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Surgery Choices for Women With DCIS or Breast Cancer

 

Are You Facing a Decision About Surgery for DCIS or Breast Cancer?

Do you have ductal carcinoma in situ (DCIS) or breast cancer that can be removed with surgery? If so, you may be able to choose which type of breast surgery to have. Often, your choice is between breast-sparing surgery (surgery that takes out the cancer and leaves most of the breast) and a mastectomy (surgery that removes the whole breast).

Once you are diagnosed, treatment will usually not begin right away. There should be enough time for you to meet with breast cancer surgeons, learn the facts about your surgery choices, and think about what is important to you. Learning all you can will help you make a choice you can feel good about.

 

Talk With Your Doctor

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Talk with a breast cancer surgeon about your choices. Find out:

  • what happens during surgery
  • the types of problems that sometimes occur
  • any treatment you might need after surgery

Be sure to ask a lot of questions and learn as much as you can. You may also wish to talk with family members, friends, or others who have had surgery.


Get a Second Opinion

After talking with a surgeon, think about getting a second opinion. A second opinion means getting the advice of another surgeon. This surgeon might tell you about other treatment options. Or, he or she may agree with the advice you got from the first doctor.

Some people worry about hurting their surgeon’s feelings if they get a second opinion. But, it is very common and good surgeons don’t mind. Also, some insurance companies require it. It is better to get a second opinion than worry that you made the wrong choice.

If you think you might have a mastectomy, this is also a good time to learn about breast reconstruction. Think about meeting with a reconstructive plastic surgeon to learn about this surgery and if it seems like a good option for you.

Check with your insurance company

Each insurance plan is different. Knowing how much your plan will pay for each type of surgery, including reconstruction, special bras, prostheses, and other needed treatments can help you decide which surgery is best for you.

 

Learn About the Types of Surgery

Most women with DCIS or breast cancer that can be treated with surgery have three surgery choices.

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Breast-Sparing Surgery

Breast-sparing surgery means the surgeon removes only the DCIS or cancer and some normal tissue around it. If you have cancer, the surgeon will also remove one or more lymph nodes from under your arm. Breast-sparing surgery usually keeps your breast looking much like it did before surgery. Other words for breast-sparing surgery include:

  • Lumpectomy
  • Partial mastectomy
  • Breast-conserving surgery
  • Segmental mastectomy

After breast-sparing surgery, most women also receive radiation therapy. The main goal of this treatment is to keep cancer from coming back in the same breast. Some women will also need chemotherapy, hormone therapy, and/or targeted therapy.

breast sparing surgery illustration

 

Masectomy

In a mastectomy, the surgeon removes the whole breast that contains the DCIS or cancer. There are two main types of mastectomy. They are:

  • Total (simple) mastectomy. The surgeon removes your whole breast. Sometimes, the surgeon also takes out one or more of the lymph nodes under your arm.
total simple masectomy illustration
  • Modified radical mastectomy. The surgeon removes your whole breast, many of the lymph nodes under your arm, and the lining over your chest muscles.
modified radical masectomy illustration

Some women will also need radiation therapy, chemotherapy, hormone therapy, and/or targeted therapy.

If you have a mastectomy, you may choose to wear a prosthesis (breast-like form) in your bra or have breast reconstruction surgery.

Breast Reconstruction Surgery

You can have breast reconstruction at the same time as the mastectomy, or anytime after. This type of surgery is done by a plastic surgeon with experience in reconstruction surgery. The surgeon uses an implant or tissue from another part of your body to create a breast-like shape that replaces the breast that was removed. The surgeon may also make the form of a nipple and add a tattoo that looks like the areola (the dark area around your nipple).

There are two main types of breast reconstruction surgery:

Breast Implant

Breast reconstruction with an implant is often done in steps. The first step is called tissue expansion. This is when the plastic surgeon places a balloon expander under the chest muscle. Over many weeks, saline (salt water) will be added to the expander to stretch the chest muscle and the skin on top of it. This process makes a pocket for the implant.

