Surgery

Almost everyone diagnosed with breast cancer has some surgery. In breast cancer treatment, surgery can:

• Remove cancer
• Help you and your care team learn more about the cancer
• Rebuild the breast after breast tissue is removed
• Help reduce pain or other symptoms

Surgery is a local therapy: a treatment that’s focused on a specific part of the body. Local therapy removes or controls cancer in the breast and nearby lymph nodes, or in other specific areas of the body if the cancer spread.

• In early-stage breast cancer, surgery to remove the cancer can reduce the risk of local recurrence.
• In metastatic breast cancer, surgery can help ease symptoms in a certain area of the body, such as back or liver pain from a tumor.

Breast cancer surgery also provides your healthcare team with more information about the cancer:

• For example, surgery can confirm whether or not breast cancer cells have spread to nearby lymph nodes, small organs that help the body filter out waste. The presence or absence of cancer cells in lymph nodes, and the number of involved lymph nodes, tell your healthcare team more about the stage of the cancer and treatments that may be appropriate.
• If you had treatment to kill cancer cells before surgery, such as chemotherapy or hormonal therapy, your team will learn during surgery how well that medicine worked. This helps with planning your future treatment.

Breast cancer surgery can also be performed to reconstruct the breast or breasts after mastectomy or lumpectomy.

Many factors help your care team determine which surgery you need. These include:

• The location of the tumor
• Information from your biopsy pathology report
• Results from imaging tests
• Whether the cancer has spread to other parts of the body, and to which part of the body
• Your personal preferences about surgery type

No matter what kind of surgery you’re having, surgery is a major physical, and often emotional, event. Anxiety or feelings of sadness are completely normal if you’ve been told you’ll need to have tissue removed from your breast. Still, there are many options available for restoring a balanced look after breast surgery if this is important to you.

Why is breast cancer surgery performed?

Breast cancer surgery is standard treatment for all stages and types of breast cancer, except metastatic breast cancer. Here are the most common reasons breast cancer surgery is recommended.

To remove as much of the cancer as possible. The goal in early-stage breast cancer is to get rid of as much of the cancer as possible through surgery, and then kill any potentially remaining cells with other local or systemic therapies. The two surgeries used are:

• Mastectomy: removal of all of the breast tissue
• Lumpectomy: removal of the tumor and a small amount of surrounding tissue

Surgery to remove the cancer may be part of your treatment plan if you have:

• Noninvasive breast cancer (DCIS)
• Early-stage breast cancer
• Locally advanced breast cancer
• A tumor or multiple tumors in the breast
• Recurrent breast cancer

Whether you need mastectomy or lumpectomy depends on the tumor location and size. In some cases, a person may be offered a choice between mastectomy or lumpectomy plus radiation, so personal preference can be a factor, too.

To check for cancer cells in nearby lymph nodes. Lymph nodes are small organs that help the body filter out waste, bacteria, and damaged cells. The sentinel node is the name doctors use to describe the first lymph node (or group of nodes) to which cancer cells are likely to spread. Usually, the sentinel node is located in the armpit lymph node area. Knowing whether cancer cells have spread to the sentinel node can impact your treatment plan. You are likely to need sentinel lymph node biopsy (SLNB) if you have:

• Invasive breast cancer
• Early-stage breast cancer
• Recurrent breast cancer

To remove lymph nodes if cancer cells are found. If your surgeon finds cancer cells in lymph nodes during SNLB, they may recommend no additional nodes be removed or removal of more nodes. The removal of additional lymph nodes in the armpit is called an axillary lymph node dissection (ALND). You may need ALND if you have:

• Three or more sentinel lymph nodes in which cancer cells are found
• A fine needle or core needle biopsy showing cancer cells in nodes near your collarbone or armpit prior to surgery; this type of outpatient biopsy may be ordered if lymph nodes in those areas appear swollen or abnormal on physical exam or on breast imaging
• Cancer cells in lymph nodes despite pre-surgery treatment with chemotherapy
• Cancer growing outside the lymph nodes

Learn more about lymph node surgery.

To ease symptoms and side effects. Surgery is rarely done for metastatic breast cancer because so far, research is unclear about whether removing the original tumor helps stop the spread of cancer cells once they’ve already spread to distant parts of the body. But sometimes tumors cause pain by pressing on nerves or bone, or cause other side effects. In these cases, your doctors may recommend surgery to improve quality of life.

