The majority of breast cancer begins in the ducts that carry milk from the milk-producing lobules to the nipple. These are called Invasive Ductal Carcinoma and Non-invasive Ductal Carcinoma, also called Ductal Carcinoma In Situ (DCIS). Invasive cancer implies that it has the ability to spread outside the breast, and the first place it tends to go is to the lymph nodes underneath the arm. Non-invasive breast cancer is confined within the ducts in the breast and rarely has the ability to leave the breast.
There are several different stages of breast cancer and these are determined by multiple factors. The TNM system classifies malignancies, to determine their associated survival statistics, which varies between different types of cancers. First, is the size or tumor (T) stage. Second is the nodal (N) stage, which is determined by discovering if cancer has spread to the nearby lymph nodes. Lastly, is the metastatic (M) stage, which is deemed 0 or 1, and is based on the fact that cancer has not or has spread to other areas of the body, respectively. For breast cancer, doctors use physical exam findings, imaging (mammogram, ultrasound, MRI, CT or PET) and biopsy information to determine what your “clinical stage” is. Recently, the “prognostic markers” have been added to this staging system to help predict prognosis. These markes are different for each person’s cancer and are determined by testing the biopsy specimen for expression of estrogen, progesterone and HER2 receptors. This information is combined with the standard TNM information after surgery to determine your final stage of breast cancer.
In general, there are two surgeries to treat breast cancer. The first is called breast-conserving surgery and involves removal of the tumor with normal tissue around it, called a lumpectomy or partial mastectomy. The tumor will be sent to a pathologist, who examines the mass under a microscope to make sure that the entire tumor has been removed with negative (or clear) margins. If it is discovered that the tumor is close to or involving one of the margins, another operation may be required in order to make sure the entire cancer is removed. This only occurs around 10-15% of the time. In most cases, if breast-conservation is chosen, radiation treatments will be given after a lumpectomy, to prevent the cancer from coming back in the location it was before. The other surgery that may be offered is a mastectomy, which is where the entire breast is removed. This can be done with or without breast reconstruction, which is typically started at the time of the mastectomy and completed at a later date. For the majority of cases, radiation is not necessary after a mastectomy for early-stage breast cancer, but there are some scenarios where it is. These are when the tumor is >5cm, involves the skin or chest wall, or when surgery shows that the cancer is involving multiple lymph nodes.
When you are diagnosed with breast cancer, it is important to determine if any of the lymph nodes are involved, because breast cancer tends to spread first to the axillary lymph nodes under the arm. This is done with a procedure called a sentinel lymph node biopsy, which is a targeted sampling of the “first” lymph nodes that drain the breast. Your surgeon will likely use a radioactive tracer, a blue dye, or both to perform this procedure, which are taken up by the lymphatic vessels, and trace to the lymph nodes. A small incision is made under the arm and your surgeon has a way of specifically identifying these nodes and removes them for testing by the pathologist. If the “first nodes” that drain the breast do not contain breast cancer, it is very unlikely that the rest of the nodes will and no more nodes will be removed. The rationale behind doing it this way is to avoid a procedure called an axillary lymph node dissection, which used to be done for all breast cancer patients, and increases the risk of lymphedema, or arm swelling. An axillary dissection may still be required if there are enough lymph nodes with cancer in them. This decision will be made by your surgeon.
It is important to understand that the survival between the two surgical options is the same, and most women with early-stage breast cancer have to make a PERSONAL decision about which option they choose. Neither procedure is “safer” than the other and this is because the survival is determined by the biology and behavior of the tumor. The surgeries are different with respect to the chest wall and recurrence rates, but the outcome in the rest of the body is the same. In cases where the tumor is large and the breast is small, it may not be possible to remove the tumor without leaving a cosmetically deformed breast. Your doctor can help determine this. In general, a lumpectomy is the “easier” of the two to recover from, as it is often done on an outpatient basis, where patients can go home the same day. In most hospitals, a mastectomy will require 1-2 nights in the hospital, depending on whether or not the breast is reconstructed and what type of reconstruction is performed. Again, it is a PERSONAL decision and not a medical decision in most cases, and the decision needs to be based on good information and not a knee-jerk reaction or fear. Your doctor will help guide you through this process.
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