Surgery for primary breast cancer

Find out about the different types of surgery for primary breast cancer, including breast-conserving surgery or lumpectomy, mastectomy and breast reconstruction.

1. Surgery for breast cancer treatment

Surgery is usually the first treatment for people with breast cancer.

The 2 main types of breast surgery are:

  • Breast-conserving surgery – the cancer is removed along with a border (margin) of normal breast tissue around it
  • Mastectomy – removal of all the breast tissue including the nipple area

Sometimes , or is offered before surgery. This may mean surgery is less extensive.

2. Which type of surgery will I have?

The type of surgery recommended for you depends on the type and size of the cancer, where it is in the breast and whether more than one area of the breast is affected. It will also depend on the size of your breast.

Your treatment team will explain why they think a particular operation is best for you.

Some people will be offered a choice between breast-conserving surgery and a mastectomy.

Long-term survival and rates of local are the same for breast-conserving surgery followed by radiotherapy as for mastectomy.

You may also have some or all of the lymph nodes removed with the breast tissue.

Discussing your options

You may find it helpful to talk through your options with your breast care nurse.

Here are some questions you might want to ask your treatment team about your surgery:

  1. What surgery will I need and why?
  2. Where will the scars be?
  3. What will my breast area look like after surgery?
  4. What side effects can I expect?
  5. How long will I take to recover?
  6. Can I see photographs of people who have had breast surgery?
  7. Can I see some breast prostheses (artificial breast forms)?

You can also call our free helpline. The helpline number can be found at the top of this page under 'Speak to a nurse'.

3. Mastectomy

A simple mastectomy is the removal of as much breast tissue as possible including the skin and nipple area.

Examples of when a mastectomy may be recommended include:

  • When the cancer takes up a large area of the breast
  • When there’s more than one area of cancer in the breast
  • If you've been diagnosed with
Illustration showing a woman's breasts. There is a bright pink crescent-shaped mark directly above the areola of the right breast.
Position of cancer in the breast.
Position of cancer in the breast.
Illustration of a woman's chest. Her mastectomy scar is shown as a pink line running across her right chest area.
Example of the position of a scar after a mastectomy.
Example of the position of a scar after a mastectomy.

If your surgeon recommends a mastectomy they should explain why. You may also decide you would prefer to have a mastectomy, even if breast-conserving surgery is an option.

4. Breast-conserving surgery (lumpectomy or wide local excision)

A lumpectomy or wide local excision is surgery to remove breast cancer along with a border (margin) of normal, healthy breast tissue.

The aim is to keep as much of your breast as possible while ensuring the cancer has been completely removed.

If you’re having breast-conserving surgery, you’ll usually have radiotherapy on the remaining breast tissue on that side.

An illustration showing a woman's chest. There is a bright pink dot shown on the right breast, a few inches above the areola.
Position of cancer in the breast.
Position of cancer in the breast.
Illustration showing a woman's chest. There is a short, bright pink line a few inches above the areola of her right breast.
Example of the position of a scar after breast-conserving surgery.
Example of the position of a scar after breast-conserving surgery.

It’s more common for people to have oncoplastic surgery. This combines breast cancer surgery with plastic surgery techniques, and means it’s less likely you’ll notice a dent or a great difference between the breasts. For more information, see our web pages about breast reconstruction.

Margins

It’s important that the cancer is removed with a border (margin) of healthy breast tissue around it to reduce the risk of any cancer cells being left behind.

The breast tissue removed during surgery will be tested to check the margin around the cancer.

  • Negative (clear) margins mean no cancer cells were seen at the outer edge of the tissue removed.
  • Positive margins mean the cancer cells are very close to or reach the edge of the tissue.

If you have negative or clear margins, it’s unlikely you’ll need more surgery to the breast.

If there are cancer cells at the edges of the margin, you may need further surgery to remove more tissue. Some people may need a mastectomy to ensure all the cancer has been removed. 

5. Surgery to the lymph nodes

Breast cancer cells can sometimes spread to the lymph nodes under the arm.

Anyone with invasive breast cancer will have the lymph nodes under the arm assessed. The outcome of this will help your treatment team recommend which treatments are best for you.

The lymph nodes

Breasts contain a network of thin tubes called lymph vessels. These are connected to the lymph nodes (glands) under the arm (axilla).

Lymph nodes are arranged in three levels: 1, 2 and 3 as illustrated below. The exact number of nodes in each level will vary from person to person.

An illustrative diagram of the lymph nodes using bright pink dots. Arrows point to level 1, 2 and 3 lymph nodes.
Diagram of the lymph nodes.
Diagram of the lymph nodes.

Checking lymph nodes before surgery

If you have invasive breast cancer, your treatment team will want to check if any of the lymph nodes under the arm contain cancer cells. This helps them decide whether you’ll benefit from any additional treatment after surgery.

Usually an ultrasound scan of the underarm is done before surgery to assess the lymph nodes.

If this appears abnormal, you’ll have a fine needle aspiration (FNA) or a core biopsy to see if the cancer has spread to the lymph nodes.

  • FNA – uses a fine needle and syringe to take a sample of cells to be looked at under a microscope.
  • Core biopsy – uses a hollow needle to take a sample of tissue to be looked at under a microscope.

Lymph node removal

If the FNA or core biopsy shows cancer has spread to the lymph nodes, you’ll usually be recommended to have all or most of your lymph nodes removed. This will be done at the same time as your breast surgery and is known as an axillary clearance.

More recently if there is cancer in three lymph nodes or fewer, some hospitals may offer chemotherapy before surgery. This is done to reduce the number of lymph nodes that need to be removed. It’s called targeted axillary dissection.

