From Clinic to Recovery · First Edition
Chapter 10 — Breast Cancer Surgery
Dr. Tamer Rushdy Elalfy · 19 min read
In this chapter
A diagnosis of breast cancer changes a patient’s life in a single conversation. The surgeon is often the first specialist she meets, and the way the diagnosis and the choices are explained shapes how she copes with everything that follows. Surgical decisions in breast cancer are rarely about survival alone: breast-conserving surgery and mastectomy give the same long-term survival, so choices about the breast, reconstruction, and the armpit depend heavily on what matters to the patient. This chapter focuses on the surgeon’s part of the conversation, within the multidisciplinary pathway. Systemic treatment and radiotherapy are described only as far as the surgeon needs to explain them.
Learning objectives After reading this chapter you should be able to:
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Table 10.1. Breast cancer surgery at a glance.
| At a glance | |
|---|---|
| Main operations | Breast-conserving surgery (lumpectomy) with radiotherapy, or mastectomy with or without reconstruction |
| The armpit | No surgery in selected low-risk patients; sentinel node biopsy; axillary dissection in selected node-positive patients |
| Hospital stay | Day surgery for most breast-conserving operations; 1 to 2 nights after mastectomy; longer after flap reconstruction |
| Risks every patient should hear | Re-excision, seroma, wound problems, numbness, shoulder stiffness, lymphedema, and reconstruction complications |
| The key counseling message | “Keeping the breast with radiotherapy and removing the breast give the same long-term survival. The choice is yours, and there is time to make it.” |
STEP 1 Explaining the diagnosis and the treatment
10.1 Giving the diagnosis
Give the result in person, in a private room, with enough time and a specialist breast nurse present. Ask beforehand whom the patient would like with her. Use the SPIKES approach of Section 1.7: find out what she already suspects, ask how much detail she wants now, say the word “cancer” clearly, pause, and respond to her emotion before moving to the plan. Most patients remember little after the word “cancer,” so end with a short written summary, the name and number of her nurse, and the date of the next appointment.
Script: giving the diagnosis “The results of your biopsy are back. I am sorry to tell you that they show a breast cancer.” [Pause.] “I can see this is a shock. Take your time.” [Wait.] “Breast cancer is very treatable, and most women are treated successfully. Our team will meet to plan the best treatment for you, and I will see you on [day] to talk it through. You do not need to make any decisions today. [Nurse’s name] will stay with you now and will be your contact.” |
Caution: when the family asks you not to tell the patient In many families, relatives ask the doctor to withhold the diagnosis to protect the patient. Acknowledge their care, but explain that the patient needs to understand her illness to consent to treatment. Ask the patient, ideally before the result is available, how much she wants to know and whom she wants involved. Most patients want to know; some prefer a relative to hear the details first. Follow the patient’s wishes, the law, and local policy, and document the conversation (Section 1.9). |
10.2 The multidisciplinary plan
Every new breast cancer is discussed by a multidisciplinary team before treatment starts. Explain that the plan depends on the type of cancer (its hormone receptor and HER2 status), its size, and whether lymph nodes are involved. For most early cancers, surgery comes first. For some, particularly HER2-positive and triple-negative cancers, or larger cancers, drug treatment is given first; this can shrink the cancer, allow a smaller operation, and show how well the cancer responds. Figure 10.1 gives the pathway in a form that can be shown to patients.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 10.1. The breast cancer treatment pathway, for use with patients.
10.3 Keeping the breast or removing it
Breast-conserving surgery followed by radiotherapy gives the same long-term survival as mastectomy for suitable early breast cancers, shown by randomized trials with 20 years of follow-up [1, 2]. Radiotherapy is part of breast-conserving treatment, not an optional extra. Mastectomy may be recommended when the cancer is large relative to the breast, involves several areas of the breast, or when radiotherapy is not possible; some patients choose it for personal reasons. A clear margin is defined as no cancer cells at the inked edge of the removed tissue, a standard that has reduced the need for re-operation [3]; patients should still be told that a second operation is sometimes needed.
