In this section, we will discuss the statistics and the most common types of breast cancer, diagnosis, staging of breast cancer and the concept of multidisciplinary treatment in breast cancer. The role of surgery in breast cancer treatment and breast reconstruction are the focus of this update. Breast cancer is the most serious breast disease and also the most common female cancer. When found early, the chance of being cured after conventional treatment is excellent. This section is devoted to help women understand what breast cancer is and how to seek treatment after the diagnosis of breast cancer. In the next several updates, we will continue the discussion on topics of breast cancer staging and its implication in treatment.
In 2007, it was estimated that 178,480 new cases of invasive breast cancer were diagnosed among women, and an additional 2,030 cases were diagnosed in men. The number of new cases of invasive breast cancer is lower than that of 2005. The small decrease may result from a real drop in breast cancer.
In contrast to invasive breast cancer being a real cancer, ductal carcinoma in situ (DCIS) is a precancerous condition. The incidence of DCIS increased significantly in the 80s and 90s in the United States. The increased number of DCIS cases is attributed largely to the routine use of screening mammography. Although the increase is across all age groups, the incidence rates in women age 50 or older have been stable since 2000. This may be due to a declined use of screening mammography in recent years.
Approximately 80% of all in situ carcinomas found between 2000 and 2004 were of ductal type. The majority of these were found by mammography alone, before reaching the size that can be felt by breast examination.
The current lifetime risk of developing breast cancer in the American woman is approximately 1 in every 8 (12.3%) compared to 1 in 11 in the 1970s. The reasons for increased incidence are multifactorial; longer life expectancy, postmenopausal hormonal replacement therapy and obesity after menopause may all contribute to the observed increase of breast cancer cases.
Second to being a female, aging increases one's risk for breast cancer development. Available data between 2000 and 2004 shows that incidence and death rates of breast cancer increase with age with 95% of all new cases and 97% of breast cancer deaths occurring in women aged 40 and older. Women aged 20-24 rarely develop breast cancer and women of 75-79 years of age have the highest incidence. After age 80, the incidence decreases, which may reflect fewer receiving screening.
Among women younger than 50 years of age, the incidence rates have not changed much. Among older women, the incidence rates started to rise in the early 1980s and continued at a slower rate between 1986 and 2001 and have decreased in recent years.
The most common sites of metastatic (spread) breast cancer are the bones, lungs, liver and brain, in an isolated form or multiple sites. Other sites such as adrenal, intestines, pleura and soft tissues may also be involved.
For most, the first step is to see a surgeon who specializes in breast diseases. The patient should always have her imaging films, slides and reports available, at the time of their consultation. A thorough history and physical examination are important parts of the consultation as not all the critical information is included in the tests reports. It is at this visit that the findings will be reviewed, discussed, the therapeutic goal will be discussed and the course of action will be determined. This includes any other tests that may be necessary for treatment planning, the options of different types of surgery and what the following treatments may be.
While each case is unique, the usual order of the treatment is:
While most will receive all of the above treatments, some patients will only need certain types of treatment. In the cases of large breast cancer, chemotherapy may be recommended before surgery. In these situations, the medical oncologist is involved at the beginning of the treatment planning. The medical oncologists are the doctors who discuss different chemotherapy regimens and recommend the appropriate drugs, including hormonal therapy. If mastectomy with immediate reconstruction is being considered, meeting a plastic surgeon at the beginning of the treatment planning is recommended. The plastic surgeon will discuss reconstruction options, optimal timing of reconstruction and make a recommendation regarding the reconstruction. Radiation commonly happens after surgery and chemotherapy if chemotherapy is needed or after surgery when chemotherapy is not needed. Patients who had a mastectomy frequently do not require radiation if the tumor was smaller than 5 cm, without skin and/or chest wall involvement, margins are clear and lymph nodes are not involved. If the tumor was hormone receptor positive, additional hormone therapy is frequently advised. The appropriate drugs such as tamoxifen, aromatase inhibitors (AI) medications and others will be discussed and recommended by a medical oncologist.
