Download Meridian Surgical Services, Inc

Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Simple Mastectomy
(right / left / both sides)
You have been diagnosed as having breast cancer, which at minimum demands surgical treatment. The
tumor may have been removed from your breast. It is now necessary to remove the breast along with a
lymph node in your armpit (sentinal node). After careful consideration, a simple mastectomy is
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
Mastectomy – The entire breast tissue is removed along with the nipple. This leaves a large pocket under
the skin where the breast used to be. Drain tubes are inserted into this cavity to prevent fluid accumulation.
Sentinal Node Biopsy – Before surgery you will receive two injections in the breast to help identify the
sentinal lymph node. A Geiger counter is used during surgery to find the node. A separated skin incision is
made and the node is removed.
Additional Procedures that may be done while in Surgery
It is impossible to accurately predict exactly what variations will be encountered during this operation.
These procedures will be performed only if necessary.
Axillary Dissection: If unable to find the sentinal node, removal of some of the lymph nodes in the arm pit
will be done instead
Alternatives for Treatment
There are several alternative treatments for breast cancer.
1. Lumpectomy/Axillary dissection – The biggest disadvantage of the treatment is that radiation is
required.
2. Simple lumpectomy – this is an inferior option because it does not show if the cancer has spread.
Radiation treatment to your breast would be required.
3. Modified Radical Mastectomy: Breast removal with removal of all arm pit lymph nodes.
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 a sentinel lymph node biopsy. 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.
(see other side)
Possible complications of a simple mastectomy
1. Paralysis/atrophy of some of the shoulder muscles (uncommon).
2. Numbness or pain on the inside of the upper arm (frequent, but rarely severe).
3. Swelling (lymphedema) in the arm on the side of the operation.
4. Increased risk of bad infections in the arm on the side of the operation.
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.
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 the day of surgery or the next day. 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 chemotherapy and possibly radiation
therapy. The final pathology report after surgery will influence this decision.
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.
HIPAA: Before and after surgery, unless otherwise 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 _________________
06/03/ljb