Considering a Mastectomy? What to Know Before Breast Cancer Surgery

Dr Chong Chee Keong Breast, Colorectal and General Surgeon MBBS (Singapore), FRCS (Edinburgh), FRCS (Glasgow), FAMS (Singapore) Specialist Accreditation in Intensive Care Medicine Specialists Accreditation Board, Medical Director & Senior Consultant

A mastectomy is an operation to remove breast tissue, most commonly as part of breast cancer treatment and, in selected high-risk patients, to reduce the risk of developing breast cancer. It is not automatically necessary after a breast cancer diagnosis, as some patients may be suitable for breast-conserving surgery instead.

When surgery is needed, one of the more difficult decisions can be whether the breast can be safely conserved or whether a mastectomy is the more appropriate option. The answer depends on the cancer itself as well as what each surgical approach would mean for treatment afterwards.

Understanding these considerations before surgery can make discussions with your breast cancer surgeon more useful, particularly when more than one medically appropriate option is available.

When Is a Mastectomy Recommended for Breast Cancer?

A mastectomy may be recommended when breast-conserving surgery is unlikely to remove the cancer adequately or is otherwise unsuitable. In some situations, both approaches may be medically reasonable, allowing the patient's preferences to play a greater role in the decision.

When Breast-Conserving Surgery May Not Be Suitable

Breast-conserving surgery removes the cancer with a margin of surrounding tissue while preserving the remainder of the breast. A mastectomy may be considered when breast conservation is unlikely to remove the disease adequately or would leave too little breast tissue for an acceptable result.

Situations that may favour mastectomy include:

• Cancer affecting separate areas of the breast that cannot reasonably be removed together
• Persistent cancer cells at the surgical margin after previous breast-conserving surgery
• A tumour that is large relative to the breast and cannot be sufficiently reduced before surgery
• Circumstances in which the radiotherapy usually required after breast-conserving surgery is unsuitable

For appropriately selected patients with early breast cancer, breast-conserving surgery followed by radiotherapy and mastectomy can provide comparable survival outcomes. Where both approaches are suitable, the decision can therefore involve both oncological considerations and the patient's preferences.

Can Treatment Before Surgery Change the Options?

The operation recommended at diagnosis is not always the operation ultimately performed. For some breast cancers, systemic treatment may be given before surgery to reduce the size or extent of the tumour.

If the cancer responds well, breast-conserving surgery may become possible for a patient who might otherwise have required a mastectomy. Whether this approach is appropriate depends on the characteristics of the cancer and the wider treatment plan.

When Is Preventive Mastectomy Considered?

Preventive, or risk-reducing, mastectomy may be considered by some people who do not have breast cancer but have a substantially increased lifetime risk of developing it. This is most relevant to individuals with certain inherited genetic changes or a particularly strong family history.

The decision usually follows specialist risk assessment and genetic counselling. Alternatives such as enhanced breast screening may also be discussed, as preventive mastectomy is not appropriate for everyone at increased risk.

What Should Be Discussed Before a Mastectomy?

Once a mastectomy is being planned, the operation itself is only part of the discussion. Your surgeon will also consider whether lymph node surgery is needed, whether breast reconstruction is appropriate and how the operation fits with the rest of your cancer treatment.

Do You Want Breast Reconstruction?

Breast reconstruction can restore breast shape after a mastectomy, but it is optional and not required as part of breast cancer treatment. Some patients choose reconstruction, while others prefer to remain flat or use an external breast prosthesis.

If reconstruction is being considered, it may be performed during the same operation as the mastectomy or at a later stage. The timing and type of reconstruction depend on factors such as the planned cancer treatment, previous surgery and whether implant-based or tissue-based reconstruction is suitable.

These options are ideally discussed before the mastectomy so that breast cancer and reconstructive surgery can be planned together where appropriate.

Will Lymph Nodes Need to Be Removed?

