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The changing face of breast surgery - advances in the surgical approach to breast cancer

Breast cancer surgery has drastically changed over the past few years and has become one of the most rapidly evolving and fascinating subspecialties in surgery. There have also been many advances in systemic therapy and radiation and, combined with surgery as so-called multi-modality treatment, they have significantly improved the outcome of patients.

Women who have been diagnosed with breast cancer, a potentially life-threatening and disfiguring disease, face many challenges and fears. Hitting the heart and soul of families this diagnosis can be particularly distressing. Treatment will often not only include surgery but may also include chemotherapy and radiation as part of the contemporary multi-modality treatment approach. This initial treatment process can take nine months or longer and patients need support to successfully navigate this difficult period.

A recent diagnosis of breast cancer can place women in to an exceptionally vulnerable position; they desperately need advice and understandably many want to rush in to treatment. It is important to emphasize here that the treatment of breast cancer is urgent but not an emergency. Not all breast cancers should have surgery as the first treatment option and ill-advised surgery can potentially worsen the outcome of the patient. Hasty decisions can compromise the outcome of the patient both from an oncological point of view and the psychological well-being of the patient. A rushed mastectomy and loss of the breast can have long-lasting effects.

There is always more than one option available and the patient should be well informed and have time to consider them. For the treating health care professional it is equally important to gather all the relevant information. A full assessment by examination and history, appropriate imaging and histology must be completed before initiating any treatment and patients should be discussed in a multidisciplinary team to establish a full treatment plan.

Although the psychological effect varies among women, many will fear radical surgery and the potential loss of the breast. Dating back to the late 19th century, all patients with breast cancer had a radical mastectomy and resection of the lymph nodes in the axilla. Fortunately, there are many more options than mastectomy available today which offer a less aggressive surgical approach while still ensuring oncological safety.

Surgery remains a central part of breast cancer treatment and is usually the first part of the multimodality treatment in early breast cancer. The majority of patients will require surgery to the breast itself as well as surgery to the axilla, which is the space under the armpit that receives most of the lymphatic drainage from the breast.

Surgery to the lymph nodes provides essential information for accurate staging and treatment decisions. Additionally, surgery can decrease the chance of local recurrence when there is lymph node involvement by the cancer. The traditional approach was to perform a standardized resection of the lymph nodes, called axillary lymph node dissection. This remains the standard of care in most patients with proven metastases to the lymph nodes. However, there are potential longterm effects with this procedure, including arm swelling (lymphoedema) and shoulder problems, and there is no proven survival benefit in resecting lymph nodes that are not involved by cancer. A procedure called sentinel lymph node biopsy was therefore developed. The main draining lymph nodes are identified during surgery with the help of radiocolloid and blue dye.

Sentinel node biopsy rather than a full axillary dissection in clinically node-negative patients has allowed axilla-conserving surgery in many women with early breast cancer. It is an accurate procedure that offers prognostication and helps to decide about adjuvant therapies without the morbidity of axillary dissection and has been a major advance in breast cancer surgery. It has become the standard of care in node-negative patients; axillary dissection would be difficult to justify in this group of patients today. Patients with a positive sentinel node usually have a completion axillary dissection. More recently, a subset of patients with a positive sentinel node have been identified in which a completion dissection can be safely avoided. These decisions are individualized and should always be discussed within the multi-disciplinary team. Overall, the trend is towards minimizing the extent of surgery in the axilla and minimizing morbidity.

A minimized extent is also the current trend in surgery to the breast itself. Breast conserving surgery is combined with postoperative radiation and the combination is referred to as breast conserving therapy. This has been well validated and is considered the preferred approach in women with early breast cancer and provides the same overall survival as mastectomy. The major benefits of breast conserving surgery are improved cosmesis and preserving sensation. Up to 80% of women will have breast conservation in European centers but rates of breast conservation vary widely among different countries. Conservation rates have been lower in the USA and the National Accreditation Program for Breast Centers has set a target of at least 50% of early breast cancers having breast conservation as a requirement for the accreditation as a breast center.

Oncoplastic breast surgery is a relatively recent development combining the oncological resection with a plastic surgical technique. This has broadened the application of breast conservation and allows resection of larger tumours or tumours in difficult areas of the breast without compromising cosmetic outcome. A French center recently achieved a final breast conservation rate of over 90% using these techniques.

While modern techniques are less morbid than radical mastectomy, a mastectomy still leads to the loss of the breast. It is important to realize that mastectomy is a highly effective operation and sometimes the preferred choice of treatment and not second choice. It is equally important to mention that many patients will overestimate their risk in the contralateral, healthy breast. A contralateral prophylactic mastectomy is indicated only in a small minority of patients and can add significant morbidity.

The National Comprehensive Cancer Network guidelines actively discourage this and recommend that it only be considered on an individual basis for women at high risk of breast cancer, such as those who carry a BRCA1 or BRCA2 mutation or other syndromes associated with a high risk in the contralateral breast. Mastectomies have evolved to include skin-sparing, areola-sparing and even nipple-sparing mastectomies in appropriately selected patients who wish breast reconstruction.

Breast reconstruction is an integral part of treatment for patient after unilateral or bilateral mastectomy and offers psychological, functional and social benefits with improved psychological health, sexuality and body image. The options of reconstruction should always be discussed before the time of mastectomy. Reconstruction can be performed immediately after mastectomy or at a later stage. In most cases an immediate reconstruction is a safe option and offers the benefit of improved body image to the patient. Although there are various techniques of reconstruction, the general approach is either based on prostheses or on the patient’s own tissue. Each of the approaches have benefits and risk and approach selection will depend on various factors.

Breast cancer treatment has become highly specialized. Decision making around the selection and sequencing of therapies and surgical approaches is complex and should always be individualized. Multi-disciplinary teams with skill in contemporary breast and reconstructive surgery are available in South Africa, both in the public as well as the private setting. With a specialized breast team, surgical options other than just mastectomy with axillary dissection are feasible and safe in the vast majority of patients.