Early-Stage Breast Cancer: Choosing Your Surgery

 

Lumpectomy and Radiation



Lumpectomy, sometimes called breast-conserving surgery, has different names depending on how much normal breast tissue is removed along with the cancer. The terms wide excision, wedge resection, partial mastectomy, and quadrantectomy all refer to lumpectomy.

All of these procedures usually leave the nipple intact. Lumpectomy surgery is usually followed by radiation to kill any cancer cells that may be left in the breast.


On this page:

How Lumpectomy Is Done

Lumpectomy
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Lumpectomy (or breast-conserving surgery) removes the cancer and saves the breast. The location of the scar depends on where the tumor was located.

Lumpectomy may be done either in a hospital operating room or in an outpatient surgery center. General or local anesthesia can be used. The surgeon makes an incision in the breast and removes the tumor along with a border of healthy tissue all around it.

This healthy tissue is a “safety zone” that helps reduce the chance that any cancer cells are left behind. The healthy tissue around the tumor is called the surgical margin. The surgeon also usually removes some lymph nodes by making a second incision under the arm.

How Lumpectomy Is Done
With lumpectomy, the surgeon makes an incision in the breast, but only removes the tumor and a small amount of tissue around it.

With lumpectomy, the surgeon makes an incision in the breast, but only removes the tumor and a small amount of tissue around it.



Surgical Margins

After the surgery, a pathologist examines the tissue that was removed to see
if there is a margin of normal tissue around the entire tumor.


Clear (Negative) Margins

If the edges of the tissue are free of cancer, the margins are called clear, negative, or uninvolved. All these terms mean that the lumpectomy removed all the cancer in the primary tumor.

Surgical Margins
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When surgeons do a lumpectomy, they want to be sure that the tissue they remove has a border of healthy tissue around the cancer. This border of healthy tissue, called clear or negative margins, is shown on the left.


Positive Margins

If there are cancer cells along the edges of the tissue, the margins are called positive or involved. This means that more breast surgery is needed. The second surgery is usually a short operation that can be done without an overnight stay in the hospital. About 40 to 50 women out of 100 will need a second surgery because they have positive margins after lumpectomy. That means that 50 to 60 women out of 100 will not need a second surgery.

If getting clear margins is difficult, the doctor may recommend a mastectomy to make sure the entire primary tumor is removed.

Lumpectomy is not complete until the surgeon has removed a border of cancer-free tissue around the entire tumor. Sometimes a pathologist will examine the margins during the surgery. If there are cancer cells in the margins, the surgeon can remove more tissue right away. However, it takes several days to fully examine the tissue. If the final report shows positive margins, another surgery is needed.


Lumpectomy and Tumor Size

Lumpectomy works best for small tumors. Women who have larger tumors may be able to have lumpectomy if they have chemotherapy first to shrink the tumor. This is called neoadjuvant chemotherapy. Among women who use this approach, one-third or more will have the tumors shrink enough to make lumpectomy possible.


What to Expect after Lumpectomy




Radiation Therapy

The x-ray energy from radiation therapy kills any cancer cells that may be left in the breast. Women who have lumpectomy with radiation live as long as women who have mastectomy.

Radiation therapy reduces the chance of cancer coming back in the breast and breast area. Without radiation, as many as 40 out of 100 women would have a local recurrence within 10 years of lumpectomy. Radiation lowers that risk to about 10 out of 100.

Radiation therapy usually starts 4 to 6 weeks after lumpectomy, allowing the breast time to heal. Women generally have outpatient radiation treatments 5 days a week for about 6 weeks. However, some researchers are testing different approaches to radiation for certain women with smaller tumors who have lumpectomy.

These newer approaches are called partial breast irradiation. Partial breast irradiation uses balloons, catheters, implanted seeds, or external beam radiation to treat just the area around the tumor, rather than the entire breast.

Partial breast irradiation takes less time than traditional radiation. It can sometimes be completed in 5 days or even less. New research shows this may work as well as traditional radiation at lowering the risk of cancer coming back. However, it is still being studied in clinical trials, and doctors do not know the long-term side effects or if it works equally well for all women.


