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Answer five questions about the cancer and about what you want, and read the statements that apply, quoted word for word from NICE NG101 and from the trials that followed people for twenty years. An educational aid to prepare for the conversation with your surgeon, not advice, and not a prediction about you. Nothing you enter leaves this page.
Answer the 5 questions and the statement that applies to that combination appears here, quoted word for word from NICE NG101: early and locally advanced breast cancer, recommendations (2018, updated 2025) and the sources listed below, with a plain line on what it means and the questions to take to your surgeon.
Without JavaScript, every statement the aid can show is listed further down the page. This is an educational aid, not advice.
The aid picks from these 18 cards; each quotes its source word for word. Read them all here, with or without the questions above.
“After a median follow-up of 20 years, the rate of death from all causes was 41.7 percent in the group that underwent breast-conserving surgery and 41.2 percent in the radical-mastectomy group (P=1.0). The respective rates of death from breast cancer were 26.1 percent and 24.3 percent (P=0.8).”
“No significant differences were observed among the three groups of women with respect to disease-free survival, distant-disease-free survival, or overall survival.”
What this means: This card is shown whatever you answer, because it is the sentence everything else hangs on. The Milan trial randomised 701 women with cancers no larger than 2 cm to radical mastectomy or to quadrantectomy with radiotherapy; NSABP B-06 randomised 1,851 women to total mastectomy, lumpectomy alone or lumpectomy with radiotherapy. Both followed people for twenty years and found no survival difference. Those are cohorts treated decades ago with the surgery and drugs of the time, and neither says anything about what will happen to you. What they establish is that keeping the breast, where the cancer allows it, did not cost survival.
“Breast surgeons will try to do an operation that means you can keep your breast (breast-conserving surgery). But sometimes they may recommend a mastectomy.”
“Offer whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins.”
What this means: Removing the cancer with a rim of healthy tissue and keeping the rest of the breast is what surgeons aim for when the cancer is a single area and small enough relative to the breast for the result to look acceptable. It comes with radiotherapy attached, and with a chance of a second operation if the margins are not clear. Neither of those is a reason not to do it; they are the things to know before you agree.
“Breast surgeons will try to do an operation that means you can keep your breast (breast-conserving surgery). But sometimes they may recommend a mastectomy. This may be when: the lump is large compared to the rest of your breast”
“Reshaping might be an option if you need part of your breast removed and you have quite large breasts. It is called therapeutic mammoplasty. The surgeon removes the tumour and an area of surrounding healthy tissue. They then reshape the remaining breast tissue to create a smaller breast.”
What this means: The ratio between the cancer and the breast, not the size of the cancer alone, is what decides whether conserving surgery leaves an acceptable shape. Where the ratio is awkward there are two ways forward: reshaping the breast at the same operation, sometimes with a reduction on the other side to match, or a mastectomy. Both are reasonable, and this is the point at which what you want about your own body is part of the clinical answer rather than an afterthought. If a mastectomy is what you choose, the reconstruction recommendations on the decisions page apply.
“Breast surgeons will try to do an operation that means you can keep your breast (breast-conserving surgery). But sometimes they may recommend a mastectomy. This may be when: the lump is large compared to the rest of your breast, there is cancer in different parts of the breast, this is called multicentric breast cancer, there is widespread DCIS in the breast, the cancer is on the skin or in underlying muscle, you have had radiotherapy to the chest before to treat another cancer, such as a previous breast cancer or Hodgkin lymphoma, you have a family history of breast or ovarian cancer and have tested positive for a gene mutation.”
What this means: Where the cancer sits in more than one part of the breast, or where there is widespread DCIS, conserving surgery cannot reliably remove all of it and leave a breast worth keeping. That makes the mastectomy a recommendation rather than a preference. What remains a choice is what happens next: immediate reconstruction, delayed reconstruction, or none.
“But sometimes they may recommend a mastectomy. This may be when: you have had radiotherapy to the chest before to treat another cancer, such as a previous breast cancer or Hodgkin lymphoma”
“Offer whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins.”
What this means: Conserving surgery works because radiotherapy follows it, and the same breast cannot usually be given a full course twice. If you have had radiotherapy to this breast or to the chest before, that is normally the reason a mastectomy is being recommended, rather than anything about the cancer itself. It is worth having it said out loud so you know which constraint you are working within.
“Offer 26 Gy in 5 fractions over 1 week for people with invasive breast cancer having partial-breast, whole-breast or chest-wall radiotherapy, without regional lymph node irradiation, after breast-conserving surgery or mastectomy.”
“Offer 40 Gy in 15 fractions over 3 weeks for people with invasive breast cancer having regional lymph node irradiation, with or without whole-breast or chest-wall radiotherapy, after breast-conserving treatment or mastectomy.”
“Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10.”
What this means: For most people that is five sessions over one week, or fifteen over three weeks if the lymph nodes are being treated or there is a reason such as an implant reconstruction. The meta-analysis of 10,801 women in 17 randomised trials found radiotherapy cut the 10-year risk of any first recurrence from 35.0 to 19.3 percent and the 15-year risk of breast cancer death from 25.2 to 21.4 percent. It is not an optional extra on the end of the operation; it is part of what makes conserving surgery as safe as a mastectomy.
“Consider not using radiotherapy for women who: have had breast-conserving surgery for invasive breast cancer with clear margins and have a very low absolute risk of local recurrence (defined as women aged 65 and over with tumours that are T1N0, ER-positive, HER2-negative and grade 1 to 2) and are willing to take adjuvant endocrine therapy for a minimum of 5 years.”
“without radiotherapy, local recurrence occurs in about 50 women per 1,000 at 5 years, and with radiotherapy, occurs in about 10 women per 1,000 at 5 years”
“overall survival at 10 years is the same with or without radiotherapy”
What this means: This is one of the few places in breast cancer where NICE writes down both numbers and hands you the choice. Leaving radiotherapy out roughly quintuples the chance of the cancer coming back in that breast over five years, from about 1 in 100 to about 5 in 100, and does not change survival at ten years. NICE also says there is no increase in serious late effects from having it in this low-risk group. The trade is five sessions and some skin change against a small extra chance of a further operation later. Check first that you actually meet every part of the definition, because it is narrow.
“Offer adjuvant postmastectomy radiotherapy to people with node-positive (macrometastases) invasive breast cancer or involved resection margins.”
“Consider adjuvant postmastectomy radiotherapy for people with node-negative T3 or T4 invasive breast cancer.”
“Do not offer radiotherapy following mastectomy to people with invasive breast cancer who are at low risk of local recurrence (for example, most people who have lymph node-negative breast cancer).”
What this means: People often choose a mastectomy partly to avoid radiotherapy, and for lymph node-negative disease that usually works. Where the lymph nodes contain macrometastases, or the margins are involved, NICE offers radiotherapy after the mastectomy as well, so the operation would be the bigger one and the radiotherapy would still happen. Since the node result often is not known until after surgery, this is a possibility to understand before you decide rather than a certainty either way.
“Offer further surgery (re-excision or mastectomy, as appropriate) after breast-conserving surgery where invasive cancer or DCIS is present at the radial margins ('tumour on ink'; 0 mm).”
“Consider further surgery (re-excision or mastectomy, as appropriate) after breast-conserving surgery for invasive cancer with or without DCIS if tumour cells are present within 1 mm of, but not at, the radial margins (greater than 0 mm and less than 1 mm).”
What this means: After the operation a pathologist measures how close the cancer came to the edge of what was taken out. Cancer at the inked edge means another operation is offered; within 1 mm it is considered, with the decision made with you. NICE moved that threshold from 2 mm to 1 mm in 2024 and said why: a smaller margin is likely to achieve better breast preservation and fewer additional surgeries, and repeated surgeries damage the appearance of the breast, affect self-esteem and are traumatic. Rates of further surgery vary between units, which makes it a fair thing to ask about here.
“Perform surgery using sentinel lymph node biopsy (SLNB) rather than axillary lymph node clearance to stage the axilla for people with invasive breast cancer if they have: no evidence of lymph node involvement on ultrasound or a negative ultrasound-guided needle biopsy.”
“Offer further axillary treatment (axillary node clearance or radiotherapy) after SLNB to people who have 1 or more sentinel lymph node macrometastasis.”
What this means: A sentinel node biopsy takes the first one to three nodes the breast drains to, which is enough to tell whether the cancer has reached the armpit, and leaves the rest. It is the single biggest thing that reduces lifelong arm swelling. If one of those nodes turns out to contain a macrometastasis, NICE offers either clearance or radiotherapy to the armpit as the next step, and those two differ a great deal in what they cost the arm.
“Offer axillary node clearance to people with invasive breast cancer who have a preoperative ultrasound-guided needle biopsy with pathologically proven lymph node metastases.”
“ALND was associated with a higher lymphedema rate in updated 5-year analyses (24.5% v 11.9%; P < .001).”
What this means: Where a needle biopsy has already shown cancer in a node before surgery, NICE offers clearance of the armpit rather than a sentinel node biopsy. That is the operation with the highest lymphoedema risk, so this is the point at which the arm needs the most attention: baseline measurement before surgery, the early signs explained, supervised physiotherapy, and a clear route to a lymphoedema service. The AMAROS figures above compare clearance with axillary radiotherapy in people whose node was found positive at sentinel node biopsy rather than beforehand, so they are not directly your situation, but they are the best measure of what clearance costs the arm.
