Your doctor will discuss with you the most appropriate type of surgery for you, depending on the size and position of the cancer. Before any operation, make sure that you have fully discussed with your surgeon why they have recommended a particular type of surgery for you, what the surgery involves, and that you have all the information you need.

This is the removal of a breast lump, together with some surrounding tissue. A lumpectomy is usually followed by radiotherapy treatment to the remaining breast tissue. This is known as breast conserving therapy. It removes the least amount of breast tissue, but leaves a small scar and sometimes a small dent in the breast. For most women, the appearance of their breast after lumpectomy is good.

Sometimes, if the lump is very small, a fine wire (guide wire) is used to mark the area so that the surgeon can find the lump more easily. A local anaesthetic is given, and the wire is then inserted by a radiologist, using x-ray or ultrasound guidance.

After a lumpectomy, the breast tissue that has been removed is sent to the laboratory to be examined under the microscope by a pathologist. The pathologist looks to see whether there is an area of healthy cells all around the cancer – this is known as a clear margin. If there are cancer or precancerous (DCIS) cells at the edge of the area of breast tissue that has been removed, there is a higher chance that the cancer will come back in the breast. 

If there is not a clear margin, more breast tissue will need to be removed a few weeks later. Approximately 1 in 8 (12.5%) of women will need to have a second operation to remove more breast tissue. Sometimes, the results from the laboratory after a lumpectomy show that taking away more tissue from the area is unlikely to remove all the cancer cells completely. In this situation, a mastectomy (removal of the whole breast) will need to be done.

This is similar to a lumpectomy, but involves removing more of the breast tissue. It is only used if a larger area of the breast needs to be removed. The effect of this type of surgery is more noticeable than lumpectomy, particularly in women who have small breasts. The treated breast is usually smaller than the other breast and may have a dent in the area where the surgery is done. In women with large breasts it is usually less noticeable. Radiotherapy to the breast is usually recommended after a segmental excision.

Removal of the whole breast (mastectomy) may be necessary if:

• The breast lump is large in proportion to the rest of the breast tissue.
• There are several areas of cancer cells in different parts of the breast.
• The lump is just behind the nipple – although if the lump is very small it is usually possible to save the breast.
• There is a small invasive breast cancer, but a widespread area of DCIS (ductal carcinoma in situ).

A simple mastectomy removes only the breast tissue.

A simple mastectomy and sentinel node biopsy or node sampling removes the breast tissue and the lower lymph glands, within the armpit.

A modified radical mastectomy removes all the breast tissue and all of the lymph nodes in the armpit. It may also be referred to as a total mastectomy and axillary clearance.

A radical mastectomy removes all the breast tissue and the lymph nodes in the armpit, together with the muscles behind the breast tissue. This is only done if the cancer is found in the muscle under the breast.

A new breast shape can often be created either at the same time as the mastectomy, or some months or years later. This is known as breast reconstruction. There are several different types of breast reconstruction. If you would like to consider having breast reconstruction, you can discuss it with your surgeon, so that they can tell you about the methods that would be suitable for you.

Research has shown that in early breast cancer, lumpectomy followed by radiotherapy is as effective at curing the cancer as mastectomy. So you may be asked to choose the treatment that you feel suits you best. Sometimes radiotherapy is still required after a mastectomy, so if you have a choice and choose mastectomy, it doesn’t mean you will always avoid radiotherapy.

The treatments have different benefits and side effects, which are listed in the section below. This can be a difficult decision to make. It is important to discuss both options fully with your doctor, breast care nurse, or one of the support organisations so that you feel confident you have made the choice that is right for you.

Lumpectomy followed by radiotherapy 

Advantages

• It is as effective at curing the cancer as mastectomy.
• It keeps the shape of the breast, but leaves a small scar.
• It causes less change to the body than mastectomy and so is less likely to affect sexuality and relationships.