Once the pocket is the correct size, the surgeon will remove the expander and place an implant (filled with saline or silicone gel) into the pocket. This creates a new breast-like shape. Although this shape looks like a breast, you will not have the same feeling in it because nerves were cut during your mastectomy.

Breast implants do not last a lifetime. If you choose to have an implant, chances are you will need more surgery later on to remove or replace it. Implants can cause problems such as breast hardness, pain, and infection. The implant may also break, move, or shift. These problems can happen soon after surgery or years later.

Tissue Flap

In tissue flap surgery, a reconstructive plastic surgeon builds a new breast-like shape from muscle, fat, and skin taken from other parts of your body (usually your belly, back, or buttock). This new breast-like shape should last the rest of your life. Women who are very thin or obese, smoke, or have serious health problems often cannot have tissue flap surgery.

Healing after tissue flap surgery often takes longer than healing after breast implant surgery. You may have other problems, as well. For example, if you have a muscle removed, you might lose strength in the area from which it was taken. Or, you may get an infection or have trouble healing. Tissue flap surgery is best done by a reconstructive plastic surgeon who has special training in this type of surgery and has done it many times before.

To learn more about breast reconstruction, see Related Resources.

 

Compare the Types of Surgery

The charts in this section can help you compare the different surgeries with each other. See how the surgeries are alike and how they are different.

Before Surgery

Is this surgery right for me?

Breast-Sparing Surgery Most women with DCIS or breast cancer can choose to have breast-sparing surgery, usually followed by radiation therapy.
Mastectomy Most women with DCIS or breast cancer can choose to have a mastectomy.

A mastectomy may be a better choice for you if:
  • You have small breasts and a large area of DCIS or cancer.
  • You have DCIS or cancer in more than one part of your breast.
  • The DCIS or cancer is under the nipple.
  • You are not able to receive radiation therapy.
Mastectomy with Reconstruction If you have a mastectomy, you might also want breast reconstruction surgery.

You can choose to have reconstruction surgery at the same time as your mastectomy or wait and have it later.

Recovering from Surgery

Will I have pain?

Most people have some pain after surgery.


Talk with your doctor or nurse before surgery about ways to control pain after surgery. Also, tell them if your pain control is not working.

How long before I can return to normal activities?

Breast-Sparing Surgery Most women are ready to return to most of their usual activities within 5 to 10 days.
Mastectomy It may take 3 to 4 weeks to feel mostly normal after a mastectomy.
Mastectomy with Reconstruction Your recovery will depend on the type of reconstruction you have. It can take 6 to 8 weeks or longer to fully recover from breast reconstruction.

What other problems might I have?

Breast-Sparing Surgery You may feel very tired and have skin changes from radiation therapy.
Mastectomy You may feel out of balance if you had large breasts and do not have reconstruction surgery. This may also lead to neck and shoulder pain.
Mastectomy with Reconstruction You may not like how your breast-like shape looks.
If you have an implant:
  • Your breast may harden and can become painful.
  • You will likely need more surgery if your implant breaks or leaks.
If you have flap surgery, you may lose strength in the part of your body where a muscle was removed.

What other types of treatment might I need?

If you chose to have breast sparing surgery, you will usually need radiation therapy. Radiation treatments are usually given 5 days a week for 5 to 8 weeks.

If you have a mastectomy, you may still need radiation therapy.

No matter which surgery you choose, you might need:

  • Chemotherapy
  • Hormone therapy
  • Targeted therapy

Life After Surgery

What will my breast look like?

Breast-Sparing Surgery Your breast should look a lot like it did before surgery.

But if your tumor is large, your breast may look different or smaller after breast-sparing surgery.

You will have a small scar where the surgeon cut to remove the DCIS or cancer. The length of the scar will depend on how large an incision the surgeon needed to make.
Mastectomy Your breast and nipple will be removed. You will have a flat chest on the side of your body where the breast was removed.

