Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Lumpectomy
(right / left / both sides)
You have been diagnosed as having breast cancer, which demands surgical treatment. You may have
already had the tumor identified in your breast After careful consideration, a lumpectomy with breast
preservation has been recommended.
Risk of an Untreated Breast Cancer
The goal of surgery is to remove all of the breast cancer, so that it does not spread in the area of the breast, in
your armpit, or elsewhere in your body. Without treatment, or with inadequate treatment, your risk of
recurrent or progressive cancer increases. Eventually death from cancer is expected if treatment is not
performed.
Description of the Procedure
Lumpectomy – The area around the breast lump will be removed along with the breast lump itself. This is
done to remove as much of the tumor as possible, for tumors tend to send out fingers of cancer into what
appears to be normal surrounding tissue. We will make a cut over the lump (or around the previous biopsy
site) and remove all the breast tissue that lies close to the tumor. The skin is then closed and a bandage is
placed over the wound. After surgery, radiation therapy is required (up to a month later).
Alternatives for Treatment
There are several alternative treatments for breast cancer.
1. Modified radical mastectomy – The biggest disadvantage of the treatment is that the breast is
removed but the advantage is that radiation is usually not required. The lymph nodes in the
armpit are removed
2. Sentinal Node Biopsy – Use of a “gieger counter” type machine is used to find and remove the
first lymph node breast cancer spreads to.
Risks/Complications of Treatment
Treatment risks fall into two categories; those that could happen during any operation under anesthesia, and
those that are specific for the lumpectomy. In any sort of medical treatment, it is impossible to predict all the
things that could go wrong. Fortunately, complications are the exception rather than the rule. Every
reasonable effort is made to avoid complications. The most common possible complications are as follows :
Possible complications of major surgery
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion is rare.
2. Infection – we take special care to prevent an infection, but it is always a possibility. An infection
can delay further treatment and prolong healing.
3. Reactions to medications – this could be many things from a minor rash to possible death.
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or, in rare cases, death.
5. Poor wound healing – breakdown of the incision.
Possible complications of a lumpectomy
1. Breast deformity - the breast may become indented where the cancer has been removed.
2. Numbness on the inside of the arm (sometimes this can be severe).
3. Nipple inversion – the nipple may scar downward permanently.
4. Chronic breast pain or tenderness.
5. Seroma formation – this is a collection of fluid beneath the wound.
6. Recurrence of the cancer – this could occur either within the area of the breast operation or
somewhere else in the body. Cure cannot be guaranteed.
(see other side)
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. You should start moving your arm within days
following the surgery. With diligence, you should gain complete motion in your arm within a few months.
Most people are able to go home a day or two following the operation. The drains will usually be removed
in four to seven days. The amount of time it takes before you will be able to return to work will partly depend
on the type of work you do, and the speed at which you heal. Most people with light job duties can return
within two weeks; if you do heavy lifting, you might want to wait up to one month before returning to work.
Most people do not require special rehabilitation in order to get function back in their arm.
Further treatment of the breast cancer may be required, including anti-estrogen therapy in addition to
expected radiation therapy. The final pathology report after surgery will influence this decision. Further
surgical therapy may also be advised, if more cancer is found in the breast.
Consent for Treatment
I understand my condition to be breast cancer and am aware of its risks if untreated. I have read and
understand the above explanation of the procedure being proposed. My surgeon has answered my
questions, and I choose to proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people receiving a breast cancer benefit from the operation, I may not.
My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless oherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment risks;
nonetheless, I understand the need for this surgery and grant permission to the surgeon to proceed on
my behalf.
SIGNATURE _____________________________________________________ DATE _________________
3/02 – 15/16