There are multiple surgical approaches that are used in the treatment of breast cancer. In the past radical mastectomy was the standard treatment for breast cancer. Currently radical mastectomy is rarely performed and is limited to locally advanced tumors that do not respond to chemotherapy. When a mastectomy is performed, we do either a simple mastectomy in which only the breast is removed or a modified mastectomy in which the breast and lymph nodes are removed. Also, rather that removing all the draining lymph nodes when it is required, we now start by removing the sentinel lymph node, and only remove other nodes if the sentinel node is positive. A new operation that is currently being performed is the nipple sparing mastectomy which can be used in selected cases.
For most women, breast conservation will be the treatment of choice since it is less traumatic, and the survival results are identical to survival rates with mastectomy. However, not all women are candidates for breast conservation, and some women prefer mastectomy. We believe women should be given the facts and encouraged to make their own choices.
Women considering breast conservation must have a clear understanding of the issue of ”margins“. The goal in breast conservation is to remove the tumor, along with a surrounding rim of normal tissue. Obtaining clear margins all around the tumor edges can be a challenge. Although the surgeon attempts to take out the entire tumor at the time of the initial surgery, in some cases the tumor cells (which are not visible during the surgery) are found by the pathologist to extend to the edge (margin) of the lumpectomy specimen, and a second operation is required. Fortunately, the vast majority of women who initially choose breast conservation will ultimately achieve a good to excellent cosmetic result. Long-term survival is equal to that with mastectomy.
Some women are either not candidates for breast conservation or choose mastectomy for personal reasons. Women considering mastectomy should be given the option of immediate reconstruction. Some women, however, are not good candidates for immediate reconstruction because of an underlying medical condition, such as diabetes. For these women there is still the option of delayed reconstruction, and this option should be taken into consideration at the time of the initial mastectomy.
Chemotherapy first (Neoadjuvant therapy)
Giving chemotherapy first (neoadjuvant therapy) is becoming a more common option. In the past, chemotherapy was given before surgery in situations where the tumor was too large to permit a mastectomy. The chemotherapy was given first to shrink the tumor so that a mastectomy could be successfully performed. It is now becoming common practice to give chemotherapy first to shrink the tumors so that less tissue is taken at the time of the lumpectomy, which leads to improved cosmetic results. This approach has the potential for a woman to retain her breasts that in the past would have required a mastectomy.
A 6-8 week course of irradiation therapy will be recommended for women undergoing lumpectomy (radiation therapy may be safely avoided in selected women with small, non-invasive cancers). The purpose of radiation is to eliminate any remaining cancer cells in the breast following lumpectomy, and it is very effective in lowering the rate of cancer recurrence in the breast (see: Radiation Therapy). There is now an alternative to standard radiation therapy which can be accomplished in just 5 days (see: Radiation Therapy). Radiation is painless and takes only a few minutes to perform. It is much like a simple chest x-ray in that a beam of energy goes through the breast without the patient being aware that anything is happening. With breast irradiation, the energy beam is much stronger then the energy for a chest x-ray. The most common side effect of breast irradiation is redness to the skin. There is no hair loss or nausea with breast irradiation as there is with chemotherapy. Most women undergoing mastectomy will not require post-operative irradiation.
Lymph nodes and Sentinel Node Biopsy
Lymph node removal will be recommended for most women with breast cancer. Lymph nodes are lima bean shaped structures that vary in size from that of a pea to the size of a marble. A primary function of a lymph node is to filter unwanted materials from the body, and this includes cancer cells. In fact, if breast cancer cells break off from the main tumor, the first place they are likely to go is to the lymph nodes under the arm (i.e. the axillary lymph nodes). One of the most important indicators of prognosis is the status of the axillary lymph nodes (i.e. no nodes involved good means prognosis; the more nodes involved, the worse the prognosis). For this reason, it was standard therapy in the past to remove all of the lymph nodes under the arm at the time of the removal of the breast cancer to determine prognosis.
It is now standard practice to remove only the first draining lymph node (sentinel lymph node) at the time of the lumpectomy or mastectomy, and have it examined under the microscope. By limiting the number of nodes removed, recovery is accelerated and the risk of complications (such as lymphedema) are minimized.