BREAST CANCER

• Breast cancer is classified as invasive when it penetrates the tissue surrounding the mammary
duct and grows in an irregular pattern.
• Metastasis occurs via lymph nodes.
• Common sites of metastasis are the bone, lungs; metastasis also occurs to the brain and liver.
• Diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the
tumor with microscopic examination of the malignant cells.

STAGES:

Stage 0

Stage 0 is used to describe non-invasive breast cancers, such as DCIS and LCIS. In stage 0, there is no
evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which
they started, or of getting through to or invading neighboring normal tissue.

Stage I

Stage I describes invasive breast cancer (cancer cells are breaking through to or invading neighboring
normal tissue) in which:

• the tumor measures up to 2 centimeters, AND

Stage II

Stage II is divided into subcategories known as IIA and IIB.

Stage IIA describes invasive breast cancer in which:

• no tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the
lymph nodes under the arm), OR
• the tumor measures 2 centimeters or less and has spread to the axillary lymph nodes, OR
• the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the
axillary lymph nodes

Stage IIB describes invasive breast cancer in which:

• the tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph
nodes, OR
• the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes

Stage III

Stage III is divided into subcategories known as IIIA, IIIB, and IIIC.

Stage IIIA describes invasive breast cancer in which either:

• no tumor is found in the breast. Cancer is found in axillary lymph nodes that are clumped together
or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone, OR
 • the tumor is 5 centimeters or smaller and has spread to axillary lymph nodes that are clumped
together or sticking to other structures, OR
• the tumor is larger than 5 centimeters and has spread to axillary lymph nodes that are clumped
together or sticking to other structures

Stage IIIB describes invasive breast cancer in which:

• the tumor may be any size and has spread to the chest wall and/or skin of the breast AND
• may have spread to axillary lymph nodes that are clumped together or sticking to other structures,
or cancer may have spread to lymph nodes near the breastbone
• Inflammatory breast cancer is considered at least stage IIIB.

Stage IIIC describes invasive breast cancer in which:

• there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may
have spread to the chest wall and/or the skin of the breast, AND
• the cancer has spread to lymph nodes above or below the collarbone, AND
• the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone

Stage IV

Stage IV describes invasive breast cancer in which:

• the cancer has spread to other organs of the body -- usually the lungs, liver, bone, or brain

Surgical Breast Procedures

 Lumpectomy
• Tumor is excised and removed.
• Lymph node dissection may also be performed.

Simple Mastectomy
• Breast tissue and the nipple are removed.
• Lymph nodes are left intact.

Modified Radical mastectomy

Halsted Radical Mastectomy

A woman may decide to have a mastectomy versus a lumpectomy based on the following:

• If the tumor is big and, after the lumpectomy, very little breast tissue would remain
• If she does not want to undergo radiation therapy after the surgery
• If she believes she will have less anxiety about a recurrence of breast cancer with a mastectomy
If the woman has tumors in more than one quadrant of the breast, most cancer doctors recommend a
mastectomy.

Risks

Most women recover with no complications; however, as with any surgery, risks are involved.

The risks of any surgery include infection, bleeding, those risks associated with general anesthesia (for
example, heart and lung problems), and reaction to medications.

Risks specifically related to the mastectomy itself are numbness of the breast skin and necrosis (tissue
death) of the breast skin. The numbness requires no treatment. Necrosis of the skin may require a return to
the operating room for revision of the scar.

Risks specifically related to mastectomy in which the lymph nodes in the armpit (axillary lymph nodes) are
removed include swelling of the arm (called lymphedema) and possible injury to the nerves in the armpit
area.

Results

• If breast cancer is detected in its earliest stage, treatment results in a 10-year survival rate (that is,
percent of women still living) of more than 90%. Long-term survival is similar whether the woman
chooses lumpectomy or mastectomy. The difference between the treatments is the risk of
recurrence locally (in the breast or on the chest wall). The 20-year risk of local recurrence after
mastectomy is 3%-5% compared to 15%-20% after lumpectomy and radiation.

o Self-examination of the breast and an annual mammography help in the early detection of
breast cancer.
o In the United States, yearly mammography screening is recommended for women older
than 40 years.
• In addition to mastectomy, treatments such as hormonal therapy, radiation therapy, and
chemotherapy (if required) improve the chances of recurrence-free, long-term survival.

Mastectomy Preparation

• A few days before the surgery, a health-care provider evaluates the woman's overall health to
ensure that she is fit for the surgery.
• Several tests, such as routine blood workup, urinalysis, and electrocardiogram (ECG), may be
performed a few days before the surgery.
• Before the surgery, the anesthesiologist examines the woman and reviews the test results.
• If the woman is taking any medication or is allergic to any medication, the surgeon and the
anesthesiologist should be informed. The surgeon and the anesthetist should also be informed if
the woman is taking any herbal supplements. Some herbal supplements, such as ginkgo, can
increase a person's risk of bleeding and, therefore, should be discontinued before surgery.
• If the surgery is scheduled for early morning, the woman is required to not eat or drink anything
after midnight on the night prior to the surgery.
• Showering with an antibacterial soap the night before the surgery may be required.
• A woman should follow any other instructions given by the health-care provider.
• The woman will be asked to sign a consent form stating that she understands the risks involved in
the surgery. She should feel free to ask the surgeon and the anesthesiologist any questions prior to
signing the consent form.

During the Procedure

• An intravenous (IV) line administers medicines that may be required during surgery.
• Heart function is monitored by an ECG machine.
 • A blood-pressure cuff is placed on the woman's arm to monitor her blood pressure during surgery.
• The operation site is washed and sterilized.
• Sterile drapes are placed over the woman to guard against infection. Only the operation site is kept
uncovered.
• General anesthesia is administered. The woman may be given a dose of antibiotics to prevent
infection.
• The surgeon makes an incision depending on the planned procedure.
• The surgeon removes the underlying breast tissue. This breast tissue is removed and sent to a
pathology laboratory for analysis. A pathologist examines the tissue under a microscope to
determine if it is benign (noncancerous) or malignant (cancerous).
• The skin is closed with stitches or staples.
• Drainage tubes are usually inserted into the operation site to drain out blood and fluid that may
continue to ooze out of the tissues after the skin is closed.
• A pressure dressing may be placed over the operation site to minimize the oozing after the surgery.
• The duration of the operation depends on the type of mastectomy being performed. Most
mastectomies take one to two hours, not including the time required for any lymph node
procedures (sentinel lymph node biopsy or axillary node dissection) or reconstruction procedures.

After the Procedure

• After surgery, the woman is taken to a recovery room where her vital signs (blood pressure, pulse,
and breathing) are monitored. Once stable, she is moved out of the recovery room.
• Depending on the severity of her pain, the woman may be given pain medications orally or by
intravenous injection. The medication does not eliminate pain, but it does reduce the pain.
• A woman undergoing a mastectomy generally stays in the hospital for one to seven days,
depending on the type of mastectomy and the type of reconstruction, if any. A few women are able
to go home the night of their mastectomy.

Next Steps

• The first follow-up visit occurs about one week after the surgery to make sure the incision is healing
well and that no postoperative complications are present.

o During this visit, the surgeon explains the results of the biopsy and, if necessary, discusses
any further treatment (chemotherapy [using medications to kill cancer cells], radiation
therapy, or both).
o Stitches that dissolve by themselves are often used to close the incision. If the surgeon
used nondissolving stitches or clips, they are removed during the first follow-up visit.
• Drainage tubes are usually removed (typically within two weeks) when the amount of fluid draining
from the operation site decreases to an acceptable volume.