Ask The Experts: When do breast cancer patients need a total mastectomy?

Breast removal surgery is not always necessary – and even when done, is only one part of cancer treatment, shares senior consultant and breast surgeon, Dr Chan Ching Wan

Patients with advanced-stage breast cancer may wonder if a total mastectomy is necessary. Here’s what you need to know before opting for this surgery. PHOTO: SOLIS BREAST CARE AND SURGERY CENTRE

Cancer is the leading cause of death in Singapore and the most common type that
afflicts women is breast cancer, with over 2,000 cases being diagnosed every year.
Nearly 1 in 12 women in Singapore will be diagnosed with breast cancer in their lifetime.

One in four women with the disease is at an advanced stage of it, with 15 per cent
presenting in stage 3 and 10 per cent in stage 4, according to Dr Chan Ching Wan, a
senior consultant and breast surgeon at Solis Breast Care and Surgery Centre.

The rest of breast cancer patients – at 75 per cent – present with early stage disease,
she adds.

Early detection of the disease offers a high chance of recovery. For some patients
whose conditions take a turn for the worse, they may wonder if they will have to go for a mastectomy to surgically remove one or both their breasts, or risk losing their lives. But the fact is that it is no longer true that mastectomy is necessary to combat late-stage breast cancer.

Dr Chan says: “Patients presenting with late-stage breast cancer all go for chemotherapy as first treatment. Half of those with stage 3 cancer may no longer need a mastectomy, but the other half will still need it.

“Patients with stage 4 cancer do not routinely need surgery, unless there are specific
skin care problems.”

A mastectomy does not offer a cancer-free guarantee. That is why senior consultant and breast surgeon, Dr Chan Ching Wan, recommends every woman to conduct self-checks and go for screening regularly for early detection of breast cancer. PHOTO: SOLIS BREAST CARE AND SURGERY CENTRE

Understanding mastectomy

There is only one type of mastectomy, which is the removal of all breast tissue possible.

The procedure is normally needed when there are multiple areas in different regions of the breast with cancer, or if the size of the cancer takes up at least 25 per cent of the size of the original breast as this does not allow for good re-shaping of the remaining breast to maintain a reasonable contour and shape.

A mastectomy is also required if patients have other medical conditions that do not
allow radiation to be safely performed.

“A mastectomy is not always necessary. If the cancer can be removed, and there is still enough breast tissue remaining that can be reshaped to retain the normal shape of the breast (although slightly smaller than before), then breast conserving surgery can be performed,” says Dr Chan.

There are variations of mastectomy, depending on breast reconstruction plans. Some considerations include whether all the skin (and the nipple complex) can be saved to perform a nipple-sparing mastectomy, or whether only the skin can be saved while sacrificing the nipple for a skin-sparing mastectomy.

As with any surgery, there is risk involved. A nipple sparing mastectomy, for instance, requires the surgeon to remove as much breast tissue as possible. In this case, Dr Chan shares, blood supply to the skin or nipple complex can be affected and the affected areas of skin or nipple complex can die, leading to darkening of the areas and formation of a scab that will eventually fall off. But these have minimal impact on the patient’s health after the surgery.

Although rare, risky scenarios of significant bleeding or wound infections can occur. A bad infection could lead to delayed treatment and also impact the appearance of the resultant scar from the surgery.

A mammogram is the most reliable screening tool for breast cancer. From age 40 to 49, women are recommended to go for mammogram screening once every year, and once every two years from age 50. PHOTO: SOLIS BREAST CARE AND SURGERY CENTRE

Key considerations for mastectomy

Breast cancer patients considering mastectomy may have further treatment after the surgery and must be aware that the cancer may return.

“Surgery is only one part of cancer treatment. Chemotherapy and radiation therapy
(when necessary) are equally important and play key roles to help control the cancer and minimise a chance of relapse. While the mastectomy aims to remove as much breast tissue as possible, there are usually small pockets that will remain. Therefore, it is possible that breast cancer could return. Fortunately, this is rare with good treatment and control,” says Dr Chan.

Removing both breasts is not necessary unless the patient carries a genetic mutation. It is advisable that patients below 45 years old should consider having genetic testing done to find out more before making a decision.

Dr Chan highlights three main things to bear in mind before opting for a mastectomy:

1. Quality of life post-surgery
The main issues are usually psychological, especially when patients choose to forgo
reconstruction, and hence end up with a flat chest on the operated side. This can lead to loss of self-confidence, depression and patients withdrawing socially from close family members and friends.

2. Recovery concerns
Physical recovery is usually smooth, even in patients with other problems such as
diabetes. Mental recovery is more challenging unless patients know what to expect and have had some mental preparation about how they will look.

3. Breast reconstruction
Immediate reconstruction is the recommended procedure today, unless the patient’s cancer is aggressive and carries a high risk of early relapse. Patients can choose to use their bodies’ natural tissues or artificial implants in breast reconstruction, depending on their lifestyle or expectations. Another option is to treat excess skin on the breast as an implant, depending on suitability, however patients who ‘qualify’ for this are few in number.

A mastectomy does not offer a cancer-free guarantee and Dr Chan recommends that breast cancer patients seek medical advice on the next course of action. Additionally, every woman should run self-checks for all lumps in the breasts and go for regular screening.

After all, early breast cancer detection can save breasts, and lives.

Make your mammogram appointment today at 6994 5477 or 8435 4167 (WhatsApp). For more information, visit

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