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Breast cancer is the most common cancer in women in the United States with constantly evolving treatment guidelines. The treatment of breast cancer often involves surgery, including breast conservation surgery or mastectomy. This activity outlines the surgical management of breast cancer and reviews the role of the interprofessional team in evaluating and treating patients who undergo surgery for breast cancer. Objectives: Identify the anatomical structures, indications, and contraindications involved in the surgical treatment of breast cancer. Describe the equipment, personnel, preparation, and technique in regard to the surgical treatment of breast cancer. Review appropriate evaluation of the potential complications and clinical significance of the surgical treatment of breast cancer. Summarize interprofessional team strategies for improving care coordination and communication to advance the treatment of breast cancer and improve outcomes. Access free multiple choice questions on this topic.

Breast cancer is the most common cancer of women in the United States (US). As of 2018, 1 in 8 women in the US will have had a diagnosis of invasive breast cancer in their lifetime. The management of breast cancer is in constant evolution.  Fortunately, survival rates continue to improve, likely due to improved individualized treatment as well as earlier detection. Surgery has been a mainstay of breast cancer treatment for several decades. It is often the sole treatment in the management of early-stage breast cancer.  Understanding the current recommendations for surgical treatment is vital in the accurate diagnosis, staging, and treatment of patients with breast cancer. Multiple landmark studies published in the last several decades have led to the transition from more radical options, such as radical mastectomy, towards breast-conserving surgery (BCS). The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 was instrumental in this transition. The study examined radical mastectomy to total mastectomy with or without radiation therapy. In patients who underwent a total mastectomy, axillary dissection was only necessary for the setting of positive lymph nodes. The NSABP B-04 trial confirmed there was no difference in disease-free survival, relapse-free survival, distant-disease-free survival, or overall survival between those who received total mastectomy or radical mastectomy. This development led to an overall shift away from radical surgical intervention.[1] To further direct treatment away from radical approaches, the NSABP B-06 trial was a randomized prospective study that included women with tumors less than 4 cm and compared mastectomy, lumpectomy, or lumpectomy with radiation. All women in the study also underwent axillary lymph node dissection as part of their surgical treatment. The study found no difference in disease-free, distant-disease-free, or overall survival between groups. Additionally, there was a significant decrease in local recurrence rates when lumpectomy was supplemented with radiation therapy, rather than lumpectomy alone.[2] This study was monumental in the evolution away from mastectomy towards breast-conserving surgery in women with early-stage invasive breast cancer.

Multiple landmark studies published in the last several decades have led to the transition from more radical options, such as radical mastectomy, towards breast-conserving surgery (BCS). The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 was instrumental in this transition. The study examined radical mastectomy to total mastectomy with or without radiation therapy. In patients who underwent a total mastectomy, axillary dissection was only necessary for the setting of positive lymph nodes. The NSABP B-04 trial confirmed there was no difference in disease-free survival, relapse-free survival, distant-disease-free survival, or overall survival between those who received total mastectomy or radical mastectomy. This development led to an overall shift away from radical surgical intervention.[1] To further direct treatment away from radical approaches, the NSABP B-06 trial was a randomized prospective study that included women with tumors less than 4 cm and compared mastectomy, lumpectomy, or lumpectomy with radiation. All women in the study also underwent axillary lymph node dissection as part of their surgical treatment. The study found no difference in disease-free, distant-disease-free, or overall survival between groups. Additionally, there was a significant decrease in local recurrence rates when lumpectomy was supplemented with radiation therapy, rather than lumpectomy alone.[2] This study was monumental in the evolution away from mastectomy towards breast-conserving surgery in women with early-stage invasive breast cancer. Despite these advances indicating similar overall survival between mastectomy and BCS when combined with radiation therapy, in recent years, mastectomy rates have continuously been increasing in number.  There are a variety of theories regarding this, but most attribute the rate of increase to younger patient age, genetic testing, patient education, and the increasing availability of reconstruction options. Also, the use of magnetic resonance imaging (MRI) of the breast has shown recent interest, particularly in patients with dense breasts, positive family history, or difficulty in characterizing a breast tumor following diagnosis.[3] It is important to note, however, that studies have demonstrated that the use of MRI has a positive correlation with mastectomy rates, despite no increase in survival.[4]

Generally speaking, surgery for breast cancer is a low-risk procedure.  However, a multitude of complications can occur for both lumpectomy and/or mastectomy. In a lumpectomy, positive margins requiring re-excision or mastectomy may occur. Additionally, both procedures may lead to a seroma, hematoma, infection, or skin necrosis. Injury to surrounding blood vessels, including the axillary vein, may occur. Nerve injury or transection may also occur, leading to sensory or motor defects. An additional complication includes lymphedema, which may occur particularly in the setting of complete axillary node dissection.

Breast cancer involves an interprofessional team to achieve the best possible outcomes. This team includes oncologic and plastic surgeons, medical oncology, radiation oncology, pathology, radiology, nurse navigators, and multiple other individuals to discuss each patient and formulate a treatment plan. Oncology specialty nursing staff will assist during procedures, provide post-procedural follow-up care, and administer medication, and answer patient questions. These nurses must keep the clinician staff up to speed on all developments for the patient's progress or lack thereof. In cases where chemotherapy will be an adjunct, a board-certified oncology pharmacist should work with the oncology team to select the appropriate agents, verify dosing, and counsel the patient on adverse effects, also reporting any concerns to the team. The outcomes for patients with breast cancer continue to improve with the increased use of interprofessional teams, as demonstrated in multiple retrospective studies.

Nurses are especially crucial in the care of patients with breast cancer undergoing surgery. Many cancer care centers employ nurse navigators or specialized oncology nurses who can guide patients through each step of treatment and answer any questions that the patient or family may have.  Additionally, nurses are especially crucial in patients who have drains placed, as proper drain care is essential to prevent infection and other complications from occurring. This care involves teaching the patient about their drains so they can properly care for themselves after discharge. Most patients do not require much pain medication following breast cancer surgery. However, if discharged with medication, especially opioids, the nurse needs to review these medications with the patient for safety purposes.

Nurses must be aware of the potential complications of these procedures to properly monitor patients in the postoperative period.  In particular, monitoring the incision for any hematoma or seroma formation to let the surgeon know of any complications that may occur. Also, if drains are present, monitoring the quality and quantity of output is essential.