Depending on the identified patient's risk factors, particularly in the presence of a strong family history for breast and/or ovarian cancer and young age, meeting with a cancer geneticist should also be part of the initial evaluation. A blood test called BRCA gene test may be recommended as a result of this meeting. If a BRCA gene mutation is found, this may change one's decision regarding the type of breast cancer surgery and in managing the unaffected breast and ovaries. It also provides valuable information to other family members for their risk of developing breast cancer.
After treatment is complete, the patient will be followed by her treating physicians periodically. Each specialist may have his or her own protocol, but frequently, women will be followed by her breast surgeon, the radiation oncologist and the medical oncologist. Patient will require a diagnostic mammography every six months during the first 2-3 years after the lumpectomy surgery and once-a-year mammography for the unaffected breast. If there is no new abnormality detected, she will then resume yearly mammography follow-up of both breasts.
At any time after a cancer diagnosis, not only patients but family and/or care givers might need some form of psychosocial support. Specialized centers, such as the Revlon/UCLA Breast Center, offer a team of specialists (including internal medicine doctors with focus on nutrition, life style, complementary medicine, psychologists), patient support groups, volunteers, and a variety of activities which can help patients to cope and better manage many aspects of life that are affected by breast cancer diagnosis and treatment.
In regards to timing, the reconstruction can be done at the same time as the mastectomy (immediate reconstruction) or at a later date, after all treatment is completed (delayed reconstruction). This will largely depend on patient's choice and the goal of treatment. Becoming familiar with different types of reconstruction and being able to see pictures of the various forms of reconstructed breasts will help one's decision making. In the vast majority of the reconstruction cases, it involves more than one operation to achieve the optimal appearance. In some circumstances, surgery might be needed for the other breast to achieve the best symmetry of both breasts.
The patient's overall health is very important when considering reconstruction as these operations are lengthy and require prolonged anesthesia time, particularly when involving a flap. Reconstructive surgeries increase the recovery time from a mastectomy and will differ greatly depending on the type of reconstructive surgery. Because of the complexity of reconstructive surgery and different considerations for the breast cancer treatment, some patients may be advised not to have breast reconstruction.
Implants Saline and silicone are the two types of breast implants available for breast reconstruction. They come in different sizes and shapes. The plastic surgeons frequently show patients different types of implants and make recommendations. The silicone implants were avoided for some time as some suggested that certain immune system diseases might be caused by silicone implants. This has not been scientifically proven and the choice depends on patient's preference and doctor's considerations. The implants need to be monitored for ruptures especially when symptomatic. Micro-ruptures may not be obvious by most imaging studies and MRI may be the most sensitive technology for detection of this condition. While the salt water (saline) is absorbed by the body and eventually eliminated in case of rupture, the silicone leak can travel beyond the breast and be trapped in the lymph nodes or accumulate in the tissues elsewhere, causing inflammatory masses.
In most cases, implant reconstruction starts with the placement of an expander behind the chest wall muscles (pectoralis and serratus muscles) and in front of the ribs. This device has different volume capacities to achieve different sizes of breasts and, over several weeks/months, the expander is inflated with saline, stretching the skin and creating a pocket under the muscle, until the desired volume is achieved. During a second procedure, the expanders are removed and replaced by an implant. Under certain circumstances, it is possible to place the implants immediately after the mastectomy. The last step of the reconstructive surgery is the nipple reconstruction which is followed by tattooing of the areola and reconstructed nipple.
The implant reconstruction is a much simpler and shorter procedure, and it tends to heal quickly. The disadvantages are that the texture of the implants is different than the real breast and this is very noticeable to the patient, whose other breast does not have an implant. Another operation to replace the implants may be necessary as they expire. During the healing process, the body forms a thin layer of tissue around the implants and this can sometimes be hardened and contracted, producing discomfort and/or pain and excessively firm breasts. This process is also known as capsule contraction and is one of the main reasons why the breast implant is not recommended in patients who require breast radiation. Symptomatic capsule contraction may require surgery for correction.