To reduce the risk of developing a new breast cancer or a recurrence of previous breast cancer if you live with high risk. If you have a strong family history of breast cancer, or you’ve tested positive for an inherited genetic mutation such as BRCA1, BRCA2, PALB2, or others, your risk of developing breast cancer is higher than it is for the average person. People with known genetic risks can choose to have prophylactic, or preventive, mastectomy to remove one or both breasts. If you are living with high risk, preventive mastectomy can lower the risk of developing another breast cancer by removing as much of the breast tissue as possible. Learn more about prophylactic mastectomy.

Preparing for breast cancer surgery

Recovering from surgery is tough. In this video, you can hear from women who’ve been there as they share things to know before surgery and tips for recovery.

Your healthcare team will help prepare you for surgery. Once your surgery is scheduled, your healthcare team will ask you to provide a full, detailed medical history, including:

• Any health conditions, such as high blood pressure
• Any previous diagnoses, such as previous cancers, heart disease, or diabetes
• Your family’s health history
• Previous surgeries and hospitalizations
• Prescription and over-the-counter medicines you take
• Vitamin and herbal supplements you take
• Your general health and lifestyle habits, such as whether you drink alcohol or smoke

It’s important that you share as much as you know and are as honest as possible, because some factors can complicate surgery. For example, your doctors need to know if you smoke because smoking raises the risk of complications such as breathing difficulties during or after surgery, and healing problems after surgery. Taking certain herbal products can have different effects on blood pressure or heart rhythm during surgery. Some herbal products can raise your risk of bleeding during surgery.

Be sure to tell your care team about all the products you use, and to follow their advice about continuing or stopping their use in the weeks before and after surgery.

Your care team will also schedule you for pre-surgical testing at the hospital to make sure anesthesia is safe for you. These tests may include:

• A chest x-ray to check your lung function
• An electrocardiogram (EKG) to check your heart rhythm
• Blood tests to look at blood counts, risk of infection, risk of bleeding, and liver and kidney function
• A urine test to check for pregnancy if you are premenopausal
• Possible imaging tests such as a CT scan to confirm tumor location and size

Visit our Preparing for surgery page for more information.

Types of breast cancer surgeries

Types of breast cancer surgeries include lumpectomy and mastectomy to remove cancer from the breast, and lymph node removal to confirm whether or not cancer cells have spread beyond the breast. Breast reconstruction surgery can rebuild a breast after mastectomy. It can also be performed for local tissue rearrangement after an extensive lumpectomy.

Knowing you need surgery can cause a lot of anxiety, and understanding more about the surgery can help you prepare and recover. Below, we’ll talk about the different types of surgery your doctor may recommend, and why they may be recommended.

Lumpectomy

Lumpectomy, sometimes called breast-conserving surgery, allows you to keep some or most of your breast tissue. Lumpectomy removes the tumor from your breast along with a small area of surrounding healthy tissue called the margin, or margin of resection. Removing a margin of healthy tissue reduces the risk of cancer coming back in the area later. Even so, lumpectomy is often followed by radiation therapy to lower the risk of recurrence even more.

You may be a candidate for lumpectomy if:

• The tumor is 5 centimeters across or less.
• The tumor is in one area of the breast, or, if you have multiple tumors, they are close enough. together to be removed together.
• Your breast is large enough compared to the size of the tumor that you’ll still have enough breast tissue left after surgery for a balanced look.
• You can get to daily radiation therapy appointments over the course of several weeks.
• You are not pregnant, since radiation can harm an unborn baby.
• You are pregnant but will not need radiation therapy right away.
• You have not been diagnosed with inflammatory breast cancer, an aggressive breast cancer that does not typically form lumps.
• You do not carry a BRCA1, BRCA2, PALB2, or other inherited genetic mutation that increases your risk of recurrence or a new breast cancer.
• You have never had lumpectomy with radiation therapy to the same breast in the past.

If the cancer is larger than 5 centimeters across but conserving your breast is very important to you, ask your medical team whether you are a candidate for chemotherapy or hormonal therapy before surgery. This is called neoadjuvant therapy. For some people, it can shrink the tumor so that lumpectomy may still be possible.

