Breast Cancer Treatment - Surgery
Surgery is the most effective treatment option ever employed against breast cancer. Halsted’s radical mastectomy (RM), which dates from the turn of the century, revolutionized the local control of the disease and demonstrated that a subset of patients could be cured by surgery alone. Halsted viewed breast cancer as a principally local-regional disease that spread in a centripetal fashion.
Fifty years later, Bernard Fisher would hypothesize that breast cancer is primarily a systemic disease and state that the surgeon’s knife had little impact upon outcome. Today, we would argue that they are both right and both wrong – breast cancer begins as a local disease and, at some point in its evolution, becomes systemic. Local control cannot cure all patients, but no patients are cured without it. Surgery remains the mainstay of local control at the turn of the millennium, and recent trends towards earlier stage at diagnosis will undoubtedly increase its role.
Many women at high risk for breast cancer consider having their breasts removed (prophylactic mastectomy) to avoid the risk of developing cancer. As with any type of surgery, if you are considering prophylactic mastectomy you should consult with your physicians and surgeon about the risks of the procedure as well as the possible outcomes.
To learn more about reconstructive surgery options and the risks associated with those procedures, you can talk to plastic surgeons, ask to see photographs of breasts after surgery, and perhaps discuss the surgical experience with other women who have chosen prophylactic mastectomy. It is to your benefit to find out everything you can before making a final decision.
Reconstructive Surgery
The goal of breast reconstruction is to create the most natural looking and feeling breast possible with minimal discomfort. Following mastectomy, women have two options for breast reconstruction, which may be performed at the time of the mastectomy or at a later date. The type of breast reconstruction that is most appropriate for you will depend on your medical situation, overall health, size and shape of your breasts, lifestyle, and goals. Prophylactic mastectomy and reconstructive surgery may or may not be covered by your health insurance
Saline implants. In this option, a plastic surgeon places tissue expanders — hollow, empty balloons — behind the breast muscles and then gradually fills them with saline (salt water). Placement of the tissue expander usually occurs under general anesthesia in an operating room. The surgery takes about one to two hours and may require a brief hospital stay or may be done on an outpatient basis. Sometimes, the procedure may be done at the same time as the mastectomy. Typically, women resume normal activity after three to six weeks. Over the course of two to four months, the expanders are slowly filled with saline to stretch the skin until fully inflated. This process is generally painless, similar to the gradual expansion of the abdomen during pregnancy. In a second operation the actual saline implants are put in place, replacing the tissue expander. The surgery is usually performed under general anesthesia and may require a brief stay or may be done on an outpatient basis.
After complete healing from prior reconstructive surgery, a third procedure is performed months later to create a nipple. For this procedure, either tissue is transplanted from other areas of the body (for example, the vulva, earlobe, toe, or upper thigh), or an area can be tattooed to make a more natural looking skin tone on the a nipple. Because saline implants can leak over time, they may need to be replaced every 5 to 15 years.
The advantage of this method is that it is the simplest reconstructive method available, and all of the surgeries are relatively minor.
The disadvantages of this type of breast reconstruction include a long, visible scar, and the requirement for multiple procedures — placing the tissue expanders, switching the tissue expanders with the implants, and nipple reconstruction or tattooing. Also, routine visits every two to three weeks to have the tissue expander(s) inflated are required. In addition, initially the breast will be relatively small until after the expander has been inflated a few times. The reconstructed breast with the implant will always feel somewhat hard and often tight, and will never droop naturally. There is also a high chance that additional surgeries will be needed over time to replace or remove implant(s) due to leakage, deflation, or other problems related to the implant.