Flaps Tissue flap reconstruction refers to the use of patient's own tissues for breast reconstruction. The sources of the flaps include tummy, back, thighs or buttocks. The first two are the most common types which are going to be discussed here. Flap reconstruction is frequently chosen over the implant whenever radiation treatment is needed. Also flap provides a more natural looking, especially when the mastectomy is limited to one side.
The TRAM flap (transverse rectus abdominis muscle) uses the tissue from the tummy to rebuild the breast. This is done with mobilization of skin, fat, blood vessels and the abdominal muscle to reach the breast site through a tunnel created underneath the skin. This technique is called pedicle TRAM flap. When blood vessels are divided from the lower abdomen and moved together with the flap to the breast site for reconstruction, they need to be reconnected to the blood vessels close to the breast to be rebuilt and this procedure is called free TRAM flap. The free flap requires an entire set of skills that involve the use of a microscope during the operation to connect the vessels attached to the flap to those in the breast area. The end result of the flap removal is a scar similar to a cesarean section, but much longer and a scar around the relocated belly button. The scar shape and extent of the reconstructed breast depend on the amount of skin that has to be removed during the mastectomy. Further procedures may be required to achieve symmetry between the two breasts. The breast contour is usually preserved and it is felt real because the tissue consistency is close to that of the breast.
DIEP flap (deep inferior epigastric artery perforator) is a newer technique and is a variation of the TRAM flap. It uses the same donor tissue and microvascular technique as the "free" TRAM flap with the differences being that the rectus muscle is removed from the abdomen and different blood vessels are being removed from the donor site. When using one's own tissue is being considered, the amount of tissue available for reconstruction of one or two breasts is an important factor for choosing the type of reconstruction. The other factors such as excessive weight, smoking and elderly age may be considered as contraindications for this procedure.
The latissimus dorsi flap reconstruction uses skin and fatty tissue attached to a portion of the latissimus dorsi muscle (large back muscle) and blood vessels. All of these structures are mobilized from your upper back and the tissues are rotated through a tunnel created under the arm and eventually positioned at the mastectomy area. The amount of tissue obtained with this technique is usually not enough to rebuild the entire breast mound and is commonly used in combination with an implant. This operation is usually offered as an option when the TRAM flap is not recommended, such as in thin patients (particularly when they were never pregnant) or patients who had an abdominal surgery that could have compromised the vessels that supply the nutrition of the tummy flap. A straight horizontal scar at the back will be formed and can be hidden under the bra. The scars in the breast are those from the previous breast surgery and mastectomy procedure.
The nipple reconstruction is the last step of the reconstruction. If desired by the patient, it is done when the breast is healed and the site and height of the nipple can be properly established. It is a very short procedure and it's done under local anesthesia. After the reconstructed nipple is healed, tattooing of the nipple areolar complex with the color matching the other breast finishes the entire reconstructive process. The reconstructed nipple has no sensation and does not react to stimulations such as temperature or touch.
As mentioned above, breast reconstruction is a process where not only the mound of breast tissue needs to be replaced but also symmetric results need to be achieved. The vast majority of the reconstruction procedures are done in steps scheduled at different times. The type of reconstruction is tailored to each individual based on the medical consideration and patient's preference.
What are the possible side effects of sentinel lymph node biopsy (SLNB)?
Sentinel lymph node biopsy is replacing axillary lymph node dissection in most breast cancer cases as this is a less invasive procedure with fewer associated side effects. As the sentinel lymph node biopsy involves only the removal of a few lymph nodes, the side effects tend to be minimal immediately after surgery and have almost no long-term side effect. Shoulder range of motion is usually not affected and several simple "do-it-your-self" exercises should help patients who may have some limitations at the beginning. Nerve damage is not common but short-lived tingling and sometimes sharp/shooting pain in the inner upper arm and in the armpit may occur. Long term dullness at the same area is rare. Because the risk of chronic arm swelling is minimal, long term lymphedema precaution protocol does not apply to patients with a few SLNs removed.