Surgical options

Nobody wants to be told they have breast cancer. But, more and more, with advances in screening, diagnosis, and treatments the word "hope" is being used.

"For the first time ever we’ve seen a decrease in the risk of dying from breast cancer over the last decade."

"No longer is it a death sentence and so no one should be afraid to get screened because they’re afraid of what might be found because the sooner we get it the more likely you’re just going to live a long, healthy life."

Two Breast Cancer Surgeons in Binghamton, New York, Dr. Michael J. Farrell and Dr. Janet Muhich, spoke with me about some recent advancements in surgical options for treating breast cancers.

(Surgeon Michael J. Farrell) "One of the things I try to impress on patients when we discuss surgical options for their therapy is what does mastectomy mean today as opposed to what is often in the public mind-set from 30 years ago where, gee, my grandmother had a mastectomy and she had a lot of trouble with you know, she had to have therapy for her arm and things of that nature. That operation basically is not done anymore today for the most part. That was considered a radical mastectomy in which muscles on the chest wall were removed along with the breast and routinely all of the lymph nodes from under the arm were removed as well and those are therapies that are not utilized like that today. So removing the breast means just that, just the breast tissue, not removing the muscles, not removing all of the lymph nodes. That’s been supplanted with a sentinel lymph node biopsy and so the impact of the disability it creates for your physical ability to do things with your arm and other activities has really changed dramatically over time. It’s much improved and it really doesn’t impinge on your physical activities after doing that."

(Dr. Janet Muhich) "Now we can do something called sentinel node biopsy which is a technique where we can use a couple types of blue dye and radioactive tracer that allow us to detect the couple of main drain lymph nodes under the arm. We remove those and they’re usually tested during surgery with a frozen section. If they are negative we don’t have to do further surgery under the arm so it’s a much quicker recovery, much less discomfort and less risk of lymphedema which is arm swelling which can sometimes develop after surgery for lymph nodes."

"Today most patients are treated with breast conserving therapy which means a lumpectomy followed by radiation treatments to the breast. That therapy is equivalent in the long-term survival of the patient to having a mastectomy and so that has really become the main treatment option in the way of surgery for breast cancer."

"When we preserve the breast, meaning you just do the lumpectomy, you sample some lymph nodes, that patient does have to have radiation," (Dr. Janet Muhich). Because radiation in that situation reduces the risk of recurrent breast cancer in the breast itself. Traditional radiation has radiated the whole breast, but there is newer technology. If someone has a Stage 1 breast cancer and if it’s small and the lymph nodes are negative, then they may be a candidate for something called partial breast radiation. If someone is a candidate what we need to do is place a small catheter, a little tube, into the cavity where the cancer had been removed and then there’s a high-dose radiation seed put into the middle of the catheter for about 10-15 minutes. That’s done twice a day for five days. So instead of having radiation for seven weeks you can do the radiation in five days. So that’s newer technologies. Another thing that’s changed a lot in the last few years was genetic testing to see if there’s a genetic reason for the patient’s breast cancer. Because if we make a diagnosis of breast cancer and we think, boy, this patient really might have a genetic mutation, we really try to get that done first because then we would counsel a patient perhaps on bilateral mastectomies instead of just treating the one breast."

"We’re now taking portions of the tumor from the breast," (Surgeon Michael J. Farrell), "and having a DNA analysis and they’re looking at the genes involved with the tumor and they have a whole panel of what we call assays to assess what things are expressed in that tumor at a genetic level to help determine, you know, is this tumor more aggressive, is it less aggressive, what’s present on that and not in helping direct the therapy. Studies are currently ongoing showing how well does doing those tests compare to the old way of doing surgery on the lymph nodes to find out. I think that’s going to be the next big progression for surgery for breast cancer."

Another term I’ve heard recently is oncoplastic surgery. What is meant by that?

"Oncoplastic surgery is a combination of using typical cancer surgery, which is the oncologic aspect in the word oncoplastic and plastic surgery. So you are combining oncologic and plastic surgery together to try to continue to do the job of removing the tumor adequately and then leaving an adequate or a good cosmetic appearance to the breast after doing so. It involves some techniques which basically involve manipulating the tissues of the breast more after the tumor comes out to try to make it look more symmetrical, to give a better result to the appearance of the breast. You’re going to remove some tissue so typically you’re not going to have the same exact appearance as the opposite side. You’re going to have a slight reduction depending upon the size of the tumor. The goal is not to have a big distortion in the appearance of the breast, to have a cavity dip into the breast where the tumor had come out or to have a big scarring effect is going to distort the appearance. Oncoplastic surgery is to try to improve all of that appearance by changing the way we make incisions, changing the way that the tissue under the skin the patient really doesn’t get to see gets manipulated to create those effects."

(Dr. Janet Muhich) I think there’s been in the last ten years a huge shift all the way around, technology-wise, better detection, earlier detection, minimally invasive approach to the surgery we do which is huge, and survival benefit or a decreased risk in mortality I should say in the last decade. The fact that we can identify women that perhaps a genetic mutation and a higher risk of breast cancer or ovarian cancer so we can counsel them."

Tell me about some new developments that they are working on right now.

"A couple things may happen. Are they going to perfect a technique that may allow us to get rid of the cancer in the breast without having to do surgery. They’ve looked at laser or looked at trying to freeze tumors so that is way done the road. But there may be a way we can eradicate the breast cancer without having to do surgery."

"There are some treatments out there for very small tumors where they are trying to destroy the disease with an image-guided system meaning they’re using an ultrasound to guide a catheter into the tumor and then they’re destroying that tumor with some application of heat, or just the opposite, some application of freezing the tumor. Those are indicated at this point in clinical trials for patients with small tumors. In that respect it avoids having to do what we think of as a traditional operation and removing the tumor. Of course, one of the big issues is a lot of women still won’t have their screening mammogram for a variety of reasons. Some are just plain afraid of the results; some are too uncomfortable to have the test. But we have to get the women to have the test to find the problem. Right now that is our main way of early detection of breast cancer so that we can treat it early and eradicate it so it doesn’t recur for the patient."

 

Series produced by WSKG’s Kathleen Cook, with funding provided by a grant from the Susan G. Komen Foundation.