Holiday 2004 Newsletter: Surgery for Breast Cancer: Progress & Hope

By Dr. Nora Jaskowiak
Assistant Professor
Department of Surgery

As is in evidence throughout this issue, breast cancer is a common disease in which huge advances have been made in both understanding and treatment. Surgery for breast cancer is no exception. The evolution of surgical options for breast cancer has been dramatic in the last forty years, taking us from the radical mastectomy of the 1960’s to the outpatient lumpectomy/sentinel node biopsy of 2004. These advances have benefited patients tremendously – minimizing pain and disability, decreasing hospital stays, speeding recoveries and facilitating implementation of adjuvant therapies, and aiding cosmesis.

In this brief article, I will touch on some of the major changes that have occurred in surgery for breast cancer. When I talk to patients about treatment options, we discuss options for the breast first, then the lymph nodes, then what the future holds. I will construct this discussion similarly.

Many women who present with early breast cancer have the option of saving the involved breast, an approach referred to as breast-conserving therapy. Beautifully done research studies with greater than twenty years of follow-up have proved that breast conservation, which entails lumpectomy followed by radiation, leads to long-term survival rates identical to more extensive operations (i.e. mastectomy). Breast conserving therapy is frequently chosen by patients, with excellent outcomes. Advances in breast imaging, including the growing use of digital mammography, ultrasound, and MRI, are assisting in better defining extent of disease preoperatively and helping patients and surgeons make the most informed choices possible.

Another major advance, in patients who require (or desire) a mastectomy, is the growing number of options for breast reconstruction. Reconstruction can be done immediately (at the same time as mastectomy) or in a delayed fashion, depending on a number of factors. For many patients, immediate reconstruction at the time of mastectomy is a viable option and this is now routinely done in a way that preserves much of the natural skin of the breast, which is of tremendous benefit cosmetically. Excellent cosmetic results can also be obtained in cases of delayed reconstruction.

Surgical staging of the lymph nodes in the underarm (axillary) area has changed tremendously over the last decade. This is primarily because of the sentinel node biopsy technique. This procedure, originally conceived for the assessment of lymph nodes in patients with melanoma, has over the last decade become the standard of care for patients with early stage breast cancer in whom no abnormal lymph nodes are felt in the underarm area. The basic theory is that the lymph drainage from the breast to the axilla does not go immediately to all 15-20 nodes that reside there, but drains preferentially to one or two “sentinel nodes” first, and that those nodes would be the most likely to show metastases, if any spread of disease has occurred. And the theory has proven correct through many well-done studies. So today, for many women, we can remove just one or two lymph nodes from the axilla, staging the cancer precisely and sparing many patients the potential serious side effects of complete axillary lymph node dissection, which include arm swelling (lymphedema) and nerve injury.

Breast cancer treatment in 2004 is a truly multidisciplinary undertaking, involving surgeons, medical oncologists, radiation oncologists, mammographers, pathologists, plastic surgeons, nurses, and social workers. All are critical to success. Surgeons, along with breast imagers, are among those who are the first to deal with patients when the cancer has just been, or is being, diagnosed. It is an incredible privilege and honor for me to be involved with patients in these early phases of diagnosis, decision making and treatment. Ongoing research will continue to help streamline surgical care of breast cancer patients, ultimately leading to better outcomes for many patients.