Disadvantages

• It is necessary to attend hospital each weekday for between 3–6 weeks for radiotherapy.
• The radiotherapy may cause short-term side effects such as skin soreness for a few weeks and tiredness for a few months.
• Some women worry that the cancer has not all been removed because some of the breast tissue is left. However, the risk of the cancer coming back is no higher than after mastectomy.
• The radiotherapy may cause long-term side effects – pain in the arm (in less than 1 in 50 women), lung damage (in less than 1 in 50 women) and a change in the size of the breast.

Mastectomy

Advantages

• After mastectomy it may not be necessary to have radiotherapy, which means avoiding the risk of radiotherapy side effects.
• Although the chances of a cure are the same with a mastectomy and with a lumpectomy and radiotherapy, some women feel that if all the breast tissue is removed, there is less risk of the cancer coming back, and feel less anxious after their treatment.

Disadvantages

• The whole breast is taken away, which some women find very distressing. It may be possible to have immediate reconstruction to form a new breast – it may take a few weeks or months until the reconstruction is complete.
• Your body will look different, which may reduce your confidence and affect sexuality and relationships.

As part of any operation for breast cancer, the surgeon will usually remove lymph glands (also known as lymph nodes) from under your arm on the side of the cancer. There are approximately 20 lymph glands in the armpit (axilla), although the exact number varies from person to person. The lymph glands are examined to check if any cancer cells have spread into them from the breast. This helps the doctors to decide what other treatment is needed.

Sampling

A few lymph glands may be removed, which is known as axillary gland sampling. If any of the lymph glands contain cancer cells, the rest of the glands may need to be removed in a further operation (axillary clearance). Chemotherapy treatment may also be recommended or the glands may be treated with radiotherapy. Lymph gland sampling is not done that often and you are more likely to have a sentinel lymph node biopsy.

Sentinel lymph node biopsy

Sentinel lymph node biopsy is a way of checking just one or two of the lymph glands to see if they contain cancer. It involves injecting a tiny amount of radioactive liquid into the area of the cancer before the operation. The lymph nodes are then scanned to see which has taken up the radioactive liquid first. A blue dye is also injected into the area of the cancer during the operation. The dye stains the lymph nodes blue. The nodes that become blue or radioactive first are known as the sentinel nodes. The surgeon removes only the sentinel nodes so that they can be tested to see whether they contain cancer cells.

Results of research trials suggest that sentinel node biopsy is as effective at detecting cancer cells in the lymph glands as lymph node sampling or clearance. Sentinel node biopsy does not increase the chance of a cure, but it does reduce the chances of side effects such as arm stiffness and swelling (lymphoedema) of the arm that can occur after sampling or clearance of the lymph glands. It can also cause less pain and does not need a drain into the wound afterwards.

If the sentinel nodes do not contain cancer cells, no further surgery is needed. If the nodes do contain cancer cells, either a further operation will be done to remove the lymph glands from the armpit (axillary clearance – see below) or the rest of the lymph glands need to be treated with radiotherapy.

Clearance

Sometimes, all the lymph glands under the arm are removed. This is known as axillary clearance, and allows the doctor to check all of the lymph glands. In this situation, any glands affected by cancer have been removed and so no further treatment to the glands under the arm is needed, although treatment with hormonal therapy or chemotherapy will usually be recommended.

If all of the glands are removed there is a risk of swelling (lymphoedema) of the arm. About 1 in 8 women who have a full axillary clearance will develop lymphoedema at some point.

All breast surgery leaves some type of scar, and the appearance of the breast afterwards depends on the type of surgery used. It can help to discuss with the doctor or nurse beforehand what your breast will look like after surgery. The surgeon may have photographs that they can show you, and you can talk to women who have already had the surgery – contact them through Breast Cancer Care.

You could also ask your specialist or breast cancer nurse if they have anyone they have already treated who would be happy to speak with you. Your breast care nurse may be aware of a local breast cancer support group where you might be able talk to someone who has had a similar operation.

Removing lymph glands can sometimes lead to lymphoedema (swelling of the arm on the affected side). This usually starts some months or years after the breast surgery. Lymphoedema is more likely to occur if all of the glands are removed. Giving radiotherapy to the axilla after surgery also increases the risk of developing lymphoedema.