by Dr. Teoh Mei Shi
Consultant Breast, Endocrine & General Surgeon
MBBS (India), MS (USM), Fellowship Breast Oncoplastic Surgery
The news of breast cancer diagnosis is often traumatic and to hear that one needs to remove the whole breast is even more damaging to her physically, mentally, as well as psychologically.
Since historically, treatment for breast cancer has always been radical mastectomy whereby the whole breast and a large portion of the muscle underlying the breast tissue is removed extensively leaving a cosmetically disfiguring appearance and terrible side effects. This has been the mainstay of treatment over the last 100 years and although less aggressive surgery are employed to minimize the side-effects known as modified radical mastectomy or lumpectomy, it is still an unacceptable surgical appearance for many women.
As newer targeted therapies and novel chemotherapy drugs are available to improve survival outcome, surgical techniques and reconstructive methods for breast cancer are also advancing. This has led to a new sub-specialty called “oncoplastic breast surgery”.
Oncoplastic breast surgery is a combination of oncological treatment for breast cancer as well as reconstructive surgery to restore and rebuild the appearance of the breast leaving the patient with a more acceptable appearance. This “cosmetic” outcome can significantly help a woman recover psychologically as well as mentally. This new approach brings a new revolution to treating the woman as a whole rather than just the cancer. It also allows treatment for breast cancer patients to be more appealing and acceptable when one need not fear losing her breasts or her womanhood.
Breast conserving surgery or lumpectomy is the surgical removal of the cancer with a surrounding cuff of normal breast tissue. It is just as effective for smaller tumors and early stage disease but may not be suitable for larger tumor or smaller breast size. Following breast conserving surgery, one still needs to go for radiation therapy to the rest of the breast tissue and also frequent mammography to prevent recurrence. Some women who refuses radiation therapy or long term mammography follow-up instead prefer to opt for mastectomy with immediate reconstruction to reduce their fear and worry.
There are more options now for reconstructive surgery but the choice will depend on many factors like the stage of the cancer, tumor to breast size ratio, tumour histology and biology, fitness of the patient and also the surgeons’ experience. Every patient has different needs too ie. her own self-image and her goals. A multidisciplinary team comprising of breast surgeon, oncologist, radiotherapist, radiologist and pathologist will usually convene to discuss with the patient to ensure the best possible surgical and oncological outcome.
Breast reconstruction can be offered immediately as a single stage during cancer surgery but it could also be in several stages or as a delayed procedure after the cancer treatment is completed. After all, proper oncological treatment for breast cancer still prevails before cosmetic appearance.
Various options for reconstruction are available such as the use of implants, or the use of tissue from the back or belly and even fat grafting. Nipple reconstruction and tattooing of the areola are also possible. Some reconstructive surgeries can be short and in a single setting while most will take longer hours and require several stages to get the ideal shape and appearance. Risks for surgery such as infections, bleeding, implant-related and flap-related complications are relatively low but nevertheless, they do occur on a case-to-case basis.
If appropriate decision is taken, oncoplastic surgery has comparatively similar survival rate and cancer recurrence rate as conventional treatment with mastectomy and lumpectomy. It also does not make diagnosing recurrences and follow up more difficult during after-care surveillance.
In developed countries where incidences of breast cancer are higher and with the availability of screening programmes, there is higher percentage of early detection of breast cancer, therefore more than 70% of the patients will choose to undergo reconstruction. In Malaysia, we are still seeing a significantly higher percentage of late stage breast cancer detection, hence we encounter more mastectomy cases.
More advanced technologies are happening to minimize breast cancer surgery in the future. We are looking at cryoablation, radiofrequency ablation as well as intraoperative radiotherapy where radiotherapy session has been reduced to one session only versus the conventional 25 sessions.
Celebrity actress Angelina Jolie certainly made headlines when she chose to have both her breasts removed as a preventive measure due to an inherited BRCA gene that puts her at high risk of developing breast cancer. She reconstructed her breasts with implants and was also able to preserve her nipple areola complex.
Breast cancer incidences are on the rise in Malaysia, roughly about 1 in 15 women will develop breast cancer in their lifetime. Be breast aware and do not fear as early detection has good survival outcome. Oncoplastic breast surgery will change the revolution for breast cancer treatment. The future tag line for breast cancer surgery would be “No women shall leave the operation theatre without a breast”.