You will have a scar over the place where your breast was removed. The length of the scar will depend on the size of your breast. If you have smaller breasts, your scar is likely to be smaller than if you have larger breasts.
Mastectomy with Reconstruction You will have a breast-like shape, but your breast will not look or feel like it did before surgery. And, it will not look or feel like your other breast.

You will have scars where the surgeon stitched skin together to make the new breast-like shape.

If you have tissue flap reconstruction, you will have scars around the new breast, as well as the area where the surgeon removed the muscle, fat, and skin to make the new breast-like shape.

To get a better idea of what to expect, ask your surgeon if you can see before and after pictures of other women who have had different types of surgery.

Remember, even though surgery leaves scars where the surgeon cut the skin and stitched it back together, they tend to fade over time.

Will my breast have feeling?

Breast-Sparing Surgery Yes. You should still have feeling in your breast, nipple, and areola (the dark area around your nipple).
Mastectomy Maybe. After surgery, the skin around where the surgeon cut and maybe the area under your arm will be numb (have no feeling).

This numb feeling may improve over 1 to 2 years, but it will never feel like it once did. Also, the skin where your breast was may feel tight.
Mastectomy with Reconstruction No. The area around your breast will not have feeling.

Will I need more surgery?

Breast-Sparing Surgery If the surgeon does not remove all the DCIS or cancer the first time, you may need more surgery.
Mastectomy If you have problems after your mastectomy, you may need more surgery.
Mastectomy with Reconstruction You will need more than one surgery to build a new breast-like shape. The number of surgeries you need will depend on the type of reconstruction you have and if you choose to have a nipple or areola added.

Some women may also decide to have surgery on the opposite breast to help it match the new breast-like shape better.

If you have an implant, you are likely to need surgery many years later to remove or replace it.

With all three surgeries, you may need more surgery to remove lymph nodes from under your arm. Having your lymph nodes removed can cause lymphedema.

Will the type of surgery I have affect how long I live?

No. Research has shown that women who have breast-sparing surgery live as long as women who have a mastectomy. This does not change if you also have reconstruction.

What are the chances that my cancer will return in the same area?

Breast-Sparing Surgery There is a chance that your cancer will come back in the same breast. But if it does, it is not likely to affect how long you live. About 10% of women (1 out of every 10) who have breast-sparing surgery along with radiation therapy get cancer in the same breast within 12 years. If this happens, you can be effectively treated with a mastectomy.
Mastectomy There is a smaller chance that your cancer will return in the same area than if you have breast-sparing surgery. About 5% of women (1 out of every 20) who have a mastectomy will get cancer on the same side of their chest within 12 years.
Mastectomy with Reconstruction Your chances are the same as mastectomy, since breast reconstruction surgery does not affect the chances of the cancer returning.

 

Think About What is Important to You

After you have talked with a breast cancer surgeon and learned the facts, you may also want to talk with your spouse or partner, family, friends, or other women who have had breast cancer surgery.

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Then, think about what is important to you. Thinking about these questions and talking them over with others might help:

About Surgery Choices

  • If I have breast-sparing surgery, am I willing and able to have radiation therapy 5 days a week for 5 to 8 weeks?
  • If I have a mastectomy, do I also want breast reconstruction surgery?
  • If I have breast reconstruction surgery, do I want it at the same time as my mastectomy?
  • What treatment does my insurance cover? What do I have to pay for?

Life After Surgery

  • How important is it to me how my breast looks after cancer surgery?
  • How important is it to me how my breast feels after cancer surgery?
  • If I have a mastectomy and do not have reconstruction, will my insurance cover my prostheses and special bras?
  • Where can I find breast prostheses and special bras?

Learning More

  • Do I want a second opinion?
  • Is there someone else I should talk with about my surgery choices?
  • What else do I want to learn or do before I make my choice about breast cancer surgery?