Table 10.2. Breast-conserving surgery and mastectomy compared, for use with patients.
| Breast-conserving surgery and radiotherapy | Mastectomy | |
|---|---|---|
| Long-term survival | The same | The same |
| The breast | Kept; shape may change, and oncoplastic techniques can help | Removed; reconstruction or an external prosthesis can restore shape |
| Radiotherapy | Needed, usually for 1 to 3 weeks | Sometimes needed, depending on the cancer |
| Further surgery | A second operation for margins in some patients | Further operations if reconstruction is chosen |
| Recovery | Usually day surgery; back to normal activity in 1 to 2 weeks | Usually 1 to 2 nights; drains; 3 to 6 weeks to recover, longer with reconstruction |
Script: helping the patient choose “For a cancer like yours, you can keep your breast and have radiotherapy, or have the breast removed. Both give the same chance of being cured. So the choice is about what matters most to you: keeping your breast, avoiding radiotherapy, how you will feel about your body, and how you want to recover. Many women find it helpful to talk this over with their family and our nurse before deciding. What thoughts do you have so far?” |
Some patients ask to have the other, healthy breast removed. For women without a high-risk gene mutation or strong family history, this does not improve survival, and the American Society of Breast Surgeons discourages it in average-risk women while supporting shared decision-making [4]. Explore the fear behind the request, and explain what removing the other breast can and cannot achieve.
10.4 Reconstruction
Every suitable patient having a mastectomy should be offered a discussion of reconstruction, even if she decides against it. Reconstruction can be immediate, at the time of mastectomy, or delayed until after other treatments. It may use an implant, the patient’s own tissue, or both. Some women prefer no reconstruction and use an external prosthesis, which is an equally valid choice. Explain that reconstruction usually needs more than one operation, that it restores shape but not normal sensation, and that radiotherapy can affect the result.
10.5 The armpit
Surgery to the armpit has become much less extensive. Patients with clinically and ultrasound-negative nodes normally have sentinel node biopsy, which removes only the first one to three nodes. For carefully selected postmenopausal women aged 50 or older with a small, low-grade, hormone receptor-positive, HER2-negative cancer, a negative axillary ultrasound, and planned breast-conserving surgery with radiotherapy, sentinel node biopsy can now be omitted [5, 6, 7]. When one or two sentinel nodes contain cancer in a patient having breast-conserving surgery and radiotherapy, removing the rest of the nodes does not improve survival and is not recommended [5, 8]. Axillary dissection is still used for selected patients with more extensive nodal disease.
The main reason for this change is lymphedema, persistent swelling of the arm. In a pooled analysis, about 6 in 100 women developed lymphedema after sentinel node biopsy, compared with about 20 in 100 after axillary dissection [9]. Figure 10.2 shows these figures as icon arrays, which many patients find easier to understand (Section 1.5).
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 10.2. Risk of arm lymphedema after sentinel node biopsy and axillary dissection, shown as icon arrays.
10.6 Genetics, fertility, and family
The American Society of Breast Surgeons recommends that genetic testing be made available to all patients with breast cancer [10]. A result can change surgical choices, and has implications for sisters, daughters, and other relatives, so it should be discussed with care and with genetic counseling where available. In communities where consanguineous marriage is common, family history should be taken in detail.
Young women should be asked about plans for children before any treatment that may affect fertility, and offered referral for fertility preservation as early as possible, ideally before chemotherapy starts [11]. Pregnancy, breastfeeding, and marriage are common concerns for younger patients; raise them openly, because many will not ask.
STEP 2 Preparation, medicines, and recovery
10.7 Before the operation
- Localization. For cancers that cannot be felt, a wire, seed, or marker is placed under imaging before or on the day of surgery. Explain the procedure and when it will happen.
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Sentinel node tracer. A small injection is given before surgery to find the sentinel node. Some tracers color the urine or the skin of the breast for a time.
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Medicines. Use the standard plans for blood thinners, diabetes medicines, and weight-loss injections (Chapters 18, 22, and 23). Ask about herbal and traditional remedies.
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Practical preparation. A soft, front-fastening bra; loose clothes that open at the front; help at home for the first week after mastectomy.
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Support. Introduce the specialist breast nurse, written information, and patient support groups.
10.8 After the operation
Breast-conserving surgery with sentinel node biopsy is usually a day case. After mastectomy or axillary dissection, one or two drains may be left for several days, and the patient may go home with them. Fluid often collects under the skin (seroma) after drains are removed and may need draining in clinic. Gentle arm and shoulder exercises start the day after surgery to prevent stiffness, increasing as the drains come out. Numbness of the inner upper arm is common after axillary surgery. Explain how and when the pathology results will be discussed, because they determine whether further surgery or other treatment is needed.
10.9 Recovery
Table 10.3. Typical recovery after breast cancer surgery.
| Activity | Breast-conserving surgery and sentinel node biopsy | Mastectomy or axillary dissection | With reconstruction |
|---|---|---|---|
| Showering | After 1 to 2 days | As advised; protect drains | As advised by the plastic surgeon |
| Arm exercises | From the next day | Gentle from the next day; full range after drains are out | As advised; avoid strain on flaps |
| Driving | About 1 week | About 2 to 3 weeks, when you can turn the wheel and brake without pain | Often 4 to 6 weeks |
| Office work | About 1 to 2 weeks | About 3 to 4 weeks | Often 4 to 6 weeks or more |
| Lifting and exercise | Light activity at once; full after 2 weeks | Build up gradually over 4 to 6 weeks | As advised; usually 6 weeks or more |
| Prayer | Normal; raise the arm gently | Pray seated at first if raising the arms or supporting the body in prostration is painful | As advised |
| Ramadan fasting | When eating normally | When recovered; discuss timing with the oncology team if further treatment is planned | When recovered |
STEP 3 Questions patients ask
“Did I cause this?”
