Surgical treatment guidelines

The psychological impact of loosing a breast varies but for most women it means some form of grieving. Breast reconstruction can alleviate the sense of deformity that may develop after a mastectomy. It is considered an integral part of the management of patients with breast cancer. Breast reconstruction can be done immediately after the mastectomy or it may be delayed for a few months. The benefits of having reconstructive surgery at the time of the mastectomy are obvious in that it helps to preserve body image. Seventy-five percent of patients overseas either have breast conserving surgery or mastectomies with immediate reconstruction, so get a second opinion if your doctor immediately suggests a mastectomy and doesn’t present any other options. You can have breast-conserving surgery in many cases, as well as reconstructions. You don’t have to be disfigured for life. The reconstructive process should be discussed with the patient prior to initial surgery.

Usually some form of surgery is performed to remove the cancerous tissue. There are two aspects to surgery the one involves what to do to the breast and the other involves what to do the glands in the armpit (axilla).

Breast Surgery
This can be either breast conserving surgery or a mastectomy and reconstruction. An oncologically sound operation is ensuring that the surgical margins need to be well clear of tumour by at least 1 cm. Whether a women has breast conserving surgery or mastectomy the mortality is equal - this is an important concept. What it means is that whether a woman chooses to have part of her breast or the whole breast including her nipple removed she will live for the same length of time regardless of the operation done provided  the cancer is cut out with 1 cm clear margins and all other cancer treatment principles are adhered to.

Breast Conserving Surgery
This involves the removal of the cancer and a small area of surrounding breast tissue. Whether this can be done depends on the size of the breast, the size of the tumour and the patient’s wishes. Most importantly a mammogram must be done prior to surgery to make sure that there are no other hidden cancers. Another important aspect is that the result must be cosmetically acceptable while still being a good cancer operation (no cancer left behind or close to the margins). Breast conservation must always be followed by radiation therapy .All patients having breast conserving surgery should have the tumour bed clipped to guide the radiation specialist.

Mastectomy
This procedure is done if the cancer appears to have characteristics of being a cancer that may be in other parts of the breast or difficult to detect on mammogram (lobular cancers) or if the cancer is of  a size or position making breast conservation not cosmetic, if the tumour to breast ratio is such that conservation cannot be done.

A mastectomy is not a second best operation and must always be planned in conjunction with a reconstruction, either immediate or delayed.

Surgery to the Axilla or armpit
Traditionally at least 8-10 lymph nodes should be removed from the axilla in all patients with an invading breast cancer. This can be done through the same incision as the mastectomy or through a separate incision with breast conserving therapy.

A recent development in breast cancer surgery is sentinel lymph node dissection. This is where a dye or radioactive isotope or a combination of both is injected into the area surrounding the cancer. The sentinel is the first lymph node to receive lymphatic drainage from that area of the breast which contains the tumour and is most likely to harbour cancer cells if the tumour has spread. This technique enables the surgeon to identify the sentinel lymph node and only that node is removed to see if it contains any cancer cells. If there is no cancer in this node an axillary dissection is not required.

This procedure should only be offered by surgeons trained in this technique and who have done at least 20 combined procedures and who have good audited results.