Most people who choose lumpectomy will need to undergo a few weeks of daily radiation therapy to reduce the risk of recurrence in the remaining breast tissue. If you’re considering lumpectomy, your surgeon will likely refer you to a radiation oncologist to talk about options.

The typical schedule for standard whole breast radiation treatment is once a day, 5 days a week, for 2 to 6 weeks. The last week of treatment often includes a boost, or extra treatment, to the area where the tumor was found. Radiation schedules can vary depending on your situation. Talk with your doctor about a schedule that can work for you.

While many people who choose lumpectomy do not have breast reconstruction, there is an option called oncoplastic lumpectomy. This kind of lumpectomy uses plastic surgery techniques to hide the scar and rearrange tissue to fill the space left after cancer removal. Some breast surgeons are trained in oncoplastic techniques, but more involved situations may require a plastic surgeon. Even if you have a traditional lumpectomy, plastic surgery can be done later, after radiation, to make any needed corrections.

If you’re considering breast reconstruction after lumpectomy, ask your surgeon to refer you to a breast reconstruction surgeon so you can understand all your options before deciding between lumpectomy and mastectomy.

Visit our Lumpectomy page to learn more.

Mastectomy

Mastectomy is surgery that removes all of the breast tissue. Sometimes, mastectomy includes removing the nipple and the areola, the area of skin around the nipple.

You may be a candidate for mastectomy if:

• You would prefer to have all of the breast tissue removed instead of just a part of the tissue.
• The tumor is larger than 5 centimeters.
• There are several tumors in different parts of the breast, and they cannot be removed together.
• There are tumors in the nipple area.
• You had a previous lumpectomy that did not completely remove the cancer.
• You’ve had previous radiation therapy to the same breast.
• You’ve been diagnosed with inflammatory breast cancer.
• You carry a known, inherited genetic mutation, such as BRCA1, BRCA2, or PALB2, that increases the risk of breast cancer.
• You have a strong family history of breast cancer, even if you tested negative for any known high-risk genetic mutations.
• You are pregnant and can’t have radiation therapy (radiation therapy can harm an unborn baby).
• Traveling to daily radiation treatments could be difficult for you.
• You do not want to, or can’t, have radiation therapy.

Most of the time, radiation is not given after mastectomy, but sometimes it is recommended. Talk with your care team about whether radiation might be needed.

If you have a mastectomy, you may choose to have breast reconstruction, either at the same time as mastectomy surgery or at a later date. Ask your breast surgeon to refer you to a breast reconstruction surgeon so you can understand all your options before you decide on lumpectomy or mastectomy.

Visit the Mastectomy page to learn more.

Lymph node surgery

If you’ve been diagnosed with invasive breast cancer after having a biopsy, your care team will likely recommend lymph node surgery to see whether cancer cells have spread to lymph nodes in the breast or the armpit area (axilla). During lumpectomy or mastectomy surgery, your surgeon can also remove one or more lymph nodes for a pathologist to analyze under a microscope. Knowing whether there is cancer in the lymph nodes helps your doctors stage the cancer and recommend treatments.

There are two types of lymph node surgery:

• Sentinel lymph node biopsy (SLNB), in which only the lymph node or nodes closest to the tumor are removed; SLNB is the most common lymph node surgery.
• Axillary lymph node dissection (ALND), in which multiple lymph nodes are removed from the armpit area.

It’s important to know about a potential side effect of lymph node surgery called lymphedema, in which lymph fluid builds up and causes pain and stiffness in the arm, hand, breast, and other areas. For more information about these surgeries and reducing the risk of lymphedema, visit our lymph node surgery and lymphedema pages.

Mastectomy versus lumpectomy

You and your care team will talk about which surgery — lumpectomy or mastectomy — makes the most sense for your situation. For some people, the characteristics of the cancer and past medical history make it clear which surgery to choose. But many people are given a choice between mastectomy alone or lumpectomy plus radiation therapy. Your personal risk of breast cancer can also impact your decision.