Breast cancer is common, and most women who develop it have no single clear cause. It is not something you brought on yourself, and it is not a punishment.
“Will removing the whole breast make me live longer?”
No. For cancers like yours, keeping the breast with radiotherapy gives the same long-term survival as mastectomy [1, 2].
“Why do I need radiotherapy if you remove the cancer?”
Radiotherapy treats any cancer cells that may remain in the breast. It is what makes keeping the breast as safe as removing it.
“Do you need to remove all my lymph nodes?”
Usually not. Most women need only the first few nodes checked, and some do not need any removed [5].
“Will my arm swell?”
About 6 in 100 women have arm swelling after a sentinel node biopsy, and about 20 in 100 after all the nodes are removed [9]. We will teach you exercises and the early signs to watch for.
“Should I have the other breast removed to be safe?”
For women without a high-risk gene or strong family history, removing the healthy breast does not help you live longer [4]. Let us talk about what worries you most.
“Will my daughters or sisters get it?”
Most breast cancers are not inherited. We offer genetic testing, and if it shows an inherited cause, we can advise your relatives about their own risk [10].
“Can I still have children?”
Many women do. Some treatments can affect fertility, so if you may want children, we will refer you to a fertility specialist before treatment starts [11].
“Can my husband or family be told first?”
If you wish, yes. It is your decision who is told and how much. We will follow your wishes.
“Can I use herbal or traditional remedies?”
Please tell us about anything you take. Some remedies interact with treatment. None can replace surgery, radiotherapy, or medicines for cancer.
“Can I have a female surgeon?”
We will try to arrange this where possible, and a female nurse will always be present during examinations.
STEP 4 Risks, warning signs, and consent
10.10 Material risks
Table 10.4. Material risks of breast cancer surgery. Square brackets mark figures to replace with unit data.
| Procedure | Band | Risk and typical frequency |
|---|---|---|
| Breast-conserving surgery | Common | Bruising, swelling, and a change in breast shape |
| Less common | A second operation to clear the margins [unit data]; infection or hematoma [unit data] | |
| Sentinel node biopsy | Less common | Arm lymphedema, about 6 in 100 [9]; numbness of the inner arm; seroma |
| Axillary dissection | Common | Arm lymphedema, about 20 in 100 [9]; numbness of the inner arm; seroma; shoulder stiffness |
| Mastectomy | Common | Seroma needing aspiration; numbness of the chest wall |
| Less common | Wound infection or delayed healing; skin flap problems [unit data]; long-term chest wall pain [unit data] | |
| Reconstruction | Less common | Implant infection or loss; firm scar tissue around an implant; partial or total flap loss [unit data] |
| All operations | Rare but serious | Blood clots; serious bleeding needing reoperation [unit data] |
10.11 Consent checklist
Before the patient signs ☐ Diagnosis given in person, with the patient’s chosen support, and the multidisciplinary plan explained. ☐ Breast options discussed: breast-conserving surgery with radiotherapy, or mastectomy, with equal survival explained. ☐ Reconstruction discussed with every suitable patient having mastectomy, including the choice of none. ☐ Axillary plan explained, including omission where appropriate, and lymphedema risk in natural frequencies. ☐ Possibility of further surgery for margins or after the pathology result explained. ☐ Genetic testing and fertility preservation discussed where relevant; pregnancy status confirmed. ☐ Localization, tracer, drains, and arm exercises explained. ☐ Who will perform the operation, including trainee and plastic surgery involvement. ☐ Teach-back done, and the patient guide given in the patient’s language. |
10.12 Warning signs
Table 10.5. Green, amber, and red warning signs after breast cancer surgery.
| Level | Signs after breast cancer surgery | What to do |
|---|---|---|
| Green | Bruising, swelling, and numbness of the chest or inner arm A soft fluid swelling under the scar after drains are removed Tiredness and low mood in the first weeks | Expected. Follow the guide; tell your nurse if fluid swelling is uncomfortable. |
| Amber | Redness, warmth, or discharge from a wound or drain site Temperature of 38 °C or more A swelling that is tense or growing quickly Swelling or heaviness of the arm on the operated side | Call the breast nurse or clinic the same day. |
| Red | A rapidly growing, tense, painful breast or chest swelling Fever with shivering and spreading redness Chest pain, breathlessness, or a hot, swollen calf A reconstructed breast that becomes pale, blue, or cold | Go to the emergency department now. Bring this guide. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Tick the operation the patient had, and add your unit’s name, the breast nurse’s phone number, and the review date before use.
