Still another operation is the subcutaneous mastectomy, in which the inner breast tissue is removed through an incision under the breast, leaving the breast skin and nipple. Although this procedure may make later breast reconstruction easier and at one time was advocated by some plastic surgeons, a number of other considerations militate against it. Most breast surgeons consider it an inadequate treatment for any type of breast cancer. Since the areola and nipple are connected to the underlying breast tissue, some is inevitably left behind. It is also difficult to remove all of the breast tissue at the edges of the incision and the portion of the breast near the armpit.
Subcutaneous as well as simple mastectomies have been used for women who are at high risk of developing breast cancer, either because of a strong family history or a biopsy showing a premalignant lesion. Some women in these situations develop an almost paralyzing fear of breast cancer and find they actually prefer to undergo a prophylactic subcutaneous mastectomy and breast reconstruction rather than live with their fears. Except in very unusual circumstances, most breast surgeons do not recommend these prophylactic mastectomies; instead they advise that the women be followed carefully for any changes that indicate cancer before undergoing treatment. Any woman considering such a prophylactic mastectomy is advised to undergo counseling beforehand.
Perhaps the most controversy has centered on the lumpectomy, also called partial mastectomy, quadrantectomy, tylectomy, or segmental mastectomy, in which only the cancer and surrounding tissue is removed, leaving the rest of the breast intact. At about the same time that Dr. Patey was developing the modified radical mastectomy in England, a group of surgeons working under Dr. Mustakallio in Helsinki, Finland, felt that removal of only the cancer, followed by radiation therapy to the breast and axillary lymph nodes, could produce equally good results. Over a period of many years and a large number of cases, they showed that this combination of lumpectomy and radiation therapy produced about the same results as a radical mastectomy if the tumor was 2 cm. (about three fourths of an inch) or less in diameter.
In 1976 the National Surgical Adjuvant Breast Project undertook a study to compare segmental mastectomy, both with and without irradiation, with simple mastectomy. In all, 1,843 women participated in the study, which was carried out at eighty-nine institutions in the United States and abroad. The women all had Stage I or II breast cancers smaller than 4 centimeters. This study found that segmental mastectomy, followed by breast irradiation in all women and adjuvant chemotherapy in women with positive nodes, provided the best chances of five-year survival. Women participating in the study were randomly assigned to one of three treatments:
Total mastectomy, segmental mastectomy alone, or segmental mastectomy followed by breast irradiation. The axillary lymph nodes in all women were examined, and those who had positive nodes also received chemotherapy. More recently, a National Cancer Institute consensus panel has recommended that chemotherapy be used only in premenopausal women.
There are still knowledgeable surgeons who do not feel that there are yet enough data to support concluding that a lumpectomy is as effective as more extensive operations. One of the characteristics of breast cancer is that, generally, the smaller the tumor, the longer the recurrence-free period after treatment. Women with breast tumors less than 2 centimeters have a ten-year survival rate of over 95 percent. Any comparison of the two therapies against small, localized cancers obviously requires a number of years, and some physicians feel that still more time is needed to show any difference in results between the methods.
Another difficulty in evaluating lumpectomy is the problem of microscopic foci tiny areas of cancer cells outside the observed lump. These have been found in 30 percent of breast cancer patients. Surgeons favoring mastectomy feel that these will later grow into cancers that must be removed. Other experts maintain that microscopic foci will not cause further trouble during the patient’s lifetime or that they can be removed when and if they do.
Whichever operation is chosen, the woman usually undergoes a number of tests beforehand, such as bone and liver scans, to search for possible metastases. These are generally done on an outpatient basis and the woman usually checks into the hospital the evening before the actual operation. On the morning of the operation, the patient is sedated before the trip to the operating room.
A simple lumpectomy may take less than half an hour to do, and the patient is sometimes sent home the same day or the next day. More typically, however, axillary lymph nodes are sampled at the time of the lumpectomy; the total procedure may take an hour to do and require three or four days of hospitalization. Mastectomies take two to four hours, and the patient usually can expect to stay in the hospital for four or five days. In some institutions, programs are being developed to teach the woman to care for herself, allowing her to go home even sooner. If breast reconstruction is done at the same time as the mastectomy, the hospital stay may be extended for a few days.
The incision for a mastectomy may be either horizontal or vertical, depending on the technique preferred by the surgeon and the location of the tumor. The patient should feel free to ask what type of incision is planned and whether she may state a preference: many women choose the horizontal incision because it is less likely to show in a swimsuit or a low-cut dress.
Another topic the patient should discuss with her surgeon before mastectomy is breast reconstruction. Although eradication of the cancer isthe chief concern of the doctor and patient, there is a trend toward immediate reconstruction at the time of the mastectomy.
After a mastectomy the incision is covered by a dressing and drainage tubes or suction devices are inserted to remove fluids. These stay in place until the amount of drainage is no longer a problem. For some women this may be several days; others may need the drainage tubes for several weeks, in which case the woman will leave the hospital with the tubes in place.
After surgery the chest may feel numb for days and the arm may lose its full range of motion. When the surgeon approves, the patient can begin simple exercises squeezing a sponge with the hand, raising the arm overhead, walking the fingers up a wall to restore full function. These exercises may also help prevent the accumulation of fluid in the arm (lymphedema). Several factors should be considered before beginning the exercises, however. For example, women who have undergone breast reconstruction should not stretch the tissues until healing is well under way, usually about seven to ten days after the operation. In any event, a woman should consult her physician for advice about specific exercises.
The stitches may be removed either before or after the patient leaves the hospital. She can usually begin to participate in a full range of activities, without arm or shoulder stiffness or numbness, within a month. Complete rehabilitation may take several months, however.