Questions about Mastectomy
Can I have breast reconstruction at the same time as my mastectomy?
Most women can undergo at least part of a breast reconstruction procedure at the same time as their mastectomy. Breast reconstruction can be done later as well. For some kinds of reconstruction, more than one surgery is needed. Women should have a full consultation with a plastic surgeon before deciding between mastectomy and breast-sparing surgery. The plastic surgeon can explain the different breast reconstruction methods, including possible complications. This information can help a woman make a choice about surgical treatment.
Can I have a mastectomy without removing the nipple? What about the breast skin?
Most surgeons recommend removal of the nipple because cancer cells can grow there. Nevertheless, with some types of cancer that are not located near the nipple, it is possible to undergo a type of mastectomy in which the nipple is saved. However, this nipple-sparing surgery is rarely done. A nipple-sparing mastectomy is more likely than a total mastectomy to leave breast cells behind that could later become cancer. Moreover, because the nerves are cut, neither the nipple nor the breast will have the same sensations after any type of mastectomy that they had before the surgery.
When breast reconstruction is done at the same time as the mastectomy, the surgeon often is able to save most of the breast skin to use in the reconstruction.
With reconstruction, can I change the size of my breasts? Can the plastic surgeon make the other breast match? Can the plastic surgeon make the breast look natural? Will I have any feeling in the reconstructed breast?
In many cases, a plastic surgeon can change the size of the breasts. Sometimes, surgery on the healthy breast also is needed so it will match the reconstructed breast. Reconstruction using a woman's own tissue often looks more natural than with implants, which tend to be higher and rounder than a natural breast. With tissue flap surgery, the breast is reconstructed using muscle, fat, and skin from other parts of the body, such as the abdomen or back. Tissue flap surgery is more complex than reconstruction with implants. Women who have had a mastectomy with reconstruction — either with implants or her own tissue — will not have much (or perhaps any) sensation in their breasts, because the nerves to the breast skin have been cut. And, although nipples can be reconstructed, they will not have any sensation.
What are the side effects of mastectomy? What about breast reconstruction?
When considering what kind of surgery to have, it is important to know that there are potential side effects common to all surgical procedures. Any surgical procedure carries a risk of infection, poor wound healing, bleeding, or a reaction to the anesthesia. Also, pain and tenderness in the affected area is common, usually only in the short term. Because nerves may be injured or cut during surgery, most women will have numbness and tingling in the chest, underarm, shoulder, and/or upper arm.
Removal of lymph nodes under the arms may be performed. This can lead to pain and arm swelling, called lymphedema, which can last a long time and be debilitating.
Breast reconstruction after mastectomy often requires multiple additional surgeries and significant recovery time. Companies that make breast implants have informed the FDA that 1 in 4 patients whose breasts were reconstructed with implants have at least one additional surgery within 3 years. With tissue flap surgery, healing can take a long time, and pain can last for months.
Keep in mind that the side effects of treatment vary for each person. Some women have many side effects or complications, others may have very few. Pain medication, physical therapy, and other strategies can help women manage side effects and recovery.
If I have a mastectomy, does that mean I won’t need other treatment after surgery?
Not necessarily. Some women with early-stage breast cancer who have mastectomy might also need radiation therapy, chemotherapy, or other treatment.
Will I need treatment after surgery?" to learn about adjuvant therapy.
I have breast cancer in my family. Should I choose the more aggressive treatment? Should I have surgery to remove my healthy breast to keep from getting breast cancer in it? Should I have genetic testing?
Most women who have breast cancer in their families will never get the disease themselves — even if a mother or sister has died of breast cancer. The risk is higher for women who are known to have a harmful mutation in either the BRCA1 or BRCA2 gene than in women with "breast cancer in their families" who don't have a mutation in one of these genes. But many women with a harmful BRCA1 or BRCA2 mutation may never get breast cancer.
Although a family history of breast cancer increases your risk of breast cancer, it is not necessary to choose more aggressive treatment or more radical surgery just because you have a family member with breast cancer. For most women, family history alone should not influence the decision about which type of surgical treatment to have for early-stage breast cancer.
