(March 16, 2009 - Insidermedicine) At the 2008 San Antonio Breast Cancer Symposium, we spoke with Dr. Lee Gravit Wilke, Assistant Professor of Surgery at the Duke University School of Medicine.
What is a mastectomy?
Dr. Wilke: A mastectomy involves removing the entire breast. It may or may not involve removing some of the lymph nodes depending on how the lymph nodes are evaluated. A mastectomy means removing the breast, usually inclusive of the nipple and the areola complex. A mastectomy is indicated in several situations. One of the primary situations is if there are multiple cancers in the breast, in which case, multiple small excisions would not be beneficial to the patients and may increase the risk that cancer would come back if we left some of the breast tissue behind. If there is a strong family history of breast cancer--if the woman carries the BRCA1 or 2 genes and wants to reduce her risk of future cancers--a mastectomy may be indicated. In addition, a mastectomy is also a choice for the woman. It's her option to choose a mastectomy--as opposed to a partial mastectomy or a lumpectomy--for her treatment.
What complication may results from a mastectomy?
Dr. Wilke: A mastectomy, just like any surgery, has complications. Those complications can include: bleeding, infection, cosmetic changes or deformity, and always, the need for additional surgery--especially if reconstruction is being considered. That's not really a complication but that's a side effect of the surgery.
What are the complications in the immediate post-op period?
Dr. Wilke: The complications from a mastectomy within the first two weeks of surgery include bleeding and infection as the primary complications. Usually, there's a drain in place after the mastectomy that drains the excess fluid. Certainly, if that drain is removed earlier, fluid can accumulate under a mastectomy incision and that will need to be drained. And that can be seen as a complication or side effect.
What are the alternatives to mastectomy?
Dr. Wilke: If somebody has a large cancer and we think they need a mastectomy because the breast size is too small to allow removal of part of the breast for the size of the tumor, we could consider chemotherapy first to try and shrink the tumor and enable conversion from a mastectomy to a partial mastectomy.
What will the surgeon be looking for during the surgery?
Dr. Wilke: The surgeon may not be looking for anything specifically during a mastectomy. A mastectomy involves an anatomic removal of the breast and has certain boundaries, such as the clavicle, the sternum, and several muscles. The surgeon will hopefully be going around all of the cancer, and not be cutting into the cancer per-se.
What is a double mastectomy?
Dr. Wilke: Certainly, a woman can always choose to remove both breasts even though only one may have cancer. The more likely the scenario, or reason, for a woman to remove both breasts is if both of them had cancer or if the woman carried the BRCA1 or 2 mutation that gives them a high likelihood of getting cancer in their lifetime. And that high likelihood is greater than 75%.
Would one require further treatment following a mastectomy?
Dr. Wilke: It depends on the type of tumor. We are learning a lot about cancer. We know that cancers are different--not all cancers are the same. In addition to mastectomies, the patient may need hormonal therapy, chemotherapy, and sometimes, radiation therapy.
How do you counsel patients on the psychological impact of having a mastectomy?
Dr. Wilke: Removing a breast is very similar to removing a limb. There are some women who actually get phantom pain or phantom feelings after they've had they're breast removed. The psychological aspects of it are very important and we offer psychological counseling, either with social workers or psychologists--if needed. We also spend, as physicians, time with the patients so that they understand what it's going to be like, and what it's going to look like by using pictures to show them what other women have had done.
If I had breast cancer and had a mastectomy...
Dr. Wilke: If I had breast cancer and needed a mastectomy, I would want to make sure that I was giving any option of breast reconstruction if at all possible. That reconstruction could be performed either immediately (if it were possible) or delayed. I understand that if I needed a mastectomy without reconstruction that would be because it's the best way to treat the cancer. I would want to make sure that we had removed the cancer in the best possible way, so that I was effectively treated and had a higher survival.