Conserve? or Remove?

Surgery Options for Breast Cancer

Can I conserve breast?
Is it safe?

After confirming cancer, doing the staging and fitness and making a decision, we have finally reached the point, where treatment starts. For the sake of discussion, we are assuming, it's a small cancer in early stage, and the first step is surgery. The decision about type of surgery is a very delicate one. But then, it is rather straight forward. The principle is clear - we encourage to conserve the breast wherever possible. Only where conservation is not possible, we go ahead with removal. Of course, the patient's choice is supreme, and there are times, when conservation is possible, but patients opt for removal. That's an indivdual call.

A surgery for breast cancer, has two parts to be tackled:
1. The Tumour in Breast
2. The Nodes in the Armpit (Axilla)

For point 1. above, for operating the tumour in the breast, there are two options:
1. We remove the whole breast - This is called as Mastectomy
2. We do not remove the whole breast. We remove only the tumour, with a cuff of one centimetre of normal tissue around it - This is called as Breast Conserving Surgery
In both the surgeries above, the nodes in the armpit have to be removed, as per the stage. In cases where the nodes are definitely 'involved', we remove all of them. When the nodes are not looking involved, we remove only a few of them and test (by a technique called Sentinel Node Biopsy and Frozen Section) - if they turn out 'negative' for cancer, we just leave behind the rest; and if they test 'positive' for cancer, then we remove them all.

Is it safe doing a Breast Conserving Surgery (BCS)? Isn't there a higher chance of the cancer coming back?

A Breast Conserving Surgery (BCS) is absolutely safe. The one point that most patients think is that, not removing the breast will cause a higher chance of the cancer coming back. But this is not correct. To explain, let's first discuss - how and where does a cancer come back?

A breast cancer can 'come back' (recur) in two ways:
1. 'Locally' - around the same area, where the breast is or the breast was.
2. 'Distant' - elsewhere - liver, lung, bone, nodes around the windpipe, in the abdomen, brain, anywhere basically.
A 'Local Recurrence' still has a chance of cure. A 'Distant Recurrence' would be near impossible to cure.

So understanding the 'recurrence' above, please note this statement: If the surgery is done by a Qualified Surgical Oncologist, whether the breast is removed (Mastectomy) or the breast is not removed (Breast Conserving Surgery), the chances of a 'Distant Recurrence' are the same (there is no difference); but, the chances of 'Local Recurrence' are more if the breast is not removed as compared to when it is removed. One should not worry much about this 'local recurrence' part and definitely opt for a Breast Conserving Surgery (if surgically feasible); in BCS, we compulsorily give Radiation to the breast which will reduce chances of cancer coming back 'locally' and besides, the patient is on a regular follow up with us, so that, in case, something comes up in the breast, we can always treat again.

So now that we have sorted out the issue of recurrence, let's focus on surgeries for breast cancer:
1. Breast Conservative Surgery - Breast is not removed
2. Modified Radical Mastectomy - Breast is removed
3. Reconstruction - Some additional surgery is done to re create the breast.

Breast Conserving Surgery (BCS)

A BCS can be done in almost 60 to 70% of all breast cancers. The first step is to rule out situations where it cannot be done:

More than one tumour in the breast - called as 'Multicentric tumour'. We come to know, if a tumour is 'multicentric' on mammography.
Large tumours - Here we give chemotherapy first, and if tumour shrinks, a BCS may be possible. If it doesn't shrink, then the breast will have to be removed.
BRCA 1/2 Mutation Positive patients - Even if tumour is small, conservation is not advisable.
Patient not suitable for Radiation Therapy - some very old patients, with heart issues and such.

Once a surgeon makes sure that a conservative surgery can be done, he plans a conservative surgery by considering the following:
Location of the tumour - Is it in 'centre' (behind the nipple and areola) or is it away, in one of the corners?
Ratio of the size of tumour to the size of breast - will the removal of tumour cause a 'loss of bulk' of breast?
Will I need some special form of plastic surgery - an Oncoplasty - or a formal reconstruction by involving a Plastic Surgeon?

In the image, the two cuts of the BCS are shown by numbers 1 and 2 and an image of a breast conservative surgery is shown below that:

1. The tumour incision: This is an 'elliptical' cut around the tumour
2. A separate cut in the armpit, to remove the nodes
So basically, a Breast Conservative Surgery is a huge topic by itself. The above is just to give you a rough idea on what and how we plan.