Tissue transfer. Some women may prefer reconstruction using their own tissue to create a breast. The most common type of tissue transfer procedure used for breast reconstruction is called a transrectus abdominis myocutaneous flap (also called a TRAM flap) and involves transplanting a flap of abdominal skin, fat, and blood vessels from the abdominal wall to the chest wall. The tissue flap may be left attached to the blood supply and moved to the breast area through a tunnel under the skin, or it may be removed and reattached to the breast area. Alternatively, skin, fat, and muscle from the back (latissimus), hip, or buttocks may be used in addition to or in place of abdominal tissue. Women who are overweight, smoke cigarettes, have had previous operations at the flap site, or have circulatory problems may not be good candidates for a tissue flap procedure. In addition, women who are very thin may not have enough tissue to create a breast mound.
References
- Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiation therapy in patients with small cancers of the breast. N Engl J Med 1981; 305:6-11.
This is the landmark report of the first randomized prospective trial of breast-conservation therapy. - Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665-73.
This is the first report of the major North American trial of breast-conservation therapy from the NSABP. - Borgen PI, Heerdt AS, Moore MP et al. Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
This is a review of all aspects of breast-conservation therapy. - Fisher B, Costantino J, Redmond C et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993: 1581-6.
This is the major trial of conservative therapy for DCIS - Adair F, Berg J, Joubert L et al. Long-term follow-up of breast cancer: the 30-year report. Cancer 1974; 33:1145-50.
This is an older report from the days before adjuvant therapy that demonstrates the effectiveness of surgery in node-positive disease. - Fisher B, Redmond C, Fisher E et al. Ten year result of a randomized clinical trial comparing radical mastectomy and total mastectomy with of without irradiation. N Engl J Med 1985; 312:674-81.
This is a very influential trial that showed that less-extensive surgery had similar results to radical mastectomy. - Warmuth MA, Bowen G, Prosnitz LR et al. Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 1998; 83:1362-8.
This report gives a good idea of the range of complications after axillary dissection.
Patrick I. Borgen and Bruce Mann
Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
This surgery takes about three to six hours and is usually performed in an operating room under general anesthesia. Typically, the hospital stay is three to eight days with an average of five days. Recovery takes approximately 6 to 12 weeks, although some report that it may take up to a year to resume a completely normal lifestyle. A nipple-areolar complex is created through one of the methods described above.
The advantages of this method include the fact that the reconstructed breast is soft and lifelike because your own tissue is used to construct the breast. Also, the procedure requires one surgery with an additional visit for women who choose to have a nipple reconstruction. Some women consider it an additional benefit that skin, muscle, and fat are removed from the abdomen (similar to a “tummy tuck”).
The disadvantages of these surgeries include the fact that flap surgery, especially the TRAM flap, is a major operation. The surgery is more extensive than breast reconstruction with implants and the recovery time is longer. With flap surgery, a long, visible scar will remain after surgery. In the TRAM procedure, there will be a long abdominal scar below the navel and there may be temporary or permanent muscle weakness in the abdominal area. If latissimus tissue is used, there will be a long scar on the back, which can usually be hidden in the bra line. There may also be additional scars on the reconstructed breast. Both surgeries are more painful than the surgeries for tissue expansion and implant surgery. However, most patients do very well and report that they are pleased with the outcome.
References
Hughes KS, et al. (1999). Prophylactic mastectomy and inherited predisposition to breast carcinoma. Cancer. 86(11 Suppl):2502-16.
J. Bostwick, 3rd. (1995). Breast reconstruction following mastectomy. CA Cancer J Clin. 45(5):289-304.
Hartrampf CR, et al. (1982). Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 69(2):216-25.
Bilimoria MM and Morrow M. (1995) The woman at increased risk for breast cancer: evaluation and management strategies. CA Cancer J Clin. 45(5):263-78
Stefanek ME. (1995). Bilateral prophylactic mastectomy: issues and concerns. J Natl Cancer Inst Monogr. 17(37-42.
Grotting JC, et al. (1989). Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg. 83(5):828-41.
Horton CE and Dascombe WH. (1988). Total mastectomy: indications and techniques. Clin Plast Surg. 15(4):677-87.