What to Expect with Traditional Radiation Therapy

Radiation therapy may be available at a local hospital or a special clinic. Find out how far you might have to travel for this therapy, because traditional radiation can require 30 or more visits.

During the first session, the radiation team will plan exactly where to aim the radiation and what dose to give. The radiation must be directed at the same part of the breast each time. The area is marked with small permanent tattoos.

The radiation treatments each last about 5 to 15 minutes and are painless. Many women say radiation therapy is a lot like having a routine x-ray. Most women continue with their usual daily activities immediately after treatment.

Near the end of a course of radiation treatments, some women receive a boost dose of radiation to make sure any remaining cancer cells are killed. Boost radiation usually comes from an external machine, like regular radiation treatments. Not everyone needs the boost dose of radiation.


Possible Side Effects of Radiation Therapy

Many women have no discomfort or side effects from radiation therapy. Other women have temporary side effects that may include:
  • Fatigue
  • Skin reactions, such as a sunburn-like rash, which can sometimes blister
  • A sense of heaviness in the breast
  • Loss of appetite or nausea (less common with modern radiation techniques than with older ones).
These side effects typically occur toward the end of radiation therapy and go away within weeks or months.

Sometimes radiation therapy causes permanent side effects, including:
  • Darkening of skin color (like a permanent suntan)
  • Skin thickening
  • A change in size in part of the breast (making it look lopsided) or the whole breast
  • Hardening of breast tissue
  • A change in the sensitivity of the skin over the breast.
Other possible side effects are generally considered rare, or they take so long to develop that they don’t have much impact on the breast cancer treatment decision. Still, they may be a concern for some women. Rare or delayed side effects of radiation include:
  • Lung or heart problems
  • An increased risk of rib fractures
  • A risk of other cancers.
Modern radiation techniques may be less likely than older techniques to cause heart problems. Radiation may also worsen lymphedema. You can learn more about this in Lymph Node Surgery.


Appearance after Lumpectomy and Radiation

Lumpectomy removes the cancer while keeping the breast. Usually, there is a scar that may fade over time. Most women are typically pleased with the results. Sometimes there is a change in the size or shape of the breast, depending on how much tissue was removed. There can also be changes in the skin color and the hardness of the breast from radiation. In most cases, the breast appears fairly normal.


Local Recurrence after Lumpectomy and Radiation

After lumpectomy, cancer can come back in the scar or skin or in the remaining breast tissue. This local recurrence can happen at any time after lumpectomy, and can usually be successfully treated with mastectomy (although for some women, a second lumpectomy may be possible).

Radiation lowers the chance of local recurrence after lumpectomy:
  • Without radiation, on average, about 40 out of 100 women would have a local recurrence within 10 years.
  • With radiation, about 10 out of 100 women would have a local recurrence within 10 years.
That means that about 90 out of 100 women who have lumpectomy and radiation will not have cancer come back in the breast and breast area within 10 years. This lower chance of recurrence may also lead to a small but important difference in survival.

These “round number” estimates are average risks. Some women may have a lower risk of local recurrence after lumpectomy—closer to 20%. Others may have a higher risk—closer to 60%. Radiation will reduce these risks to 5% and 15%, respectively.

Chemotherapy and hormone therapy canalso reduce the risk of local recurrence. This results in a few situations where women and their doctors may consider lumpectomywithout radiation and use chemotherapy and/or hormone therapy instead. One example is women older than 70 who are going to take tamoxifen or aromatase inhibitors (forms of systemic therapy for women with hormone receptor–positive tumors).

Studies have shown that older women who have a lumpectomy followed by hormone therapy have a slightly higher chance of local recurrence, but similar survival rates, compared to women who have lumpectomy, radiation, and hormone therapy.

Some older women and their doctors may feel that the extra benefit they might get from having radiation isn’t worth the time and energy and possible side effects. Women who have other serious health problems and also have a low risk of recurrence to begin with may also consider lumpectomy without radiation followed by hormone therapy.

However, for most women and their doctors, the addition of radiation makes lumpectomy a reasonable alternative to mastectomy.



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