Research shows that:

• Lumpectomy plus radiation therapy works just as well as mastectomy alone in women with tumors less than 5 centimeters across, if no cancer cells were found in the surgical margin.
• Women with a higher risk of developing breast cancer, because of genetic mutations or family history, might be able to lower their risk of a second breast cancer by having a preventive mastectomy (surgery to remove the healthy breast or breasts).

Deciding between mastectomy and lumpectomy is based on a few different things:

• Your doctor’s recommendation based on the breast cancer type, tumor size, and lymph node status
• Whether you are able to get to daily radiation therapy appointments for several weeks, or cannot have radiation therapy because of past treatment or other medical reasons
• The importance of your breasts to your sexual life or feelings of femininity
• Whether keeping most of your breast tissue causes anxiety about the possibility of cancer recurrence
• Whether you’re considering breast reconstruction techniques, such as oncoplastic lumpectomy or more extensive breast reconstruction, during or after surgery

If you’re deciding between lumpectomy plus radiation or mastectomy, let your care team know what’s most important to you.

Breast reconstruction surgery

Breast reconstruction is surgery to rebuild a breast after cancer is removed with mastectomy or lumpectomy. There are many types of reconstruction surgery. You can choose to have your breast reconstructed at a time that works best for your situation. Breast reconstruction can happen:

• In a one-step procedure at the time of cancer-removing surgery
• In a series of steps, some during and some after cancer-removing surgery
• Months or years after cancer-removing surgery

It’s a good idea to know your reconstruction options before you decide on lumpectomy or mastectomy, because the size of the tumor and whether you choose to remove all or part of the breast will impact your reconstruction options.

Though in the U.S. about 20 to 40 percent of women who have mastectomy have reconstruction, more and more women are choosing to have mastectomy of one or both breasts and have no reconstruction. This is sometimes called going flat. Whether you choose to have breast reconstruction is a personal decision. You have to do what’s best for you.

If you do not choose breast reconstruction, you have the option to place a breast form, or prosthesis, in your bra after surgery to maintain symmetry.

If you’re interested in exploring your reconstruction options, ask your breast surgeon to refer you to a breast reconstruction surgeon who can provide insights on which technique may make most sense for you and your lifestyle.

To learn more, visit our breast reconstruction section.

Localization before surgery

Localization is a two-step technique that precisely guides surgeons to the cancer that needs to be removed:

1. The first step of a localization is placing a marker into the biopsy site. Marker placement can be performed by a radiologist or a surgeon:

• At the time of biopsy
• After biopsy, days or weeks before cancer-removing surgery
• On the day of cancer-removing surgery either before or during surgery

2. The second step of localization happens on the day of surgery. In this step, a radiologist or surgeon uses a wire or wire-free localization method to help guide the surgeon to the precise location of the cancer to be removed during lumpectomy or lymph node removal

Wire localization

In wire localization, also called needle localization, a radiologist uses imaging and a needle to guide a thin wire with a hook at the end through the breast tissue to the marker (usually a metal clip) that was placed at an earlier time. This procedure can be used before lumpectomy surgery.

If no marker was placed in the breast, or if the marker moved to a different location (migration) after it was placed, ultrasound can be used to guide the wire directly into the tumor.

After the needle guides the wire to the cancerous area, the needle is removed. The wire remains, partly inside of the breast and partly sticking out of the breast. This process can be painful for some women.

Wire localization happens on the day of surgery because there is a risk that the wire would be dislodged if a person went home after wire placement. Still, due to surgery schedules, wire localization can often require waiting several hours with the wire in place before it’s time to go into the operating room. This can also be painful.

During lumpectomy, while you are asleep, the surgeon removes the wire together with the tumor and previously placed biopsy clip.

If the wire is guided across a large part of the breast to get to the cancerous area, it can sometimes result in more tissue being removed during lumpectomy than if a wire were not used.

Wire-free localization

Newer localization techniques do not rely on wires. Instead, a wire-free marker can be used together with a wire-free detection device to localize the cancer site.

Wire-free markers can be placed by a radiologist at the time of biopsy or any time before cancer-removing surgery. Wire-free markers include:

• Magnetic seeds, detected by a probe that picks up the magnetic signal
• Radar reflectors, detected by a probe that emits radar waves
• Radiofrequency identification markers that have a numbered tag; a radiofrequency probe can detect the tag
• Radioactive seeds that can be found with a radiation detection probe
• Natural mineral-based (non-metal) clips that can be found with ultrasound technology

Wire-free localization avoids some of the risks that come with wire localization, such as spending extra hours undergoing wire placement and waiting for surgery with the wire in the breast, which can be painful.