“For people having investigations for early and locally advanced invasive breast cancer: perform pretreatment ultrasound evaluation of the axilla and if abnormal lymph nodes are identified, perform ultrasound-guided needle sampling.”
What this means: NICE asks for the armpit to be scanned before treatment and any abnormal node sampled with a needle, because that result decides which armpit operation you have and therefore most of your long-term arm risk. If nobody has told you the result, it is worth asking for it before the operation is booked rather than after.
“Offer breast reconstruction to people after they have had mastectomy for breast cancer.”
“Offer both breast reconstruction options to women (immediate reconstruction and delayed reconstruction), whether or not they are available locally.”
“Offer immediate breast reconstruction to women who have been advised to have a mastectomy, including those who may need radiotherapy, unless they have comorbidities that rule out reconstructive surgery.”
What this means: Two sentences here are worth carrying into the room. Both timings must be offered even where the local service does only one, which is grounds for a referral elsewhere. And needing radiotherapy is not by itself a reason to refuse immediate reconstruction, although it does change which kind is sensible: NICE notes that implant-based reconstructions may be more affected by radiotherapy than flap reconstructions, and Cancer Research UK describes the usual route of a tissue expander first and an exchange after radiotherapy. Expect more than one operation either way.
“Be aware that some people may prefer not to have breast reconstruction surgery.”
“Some people choose not to have breast reconstruction. Your surgeon and breast care nurse will talk to you about all your options. They will explain the advantages and disadvantages to help you make the right decision for you.”
What this means: NICE puts this sentence immediately after the one requiring reconstruction to be offered, which is the guideline saying that declining is an answer rather than a failure to decide. What is worth asking for anyway is a flat closure done well, because a chest wall left even and without loose skin is a surgical result in its own right, and a prosthesis fitting service if you want one. You can change your mind later: delayed reconstruction stays possible for years.
“More than 1 operation is usually needed to complete the reconstruction”
“No clear differences in satisfaction with completed reconstructions”
“The new breast will feel and look different to the one removed. But some women find that immediate reconstruction helps them to cope more easily with their feelings about the loss of a breast.”
What this means: Immediate means waking with a shape, usually fewer operations and less scarring because the existing skin is used, but limited time to decide and a risk that a complication delays chemotherapy, which works best started within six weeks of surgery. Delayed means a period with no breast, which a prosthesis can fill, but time to choose, time to lose weight or stop smoking first, and a reconstruction that cannot be derailed by cancer treatment. NICE found no clear difference in satisfaction with the finished result either way. Whichever you choose, the reconstructed breast is a shape rather than a restored breast, and it has little sensation.
“If you have a large amount of breast tissue taken you may be left with a dent in the breast. This means the treated breast ends up looking much smaller than the other breast. But it is sometimes possible to get back the shape. Your surgeon may suggest a partial reconstruction of the breast.”
“You may still need radiotherapy to the remaining breast tissue to reduce the risk of the cancer coming back.”
What this means: Conserving surgery can leave a dent, and radiotherapy afterwards can make the breast smaller and firmer over time, so the two breasts may not match. Filling the dent with nearby tissue, or reshaping the breast at the same operation, is often possible and is best planned before rather than after. If a mastectomy ends up being the choice instead, the reconstruction recommendations on the decisions page apply.
“Inform people having breast cancer treatment about their risk of developing lymphoedema after treatment. Before treatment starts, give them information in a suitable format to take away and refer to.”
“Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema.”
What this means: Lymphoedema is decided by what happens to the armpit rather than to the breast, it is lifelong once it starts, and nearly everything that reduces it is arranged in the first month: the smallest armpit operation the cancer allows, radiotherapy instead of clearance where that is an option, a baseline measurement of the arm, the early signs explained, and a route to a lymphoedema service that does not depend on you finding it. NICE requires the information before treatment starts. If nobody has given it to you, ask.
“When discussing the benefits and risks of further surgery, follow the recommendations on: enabling patients to actively participate in their care in NICE's guideline on patient experience in adult NHS services and communicating risks, benefits and consequences in NICE's guideline on shared decision making.”
What this means: Shown last whatever you answered. Nothing in this aid is a recommendation for you: it is the set of statements that apply to the answers you gave, so that you arrive at the appointment knowing which questions are still open. Which drugs follow the operation depends on the receptor result, and that is on the page for your type of breast cancer.
Each combination of answers maps to a fixed set of cards, and every card quotes the statement it implements with the page it was read from; nothing is scored or inferred. Where the sources disagree, both are quoted. The mapping is data in the OnCo repository and is tested against every combination of answers. Checked 2026-09-25.
This is an educational aid to prepare for a conversation with your surgical team. It is not medical advice, and it cannot see your scans or your history. OnCo is orientation, not medical advice.