Our primary aim while treating breast cancer is to save lives and preserve the natural look of a woman’s breast. Breast preservation is called “lumpectomy” or “partial mastectomy” and involves removing the breast cancer with a surrounding rim of normal breast tissue. When combined with radiation treatment, breast preservation gives women an equal survival or recurrence rate as compared to removing the entire breast (mastectomy). Unfortunately, breast preservation or conservation is reserved for those women who have only one cancer in their breast, have a cancer which isn’t too big that its removal would cause a poor cosmetic outcome, and for those women who can undergo radiation therapy.
“Lumpectomy” with radiation results in a 5-15% recurrence rate in the breast over 10 years and has been found to be just as good a treatment in saving lives as total mastectomy.
In order to preserve the natural look of a women’s breast we use oncoplastic technique, which is defined as using plastic surgical principles during cancer surgery. This means that within the confines of safely removing the cancer all surgical decisions are made with cosmesis in mind. The location of incisions is important in how a breast will look after surgery. We prefer to hide them in the armpit, the crease underneath the breast, or in the darker skin around the nipple. We also attempt to limit the amount of skin and breast tissue removed to just what is needed for cancer control. Sometimes when a large breasted woman gets breast cancer, we can do a simultaneous breast reduction and breast lift on both breasts.
However, not all women with breast cancer can preserve their breast and some may chose not to. For these women we perform a total mastectomy which removes over 95% of breast tissue. This can be combined with or without plastic surgical reconstruction. Most women who have a mastectomy will not need radiation therapy. Choosing to remove the other, unaffected breast has been shown to decrease the risk of getting another cancer but has never been shown to improve a women’s survival.
Breast reconstruction after mastectomy is almost always performed at the time of the mastectomy. The plastic surgeons use either a women’s own tissue or breast implants or a combination of the two, in order to reconstruct the breast. Tissue used for reconstruction can come from the stomach combining with a “tummy tuck”, or from the back, or less commonly from the buttocks. Breast implants can be filled with salt water or silicone, and both have been found to be safe.
The most important staging information that relates to risk of recurrence and survival is lymph node status. Breast cancer that has spread to lymph nodes in the armpit is more aggressive and needs to be treated with whole body therapies like chemotherapy and/or hormonal therapy. Even though a physician may not feel any suspicious lymph nodes in the armpit, there still remains a 20% chance that there is nodal spread. For women with breast cancer where no suspicious nodes are felt, we perform the sentinel lymph node biopsy. This technique involves injecting a radioactive tracer and/or a blue dye into the breast tissue around the breast cancer. This then flows through the lymph channels towards the first set of nodes that drains the area around the breast cancer. A small incision is made in armpit and the nodes are identified visually or with the help of a hand-held Geiger counter. These first nodes are the sentinel nodes and are the nodes most likely to contain cancer if the cancer has spread. On average we remove two nodes during the biopsy. Generally, with breast preservation surgery no other lymph node surgery is required, but during mastectomy if tumor is found in the sentinel nodes then additional nodes need to be removed.
It is extremely important for women who are undergoing breast preservation surgery that they combine it with radiation. Breast recurrence rates for “lumpectomy” are 5-15% with radiation but climb to as high as 40% without radiation. There is also felt to be a survival advantage as well. For every 4 recurrences that are prevented, a woman’s life is saved.
Absolute Contraindications for radiotherapy: Pregnancy, prior radiation, positive surgical margins
Relative Contraindications for Radiation: Collagen Vascular Disease, tumor size, breast size.
Whole Breast Radiation
Radiation of the whole breast is the standard technique with the longest track record. It involves 6 ½ weeks of radiation, going every day for treatment except weekends. The most common side effects are fatigue and getting a burn on the breast skin which resembles a bad sun burn.
Partial Breast Radiation
Researchers noted that while we have traditionally radiated the whole breast, most recurrences actually occur around the surgery site. Techniques have now been developed and approved to provide radiation to the surgery site only. These have been shown to be effective and safe although whole breast radiation is still reserved for high risk cancers. There are different types of partial breast irradiation; 3D conformal, balloon brachytherapy, and intaopereative radiation. Treatments can be shortened to 5 days in 3 D Conformal and balloon brachytherapy, and just one treatment for intraoperative radiation. The 3 D Conformal radiation involves external beams of radiation that when combined in a pattern as designated by 3 D imagery, radiates the margins of the surgical resection. Brachytherapy uses a catheter that has a balloon at one end that fills the surgical cavity and then exits the skin. Treatment involves placing a radioactive seed periodically into the balloon catheter for a series of a 5 day treatments twice a day. Intraoperative radiation takes place during surgery while the patient is asleep. A probe is placed into the surgical cavity and delivers a one-time radiation dose for 10-55 minutes.
Partial breast irradiation is best for women who are 50 years of age or older, have small tumors of three centimeters or less, and have no lymph nodes involved. Benefits of these techniques are that they require less time and can spare the surrounding tissue such as heart and lung from being exposed to radiation.
For women with breast cancer who have been determined to have a risk of whole-body recurrence of greater than 10%, chemotherapy should be considered. Chemotherapy reduces the risk of recurrence and death from breast cancer by approximately 45%. Regimens last from 4-6 months with chemotherapy given at 2-3 week intervals. Common side effects include fatigue, hair loss, weight changes, and peripheral neuropathy. Serious complications occur in 1% of cases which includes leukemia.
Triple-negative breast cancer is an aggressive type of breast cancer that has no receptors for estrogen, progesterone (female hormones), nor Her2/neu (tumor marker). The threshold for getting chemotherapy is lower in this type of breast cancer since the risk of recurrence is high. For more information click here.
Cancers that are positive for staining of the Her2/neu receptor, have a more aggressive subtype. Fortunately, for these women there is a drug call Hercepten that is specifically directed against these cells. This is taken intravenously monthly for one year.
For more information click here.
This information does not replace expert evaluation and advice from a trained breast care professional. If you have noted any breast problems please seek care from a breast surgeon as soon as possible.