Women who have a family history of breast cancer do have an increased risk of getting breast cancer in their healthy breast. Sometimes these women decide to have the healthy breast removed to lower their risk of cancer in the future. Occasionally, women with a known harmful BRCA1 or BRCA2 mutation or a strong family history of breast cancer decide to have both their breasts removed as a preventive measure, even if they have never been diagnosed with breast cancer. Preventive mastectomy reduces the risk of future breast cancer, but it does not eliminate the risk completely because cancer can occur in any remaining breast tissue or on the chest wall. The disadvantage is that the surgery will be unnecessary for many women who choose it, because many women who have a breast removed as a preventive measure would never have gotten breast cancer even if the breast (or both breasts) were not removed. Women thinking about preventive mastectomy should get a second professional opinion before taking this step.
Instead of surgery, hormonal therapies can be used to reduce the risk of breast cancer among women at high risk of the disease. These include the drugs tamoxifen for women older than 35 and raloxifene for postmenopausal women. These drugs have side effects, and women should discuss the benefits and risks with their doctors.
Women with a known harmful BRCA1 or BRCA2 mutation also have a higher risk of ovarian cancer and sometimes elect to have the ovaries removed to prevent ovarian cancer. Removing the ovaries also decreases the risk of breast cancer in women who have not reached menopause.
Women with early-stage breast cancer should talk to their doctors about the effect of family history on their own personal risk of a second breast cancer, as well as about risk-reducing strategies. Some women with a family history of breast and/or ovarian cancers might want to speak with a genetic counselor. A genetic counselor can talk about whether genetic testing for a BRCA1 or BRCA2 gene mutation might be appropriate. This information might help a woman decide on breast cancer treatment and risk-reducing approaches, including preventive mastectomy and hormone therapy.
I am worried about paying for treatment. Does one surgery cost more than the other?
Cost should not heavily influence a woman’s decision about which type of surgical treatment to have for early-stage breast cancer. Breast-sparing surgery followed by radiation may have more short-term costs but less long-term costs than mastectomy. Yet, specific costs are unique to each woman and her treatment needs. Contact your insurance company to find out what part of the costs you might have to pay. If you don’t have insurance or need financial help, there are government-sponsored and private programs to help.
I know that some women have arm swelling and pain after breast cancer surgery. Why does this happen?
Many women treated for breast cancer have arm swelling and pain, called lymphedema (LIM-fih-DEE-muh). It can happen after surgery to remove the underarm lymph nodes. Radiation therapy to the lymph nodes also can cause lymphedema. And other factors, such as being overweight and the location of the tumor, also can affect risk. Lymphedema may develop within days or many years after treatment. It can cause long-term physical, emotional, and social problems for women.
The risk of lymphedema goes up with the number of lymph nodes removed. When both surgery to remove the underarm lymph nodes and radiation therapy are performed, lymphedema can affect up to 48 percent of patients.
Because lymph node status is needed to determine the stage of a woman’s breast cancer, most women diagnosed with breast cancer will need to have some lymph nodes removed no matter what surgical treatment they choose.
Many doctors are now using sentinel lymph node (SLN) biopsy, which lessens the risk of lymphedema because fewer lymph nodes may need to be removed than with axillary lymph node dissection. The results of studies looking at SLN biopsy are promising, but additional studies are evaluating patient outcomes with SLN biopsy, including whether it affects survival. Many women elect to have SLN biopsy, and women interested in SLN biopsy should ask their doctors if it is available to them. Women who have SLN biopsy should make sure it is done by an experienced team.
Will I need treatment after surgery?
Some women have treatment after surgery to increase the chances of a cure. This is called adjuvant therapy. It includes radiation therapy, chemotherapy, hormone therapy, and new therapies being studied. The type of adjuvant therapy a woman’s doctor may recommend depends on many factors, such as cancer stage, the type of cancer she has, and whether she has reached menopause. Sometimes, a combination of treatments is recommended. You can talk to your doctor about the benefits, risks, and side effects of the adjuvant therapy recommended for you.
