Breast Cancer and Surgery
What is Breast Cancer?
Breast cancer is the most common cancer in Australian women and often involves breast cells in the ducts and lobules. According to Cancer Australia, the number of new cases of breast cancer diagnosed in 2016 estimated to approximately 16,084, from which about 3,073 resulted in deaths. Male breast cancer, on the other hand, accounts for only about 1% of total cases, with approximately >400 deaths will be estimated in 2016. Despite decades of epidemiological research in addition to the identification of various factors that influence the risk of its occurrence, it is expected that the incidence rate of breast cancer will continue to increase with age and generation.
Symptoms and Signs of Breast Cancer
Many breast cancers are discovered typically during a physical breast examination or mammography, where patients experience one or more of the following symptoms:
- Paget’s disease of the nipple – which manifests as changes to the skin (i.e. erythema, crusting, scaling and abnormal discharge). These alterations usually appear so benign that patients tend to ignore them, delaying any forms of diagnosis.
- Asymmetry or dominant mass – this is a common finding during physical examination and represents a mass which is distinctly different from most of the surrounding tissue. Benign disorders are usually characterised by diffuse fibrotic changes in a quadrant of the breast (more commonly the upper outer quadrant). A sign of cancer is usually observed with a slightly firmer thickening in one breast, not the other.
- Inflammatory Breast Cancer – typically affects the lymphatic vessels in the breast skin, causing the breast to become red, inflamed and enlarged.
- Advanced Breast Cancer – these are characterised by exaggerated skin markings that are caused from skin oedema as a result of invasion of dermal lymphatic vessels; satellite nodules or skin ulcers; or by a fixation of the mass to the overlying skin or chest wall.
Breast Cancer Surgical Types and Procedures
When it comes to treating breast cancer, patient survival rate has significantly increased over the years as a result of progress in diagnosis and treatment. For most types, the options include surgery (Mastectomy and Breast Conservation Therapy), Radiation Therapy and Systemic Therapy (Hormone Therapy, Chemotherapy or both). However, the treatment decision will depend on the type of tumour involved and the characteristics of each patient. This article will focus on two surgical procedures: Mastectomy and Breast Conservation Therapy.
Radical Mastectomy was developed by Halsted in the 19th century, and is a procedure that is accompanied by the amputation of:
- the entire breast
- skin and fat
- pectoralis major and other minor chest muscles
- axillary lymph nodes under the ipsilateral arm
Radical mastectomy is one of the most disfiguring breast cancer surgeries. This resulted in further investigation of other options due to the realisation that most of the breast cancer cells did do not occur in the chest muscles.
Modified Radical Mastectomy, in comparison to Radical Mastectomy, involves a less extensive procedure, which do not include the removal of pectoral muscles.
Simple Mastectomy involves removing the entire breast using an elliptical incision, which encompasses the nipple-areola complex. Unlike Radical Mastectomy, it does not remove the pectoral muscles nor axillary lymph nodes.
Skin-Sparing Mastectomy (SSM) allows all of the breast skin and pectoral muscles are preserved, except for the nipple and the areola, which are removed. This allows for better results after breast reconstruction, as the procedure avoids making any scars on the breast as well as enough skin to cover the wound.
Nipple-Sparing Mastectomy (NSM), which was previously known as Subcutaneous Mastectomy, not only preserves the skin, but also the nipple and areola of the breast.
Breast conserving therapy (BCT), also known as breast conservation surgery, has evolved rapidly in recent years and has become the standard of treatment in early breast cancer (i.e. Stages I and II tumors). The goal of BCT is that it aims to achieve a cosmetically acceptable breast, while at the same time eradicate any microscopic residual disease through moderate-dose radiation therapy (RT). The main advantage of this surgical option over mastectomy is that it is less extensive and it offers the patient an opportunity to keep the breast. BCT includes the following: lumpectomy, wide excision and quadrantectomy.
Although breast conserving surgery is an acceptable alternative to mastectomy, it is not applicable to all patients in treating breast cancer. Hence, mastectomy may provide more satisfactory outcomes in terms of tumor control and breast cancer treatment.