy, is very rarely performed today. It was developed in the late 1800s, when it was thought that more extensive surgery was most likely to cure cancer. A radical mastectomy involves removal of the breast, all surrounding lymph nodes up to the collarbone, and the underlying chest muscle. Women were often left disfigured and disabled, with a large defect in the chest wall requiring skin grafting, and significantly decreased arm sensation and motion. Unfortunately, and inaccurately, it is still the operation many women picture when the word mastectomy is mentioned.
Surgery that removes breast tissue, nipple, an ellipse of skin, and some axillary or underarm lymph nodes, but leaves the chest muscle intact, is usually called a modified radical mastectomy. This is the most common type of mastectomy performed today. The surgery leaves a woman with a more normal chest shape than the older radical mastectomy procedure, and a scar that is not visible in most clothing. It also allows for immediate or delayed breast reconstruction.
In a simple mastectomy, only the breast tissue, nipple, and a small piece of overlying skin is removed. If a few of the axillary lymph nodes closest to the breast are also taken out, the surgery may be called an extended simple mastectomy.
There are other variations on the term mastectomy. A skin-sparing mastectomy uses special techniques that preserve the patient's breast skin for use in reconstruction, although the nipple is still removed. Total mastectomy is a confusing expression, as it may be used to refer to a modified radical mastectomy or a simple mastectomy.
Many women choose to have breast reconstruction performed in conjunction with the mastectomy. The reconstruction can be done using a woman's own abdominal tissue, or using saline-filled artificial expanders, which leave the breast relatively flat but partially reconstructed. Additionally, there are psychological benefits to coming out of the surgery with the first step to a reconstructed breast. Immediate reconstruction will add time and cost to the mastectomy procedure, but the patient can avoid the physical impact of a later surgery.
A mastectomy is typically performed in a hospital setting, but specialized outpatient facilities are sometimes used. The surgery is done under general anesthesia. The type and location of the incision may vary according to plans for reconstruction or other factors, such as old scars. As much breast tissue as possible is removed. Approximately 10 to 20 axillary lymph nodes are usually removed. All tissue is sent to the pathology laboratory for analysis. If no immediate reconstruction is planned, surgical drains are left in place to prevent fluid accumulation. The skin is sutured and bandages are applied.
The surgery may take from two to five hours. Patients usually stay at least one night in the hospital, although outpatient mastectomy is increasingly performed for about 10% of all patients. Insurance usually covers the cost of mastectomy. If immediate reconstruction is performed, the length of stay, recovery period, insurance reimbursement, and fees will vary from mastectomy alone. In 1998, the Women's Health and Cancer Rights Act required insurance plans to cover the cost of breast reconstruction in conjunction with a mastectomy procedure.
Preparation
Routine preoperative preparations, such as not eating or drinking the night before surgery, are typically ordered for a mastectomy. On rare occasions, the patient may also be asked to donate blood in case a blood transfusion is required during surgery. The patient should advise the surgeon of any medications she is taking. Information regarding expected outcomes and potential complications should also be a part of preparation for a mastectomy, as for any surgical procedure. It is especially important that women know about sensations they might experience after surgery, so they are not misinterpreted as a sign of poor wound healing or recurrent cancer.
Aftercare
In the past, women often stayed in the hospital at least several days. Now many patients go home the same day or within a day or two after their mastectomies. Visits from home care nurses can sometimes be arranged, but patients need to learn how to care for themselves before discharge from the hospital. Patients may need to learn to change bandages and/or care for the incision. The surgical drains must be attended to properly; this includes emptying the drain, measuring fluid output, moving clots through the drain, and identifying problems that need attention from the doctor or nurse. If the drain becomes blocked, fluid or blood may collect at the surgical site. Left untreated, this accumulation may cause infection and/or delayed wound healing.
After a mastectomy, activities such as driving may be restricted according to individual needs. Pain is usually well controlled with prescribed medication. Severe pain may be a sign of complications, and should be reported to the physician. A return visit to the surgeon is usually scheduled seven to ten days after the procedure.
Exercises to maintain shoulder and arm mobility may be prescribed as early as 24 hours after surgery. These are very important in restoring strength and promoting good circulation. However, intense exercise should be avoided for a time after surgery in order to prevent injury. The specific exercises suggested by the physician will change as healing progresses. Physical therapy is an integral part of care after a mastectomy, aiding in the overall recovery process.
Emotional care is another important aspect of recovery from a mastectomy. A mastectomy patient may feel a range of emotions including depression, negative self-image, grief, fear and anxiety about possible recurrence of the cancer, anger, or guilt. Patients are advised to seek counseling and/or support groups and to express their emotions to others, whether family, friends, or therapists.
Assistance in dealing with the psychological effects of the breast cancer diagnosis, as well as the surgery, can be invaluable for women.
Measures to prevent injury or infection to the affected arm should be taken, especially if axillary lymph nodes were removed. There are a number of specific instructions, all directed toward avoiding pressure or constriction of the arm. Extra care must be exercised to avoid injury, to treat it properly if it occurs, and to seek medical attention promptly when appropriate.
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.
Risks
Risks that are common to any surgical procedure include bleeding, infection, anesthesia reaction, or unexpected scarring. 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 be scarring around where the lymph nodes were removed, resulting in decreased arm mobility and requiring more intense physical therapy.
Approximately 10% to 20% of patients develop lymphedema after axillary lymph node removal. This swelling of the arm, caused by faulty lymph drainage, can range from mild to very severe. It can be treated with elevation, elastic bandages, and specialized physical therapy. Lymphedema is a chronic condition that requires continuing treatment. This complication can arise at any time, even years after surgery. A new technique called sentinel lymph node mapping and biopsy, which may eliminate the need for removing many lymph nodes, is being tested.
Normal results
A mastectomy is performed as the definitive surgical treatment for breast cancer. The goal of the procedure is that the breast cancer is completely removed and does not recur.
Abnormal results
An abnormal result of a mastectomy is the incomplete removal of the breast cancer or a recurrence of the
cancer. Other abnormal results include long-lasting (chronic) pain or impairment that does not improve after several months of physical therapy.
Resources
BOOKS
Berger, Karen J., and John Bostwick III. A Woman's Decision: Breast Care, Treatment and Reconstruction. St. Louis, MO: Quality Medical Publishing, 1998.
Robinson, Rebecca Y., and Jeanne A. Petrek. A Step-by-Step Guide to Dealing With Your Breast Cancer. New York:Carol Publishing Group, 1999.
Zuckweiler, Rebecca. Living in the Postmastectomy Body: Learning to Live in and Love Your Body Again. Point Roberts, WA: Hartley and Marks, 1998.
PERIODICALS
Frost, Marlene, et al. "Long-term Satisfaction and Psychological and Social Function Following Bilateral Prophylactic Mastectomy." Journal of the American Medical Associa tion (20 July 2000): 319-24.
Lynden, Patricia. "Your Breasts or Your Life." American Health for Women (16 June 1997): 29-31.
ORGANIZATIONS
American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA30329-4251. (800) 227-2345. <http://www.cancer.org>.
National Lymphedema Network. 2211 Post St., Suite 404, SanFrancisco, CA 94115-3427. (800) 541-3259 or (415) 921-1306. <http://www.wenet.net/~lymphnet/>.
Y-ME National Organization for Breast Cancer Informationand Support. 18220 Harwood Ave., Homewood, IL 60430.24-hour hotlines: (800) 221-2141 or (708) 799-8228.