Radiation therapy uses high energy x-rays or other types of radiation to kill cancer cells or to keep them from growing. Breast-sparing surgery should be followed by whole breast radiation therapy to the saved breast. Some women who have mastectomy also might need radiation therapy to the lymph nodes near the breast and the chest wall.
Chemotherapy uses drugs to kill cancer cells or to stop them from dividing. In some cases, chemotherapy is used before surgery to shrink the size of a tumor so that a woman can have breast-sparing surgery. This is called neoadjuvant chemotherapy.
Hormone therapy is used for breast cancers that are estrogen receptor-positive. This means that the female hormone estrogen stimulates this type of breast cancer to grow. Hormone therapy stops cancer cells from growing by reducing the production of hormones or blocking their action. Hormone therapy is not indicated if breast cancer is estrogen receptor-negative. Hormone therapy includes:
- Tamoxifen (tuh-MOK-suh-fen) — A drug that blocks estrogen’s action. Tamoxifen slightly increases the risk of blood clots and uterine cancer in women who have a uterus. It is usually taken for 5 years.
- Aromatase (uh-ROH-muh-tayz) inhibitors — Drugs that decrease the production of estrogen. It is given to some postmenopausal women who have hormone-dependent breast cancer. This is breast cancer that needs estrogen to grow. Aromatase inhibitors are taken for 5 years. Women who take tamoxifen often take an aromatase inhibitor after the tamoxifen treatment is done.
- Ovarian ablation — Surgery, radiation, or drugs stop the ovaries from making estrogen in premenopausal women.
New cancer treatments are being studied. Some women with early-stage breast cancer may be able to benefit from new cancer treatments by taking part in clinical trials. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment. Learn about clinical trials for women with early-stage breast cancer at https://clinicaltrials.gov
These are some other questions that breast cancer patients commonly ask their doctors: What's your recommendation? What treatment would you recommend if I were your wife/sister/daughter? What do most of your patients in my situation decide?
Most doctors will answer these questions honestly. However, a doctor's opinions may be affected by his or her age, training, and other personal influences. For example, research shows that older doctors, male doctors, doctors working in community hospitals, and doctors in the South and Midwest are more likely to perform mastectomies. Younger doctors, female doctors, doctors working at university medical centers, and doctors working in the Northeast are more likely to perform breast-sparing surgery.
These differences are probably related to the kind of training a doctor has had. Doctors who were trained within the last 20 years and who work at university-based medical centers may be more aware of the recent research indicating that survival is the same for breast-sparing surgery and mastectomy, and may have received more training on how to perform breast-sparing surgery and sentinel lymph node biopsy. However, there are certainly older doctors and doctors at community hospitals who are very well-informed about current treatment options and well-trained to perform them.It is important for you to feel comfortable discussing your preferences and participating in the decisions about your surgical treatment. Research shows that women are happier if they help make treatment decisions, rather than simply following their doctor's recommendations.
What happens when each treatment ends? How often do I see you?
These are questions that each woman should ask, and doctors should be prepared to answer. Several kinds of doctors and health professionals are involved in the treatment of breast cancer, and this should be clearly explained to the patient.
Should I get a second opinion?
Your cancer treatment involves several important decisions. A second opinion may help you feel more confident in your decision-making. Well-qualified doctors welcome a second opinion and can give you the name of another surgeon, radiation oncologist, or medical oncologist. In fact, health insurance often will pay for, and even requires, a second opinion if treatment is involved. And, feel free to ask your doctor for copies of your medical records.
More information on early-stage breast cancer treatment
For more information about early-stage breast cancer treatment, call womenshealth.gov at 800-994-9662 (TDD: 888-220-5446) or contact the following organizations:
- American Cancer Society
- CANCER101 Inc.
- National Breast and Cervical Cancer Early Detection Program, CDC, HHS
Phone: 800-232-4636 (TDD: 888-232-6348)
- National Cancer Institute, NIH, HHS
- Susan G. Komen for the Cure
- Y-ME National Breast Cancer Organization
Phone: 800-221-2141 or 312-986-8338