Breast Conserving Surgery depiction.
Breast Conserving Surgery marking during surgery.
Breast Conserving Surgery post surgery scar.
Mastectomy tumour and marking of surgery

Modified Radical Mastectomy

Mastectomy means removal of the breast. We do a mastectomy in the following situations:

Multicentric tumour - There is more than one tumour in the breast, seen on mammography.
Large single tumours not shrinking by chemotherapy
BRCA 1/2 Mutation positive patients
Patient choice - sometimes, even when conservation is possible, patients opt for a mastectomy

In patients going for mastectomy, a choice of reconstruction is usually given. However, in some aggressive cancers, where there are lots of nodes positive and not responding to chemotherapy, we advise reconstruction later on, after a few years, once all treatment is over.
In the image above, the large tumour is shown which has not responded to chemotherapy. Hence the patient has come up for Mastectomy. The incision ('cut') is in the form of a 'tear drop'. There is only one large cut in mastectomy, shown by black line labelled '1' in the image. From that cut only, we can remove all the lymph nodes in the armpit.


Reconstruction means, doing a procedure (usually by a Plastic Surgeon team), in addition to either BCS (Breast Conserving Surgery) or MRM (Modified Radical Mastectomy), to achieve a good cosmetic outcome. In a BCS, if the tumour is large, there will be a big 'defect' or 'hole' which needs to be filled up to give shape to the breast. In Mastectomy, the whole breast is being removed and we need to recreate the whole breast. Follwoing are some examples of reconstruction:

Oncoplasty: This involves rotating local fat in the breast. However, it can be done only in select few cases.
Fat grafting: for smaller defects
Silicone Implants
Pedicled Flaps: A muscle (usually from back) along with overlying area of skin, is rotated and brought into the area of breast to give shape
Free Flaps: These are the most advanced and best forms of reconstructions. A muscle along with area of skin and 'live' blood supply, is disconnected from one area and brought into area of the breast, where the tiny blood vessels of the muscle are 'joint' to blood vessels in the area of breast

Please Note:

The topic - 'Surgery for breast Cancer' is so vast, it's a book by itself! So it's just not possible to write everything here in short. Our aim here, is to give you a fair idea, to help you in decision making. There are many topics listed below, which we have not covered above at all, and we will encourage you to read them on Dr. Google:

Axillary Lymph Node Dissection - why and how much to be done
Sentinel Lymph Node Biopsy
All procedure as mentioned in the reconstruction
Of course, as time goes, we will keep on adding more and more topics.

Our Approach at this Step

After reviewing breast examination findings for my patient, and reviewing her mamography and PET CT reports, and keeping in mind, her age and fitness, my focus is now to guide the patient on what surgery is feasible. In most cases, a conservative surgery will be feasible. While in some, it won't be possible and we have to remove the breast. Like I mentioned above, quite a few patients are wary of conservative surgery due to fear of recurrence. I always ask the patient, why so; I prefer to see what the patient is thinking, and then, if i believe that there is a misconception in the patient's mind, I try to clear it. After a healthy discussion (sometimes, multiple sessions of discussion), the patient comes to a decision. When given the option of BCS, I manage to convince most of my patients about its safety. There are some though, who opt for Mastectomy, with a cool mind (after understanding everything), and well, fair enough, every one has their own choice, ultimately. As long as I have done my job of clarifying to the last word, I think it's fine. My aim is always to help the patients take an 'informed decision' and not decisions based on myths and misconceptions in their mind. Also, I always talk about reconstruction, where needed, and involve my Plastic Surgery colleagues for the same, who counsel the patient about the optinos of reconstruction. So now, the decision of type of surgery is done, and next we plan, where to do the surgery. I guide them to hospitals where I am attached and the patient selects one, according to their comfort.

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Journey of BC: Diagnosis

1. I feel a lump! - The first visit to doctor
2. Is it really cancer? - Confirmatory tests
3. What is the stage? - Staging and fitness tests
4. Will it be surgery first? or chemo first? - Treatment planning and sequence

Journey of BC: Surgery

5. Should I conserve or remove breast? - Choice of Surgeries for breast cancer - You are presently on this page
6. How long will be the surgery? - Admission and Surgery
7. Care after surgery - Precautions and guidelines
8. What next? - The Pathology Report

Journey of BC: Further Treatment

9. How many chemo cycles? - Chemotherapy Consultation
10. Is a PORT necessary? - ChemoPORT insertion
11. Will I be normal during chemo? - The Chemotherapy time
12. Is Radiation painful? - Radiation Therapy
13. Yes!! I did it! - Treatment is over
14. How frequently do I meet doc? - Follow up guidelines

Other Topics

Risk Factors - The Risk Factors for Breast Cancer
Symptoms of Breast Cancer - Know the Symptoms of Breast Cancer
Early Detection of Breast Cancer - The Guidelines

Neo Adjuvant Chemotherapy (NACT) - For LABC
Sentinel Node Biopsy - How is it done?
Targeted Therapy - Trastuzumab
Hormone Therapy - Who gets it?