Instead, with wire-free localization, the surgeon uses a wireless probe to quickly find the marker, either while you are asleep in the operating room, or in some cases, while you are in the preoperative holding area.

Still, there are situations in which wire-free localization cannot be used:

• Some wire-free markers are incompatible with MRI. If MRI is needed to detect the cancer, wire localization may need to be used.
• If a cancerous area is too large for one marker to localize it, but small enough that multiple wire-free markers might be hard to tell apart, a radiologist or surgeon may decide to use wire localization instead.
• It is less expensive for hospitals to use wire localization than wire-free localization, so wire-free localization may not be available at all cancer centers across the U.S.

If having wire-free localization is important to you, ask if it’s available at your center. If not, you may need to check with other hospitals to find out what options are available.

Questions to ask your doctor about breast cancer surgery

We know how stressful it can be to make decisions about breast cancer surgery, and that it can be hard to remember all the details coming at you during appointments. Taking a list of questions to your surgeon appointments can help. It can also help to bring someone with you who can take notes.

Here are some questions to ask your surgeon:

• Are you a board-certified surgeon?
• What type of surgery do you recommend for my diagnosis?
• Did you receive special training to perform this type of surgery?
• What are the side effects of the surgery you’re recommending?
• Will I need additional treatment following the surgery?
• How soon will I need surgery?
• How long will the surgery take?
• Will I need to stay overnight in the hospital?
• How will I feel after surgery?
• Is breast reconstruction an option for me? If so, can you refer me to a breast reconstruction surgeon?
• Is there someone at the hospital I can talk to about ways to pay for surgery?
• Will a marker be placed in my breast or lymph node?
• Does your hospital use wire or wire-free localization? Do you offer different options?

Visit our Questions to ask your oncologist page for more helpful questions to ask your medical team.

Possible side effects

The side effects of breast cancer surgery can include:

• Pain and tightness in the breast, chest, armpit, and any donor tissue sites used in breast reconstruction, such as the abdomen
• Swelling that is temporary
• Scar tissue at the site of the operation
• Limited range of motion
• An increased risk of developing lymphedema, a buildup of fluid in your hand, arm, breast, chest wall, or torso on the side you had surgery
• Swelling that results from lymphedema
• Bleeding at the surgical wound
• Infection
• Loss of sensation of the breast and nipple tissue

It’s important to know that many of these side effects are temporary. Some side effects can be reduced with post-surgery gentle arm exercises that your care team can show you. Ask your surgeon about all potential side effects and ways to manage them if they happen.

Recovery outlook

Recovery after surgery looks different for everyone. Here are some things to expect once you are taken out of the operating room:

• Immediately after surgery, you’ll be moved to a recovery room where your care team will monitor you. When you wake up, your body may feel sore, and you’ll feel tired from the anesthesia. If you are nauseous, you can ask for anti-nausea medicine. For some surgeries, you’ll be released to go home from this room. For others, you’ll be moved to another room to stay overnight as directed by your care team. How long you stay depends on the surgery type and any complications.
• When it’s time to go home, you will need someone to drive you. Right after breast surgery, there can be limited range of motion in your arm on the side of the surgery. You will also likely be on pain medication that may make you feel sleepy. This can make driving unsafe.
• Your care team will send you home with information about:
  • Caring for surgical drains, small tubes that are temporarily sewn into the chest or underarm area to help pull accumulated blood and other fluid away from the surgical site
  • Caring for surgical incisions as they heal
  • Prescribed medicines, including antibiotics and any medicines to manage pain
• At home, it can be helpful to have a place ready for you to sit with easy access to necessary items (such as water, food, and entertainment) and where you can sleep comfortably, such as a recliner. You can prepare this ahead of time or ask a friend or loved one to create this space for you.

Many people can do normal daily tasks 4 weeks after mastectomy, or 2 weeks after lumpectomy. These timeframes are estimates, though, so it’s normal for some people to need longer as they recover. If you have reconstruction at the time of surgery, your recovery time will also be longer.