PATIENT GUIDE Your Breast Cancer Operation For you and your family. Your breast nurse will go through it with you. |
The operation you had
☐ Removal of the cancer, keeping the breast (lumpectomy)
☐ Removal of the breast (mastectomy)
☐ Breast reconstruction
☐ Sentinel node biopsy (the first few lymph nodes)
☐ Removal of the lymph nodes from the armpit
Your breast nurse
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Name: ______________________ Phone: ______________________
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Your nurse can answer questions, help with drains and exercises, and support you and your family.
1. Pain and pain medicines
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Take your pain medicines regularly for the first few days, as we told you.
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Numbness of the chest or inner arm is common and may last for months.
2. Your wounds and drains
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Keep your dressings dry until we tell you to shower.
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If you go home with a drain, empty it and write down the amount each day, as the nurse showed you.
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After the drain comes out, fluid may collect under the skin. This is common. Call your nurse if it feels tight.
3. Eating and drinking
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Eat a normal, healthy diet with plenty of protein, fruit, and vegetables.
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Tell us about any herbal or traditional remedies before you take them.
4. Arm exercises, rest, and clothes
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Start your arm exercises the day after surgery, as shown. Do them every day to prevent a stiff shoulder.
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Wear a soft, front-fastening bra and loose clothes that open at the front.
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Rest, but walk every day.
5. Getting back to normal
| Activity | After lumpectomy | After mastectomy or node removal |
|---|---|---|
| Driving | About 1 week | About 2 to 3 weeks |
| Office work | About 1 to 2 weeks | About 3 to 4 weeks |
| Lifting and exercise | Light at once; full after about 2 weeks | Build up slowly over 4 to 6 weeks |
| Prayer | As usual; raise your arm gently | Pray sitting at first if raising your arms or prostration hurts |
6. Results and next steps
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We will discuss the results of your operation on: ______________________
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You may need more treatment, such as radiotherapy or medicines. Your team will explain this.
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Feeling low, worried, or tearful is common. Talk to your nurse; support is available.
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Bruising and swelling; numbness of the chest or inner arm; a soft swelling after the drain is removed; tiredness | This is normal. Keep following this guide. |
| AMBER | Redness, warmth, or discharge from a wound; temperature of 38 °C or more; a tight or fast-growing swelling; swelling or heaviness of the arm | Call your breast nurse today. |
| RED | A fast-growing, tight, painful swelling; fever with shivering; chest pain or short of breath; a hot, swollen leg; a reconstructed breast that turns pale, blue, or cold | Go to the emergency department now. Take this guide with you. |
My contacts Breast nurse: ______________________ Hours: ______________ Out of hours: ______________________ My questions: ____________________________________________________________ [Unit name] [Guide version and review date] |
References
1. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233-1241.
2. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227-1232.
3. Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology–American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. J Clin Oncol. 2014;32(14):1507-1515.
4. Boughey JC, Attai DJ, Chen SL, et al. Contralateral prophylactic mastectomy consensus statement from the American Society of Breast Surgeons: additional considerations and a framework for shared decision making. Ann Surg Oncol. 2016;23(10):3106-3111.
5. Park KU, Somerfield MR, Anne N, et al. Sentinel lymph node biopsy in early-stage breast cancer: ASCO guideline update. J Clin Oncol. 2025.
6. Gentilini OD, Botteri E, Sangalli C, et al. Sentinel lymph node biopsy vs no axillary surgery in patients with small breast cancer and negative results on ultrasonography of axillary lymph nodes: the SOUND randomized clinical trial. JAMA Oncol. 2023;9(11):1557-1564.
7. Reimer T, Stachs A, Veselinovic K, et al. Axillary surgery in breast cancer: primary results of the INSEMA trial. N Engl J Med. 2025;392(11):1051-1064.
8. Giuliano AE, Ballman KV, McCall L, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA. 2017;318(10):918-926.
9. DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500-515.
10. Manahan ER, Kuerer HM, Sebastian M, et al. Consensus guidelines on genetic testing for hereditary breast cancer from the American Society of Breast Surgeons. Ann Surg Oncol. 2019;26(10):3025-3031.
11. Oktay K, Harvey BE, Partridge AH, et al. Fertility preservation in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol. 2018;36(19):1994-2001.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.