Sentinel lymph node biopsy

Sentinel lymph node biopsy is used if tests before surgery show no evidence of the lymph nodes containing cancer cells.

It identifies whether the sentinel lymph node (the first lymph node that the cancer cells are most likely to spread to) is clear of cancer cells. There may be more than one sentinel lymph node.

Sentinel lymph node biopsy is usually carried out at the same time as your cancer surgery but may be done before.

A small amount of radioactive material (radioisotope) and sometimes a dye is injected into the area around the cancer to identify the sentinel lymph node. Once removed, the sentinel node is examined under a microscope to see if it contains any cancer cells.

As the dye leaves your body, you may notice your urine is a bluish-green colour for one or two days after the procedure. The skin around the biopsy site may also be stained a blue-green colour. Some people may have a reaction to the dye but this is rare and is easily treated if necessary.

If the sentinel node does not contain cancer cells, this means the other nodes are clear too, so no more will need to be removed.

If the results show there are cancer cells in the sentinel node, depending on how much is found you may be recommended to have:

  • Further surgery to remove some or all of the remaining lymph nodes
  • Radiotherapy to the underarm
  • No further treatment to the underarm as long as you are having radiotherapy to the breast and chemotherapy or hormone therapy treatment

If you’re having chemotherapy before your surgery, your specialist may want you to have a sentinel lymph node biopsy before starting chemotherapy. This can help with planning any further treatment to the underarm after chemotherapy.

If you have DCIS you will only need a sentinel lymph node biopsy if you are having a mastectomy, or if there is a high chance you have some invasive breast cancer.

Isolated tumour cells (ITCs), micrometastases and macrometastases

Your doctor may use one of these terms when discussing your sentinel lymph node biopsy result:

  • ITCs are single cancer cells or small clusters of cells no bigger than 0.2mm
  • Micrometastases are cancer cells larger than 0.2mm but not bigger than 2mm
  • Macrometastases are cancer cells larger than 2mm

If you’re diagnosed with ITCs or micrometastases, you will not usually need any further treatment to your axilla (under the arm).

If you have one or two sentinel nodes with macrometastases, you may or may not need further treatment to your axilla. This will depend on several factors including other characteristics of the cancer, for example what the grade is and whether you’re having hormone therapy. Your doctors may talk about going into a clinical trial that is comparing treating versus not treating the axilla.

If you have three or more sentinel nodes with macrometastases, you will need further treatment to the axilla.

Assessing lymph nodes during surgery

Some hospitals are set up to assess the lymph nodes during breast surgery. The removed nodes will be looked at by a pathologist, who will tell the surgeon the result during the operation.

The most common test used is called One Step Nucleic Acid Amplification (OSNA).

If the sentinel node contains cancer cells, the surgeon may then remove more lymph nodes.

Having lymph nodes assessed during surgery avoids a second operation.

6. Breast reconstruction

If you’re going to have a mastectomy, you will usually be given the option of having breast reconstruction.

If you choose to have breast reconstruction, you may be able to have it at the same time as the mastectomy. If this is the case your breast surgeon might discuss other types of mastectomy.

  • A skin-sparing mastectomy – removal of the breast and nipple area without removing much of the overlying skin of the breast.
  • A nipple-sparing mastectomy – removal of all the breast tissue, without removing much of the overlying skin and the nipple area of the breast.

7. The unaffected breast

Some women who are having a mastectomy wonder whether they should have their unaffected breast removed as well.

Evidence shows this is not usually necessary unless someone has a higher risk of developing primary breast cancer in the other side. This might be because they have inherited an altered gene or have a significant family history of breast cancer.

Many women overestimate their risk of developing a new primary cancer in the other breast or mistakenly believe breast cancer can spread from one breast to the other. It’s important to discuss your individual situation with your surgeon.

8. Prostheses, bras and clothing after a mastectomy

You may like to read our information about:

9. Going into hospital and pre-assessment

Going into hospital may be a new experience for you and you might feel anxious, particularly if you’re not sure what to expect.

You may find it helpful to read our booklet Your operation and recovery, which has more information about your admission to hospital, during your stay and your recovery at home.

Pre-assessment

Before your operation you will have a pre-assessment. This is to check your overall health and go through your planned surgery.

You’ll usually be asked to attend a pre-assessment clinic shortly before your surgery date, but sometimes this assessment is done once you’re in hospital for your operation.

What should I take with me to hospital?

Your hospital team should give you information about your admission and hospital stay as well as what to take with you.

You will usually be given a telephone number at your pre-assessment appointment. You can call if you have any questions about preparing for surgery, or are unclear about any instructions you have been given (such as stopping eating and drinking).

How long will I be in hospital?

The length of your hospital stay will depend on what type of surgery you have, how you recover and the support available at home.

Some people who've had breast surgery without reconstruction may have surgery as a day case or stay overnight, being discharged within 23 hours of admission.

Your treatment team will talk to you about how long you’ll be in hospital.

What to expect on the day

You will usually be admitted to the hospital on the morning of your operation or occasionally the day before. You will have pre-surgery checks that include a visit from the anaesthetist and a doctor from the surgical team.

Once the pre-surgery checks have been done, you’ll be taken to the anaesthetic room. You’ll be given a combination of drugs into a vein. This will usually include an anaesthetic, pain relief and anti-sickness drugs.

You’ll usually be asked to take deep breaths and as the anaesthetic takes effect you will fall into a deep sleep. Once you are fully anaesthetised you will be taken into the theatre.

For more information about going into hospital, see our booklet Your operation and recovery.

Temporary breast prostheses and post-surgery bras

Find out more about which bras to wear immediately after surgery.

You can also find out more about wearing a temporary breast prosthesis if you’ve not had immediate reconstruction. 

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This information was published in June 2022. We will revise it in June 2024.

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