Breast cancer surgery may include assessment of the lymph nodes under the arm because their involvement can affect cancer staging and subsequent treatment. The extent of lymph node surgery depends on what is already known about the cancer before the operation.

Some patients undergo a sentinel lymph node biopsy, which examines the first lymph nodes most likely to receive cancer cells from the breast. More extensive lymph node surgery may be required in selected cases where cancer has been identified or further assessment is necessary.

Your surgeon can explain whether lymph node surgery is recommended alongside the mastectomy and what this may mean for risks such as lymphoedema.

Will I Still Need Treatment After a Mastectomy?

A mastectomy does not necessarily complete breast cancer treatment. Depending on the cancer and the final pathology findings, further treatment may still be recommended to reduce the risk of recurrence.

For example, chemotherapy or radiotherapy may be advised in some patients, while hormone or targeted therapies may be used when the cancer has specific biological features. Your treatment team will consider the pathology results after surgery alongside information already gathered before the operation.

This is why choosing a mastectomy should not be viewed as a way to automatically avoid chemotherapy or radiotherapy.

What Should You Expect Before and After a Mastectomy?

Recovery after a mastectomy varies between individuals and depends on the extent of surgery, whether lymph node procedures were performed and whether breast reconstruction was carried out at the same time. Knowing what to expect can help you prepare for the weeks and months ahead.

How Can You Prepare for a Mastectomy?

Before surgery, you may undergo a pre-operative assessment to check your general health and identify anything that could affect the operation or recovery. Your care team will also advise you about medications that may need to be temporarily adjusted and any instructions for the day of surgery.

It is also worth planning for the first stage of recovery at home, particularly if you normally manage work, caregiving or physically demanding household tasks without assistance.

Will You Have Surgical Drains After a Mastectomy?

Some patients have one or more surgical drains placed after a mastectomy to remove fluid from the operated area. Whether drains are needed and how long they remain in place depends on the operation performed and the surgeon's approach.

If you go home with a drain, your care team will explain how to manage it and when it is likely to be removed. The length of the hospital stay also varies, particularly when breast reconstruction is performed at the same time.

What Are the Possible Complications of a Mastectomy?

As with any operation, a mastectomy carries risks such as bleeding, infection and problems with wound healing. Fluid may also collect beneath the skin after surgery, known as a seroma.

Some effects are more specific to breast surgery. Numbness or altered sensation around the chest is common because nerves may be affected during the operation. If lymph nodes are removed, there may also be a risk of lymphoedema affecting the arm.

Your individual risk depends partly on the extent of surgery and whether additional procedures, such as lymph node surgery or reconstruction, are performed.

How Long Does Recovery After a Mastectomy Take?

Recovery varies according to the extent of the operation. In the early weeks, discomfort, swelling and tightness around the chest are common, and shoulder movement may initially feel restricted.

Everyday activities can usually be reintroduced gradually as healing progresses, but returning to work or exercise depends on the demands involved and your surgeon’s advice. Recovery generally takes longer when breast reconstruction is performed at the same time.

You may also be given exercises to help restore shoulder and arm movement after surgery, particularly if lymph node surgery has been performed.

Discuss Your Breast Cancer Surgery Options with Dr Chong

When more than one surgical approach may be possible, discussing the differences between breast-conserving surgery and mastectomy can help you understand what each option would mean for your wider treatment. Your surgeon can also explain how reconstruction or lymph node surgery may fit into the operative plan where relevant.

At Maven Surgery, patients with breast cancer can receive surgical assessment and treatment planning as part of their wider cancer care. Dr Chong Chee Keong is a breast, colorectal and general surgeon with over 20 years of clinical experience. He works with multidisciplinary cancer teams where appropriate so that surgical decisions can be considered alongside other parts of breast cancer treatment.

If you have been diagnosed with breast cancer and are considering your surgical options, speak with Dr Chong about whether breast-conserving surgery or mastectomy may be appropriate for your situation.

Frequently Asked Questions (FAQs) About Mastectomy