Breast cancer treatment – Halsted to 2012
Mrs Jacqueline Lewis MB BCh BAO FRCS(Plast) is a consultant breast surgeon at Bupa Cromwell Hospital and Charing Cross Hospital.
Breast cancer treatment has come a long way since the time of our grandmothers. There have been advancements in adjuvant therapies, diagnostics and surgery, and the multidisciplinary approach has revolutionized care. Surgeons are no longer frequently faced with having to cut away large chunks of cancerous tissue with a wide margin of normal surrounding flesh for an advanced fungating tumour.
Breast cancer surgery
In 1889 Halsted described a novel procedure for the treatment of breast cancer – the radical mastectomy. At the turn of the 20th century breast cancer was a devastating disease with no documented successful treatment, surgical or otherwise. In addition, it was uncommon to operate for palliation, and as a result, most women suffered with their cancerous growths spreading and invading the chest wall. Halsted’s operation of en-bloc removal of the breast, lymph nodes and muscles of the chest wall had the immediate impact of removing the necrotic foul-smelling tumour and offered real hope for victims of breast cancer at the time, even if cure was not always possible.
As time has gone by, the surgical pendulum has swung from the radical mastectomy to removing less and less tissue – breast conserving surgery. This is because the survival rates of women having breast conservation surgery and mastectomy are comparable (if not equivalent) because of the addition of effective adjuvant therapies. This concept however, has led to a significant number of women feeling they were left ‘mutilated’ despite conserving their breast.
The UK Department of Health has been a leader in supporting an innovative programme to expand training in breast reconstruction in the United Kingdom. Over the last decade, over 100 trainee surgeons have participated in this programme aimed at producing surgeons fit to practice in modern oncoplastic and reconstructive breast surgery. Patients in the UK are now better able to access surgeons with experience in the full range of procedures encompassed by oncoplastic breast reconstructive surgery, which include:
- appropriate adequate surgery to extirpate the cancer
- partial reconstruction to correct wide excision defects
- immediate and delayed total reconstruction with access to a full range of techniques
- correction of asymmetry of the reconstructed and the contralateral unaffected breast.
Sentinel node biopsy
A frequently asked question and most feared complication regarding axillary node surgery is the likelihood of lymphoedema or swelling of the arm. It occurs in 15-40 percent following axillary node clearance and is more likely if combined with radiotherapy to the axilla. With the advent of sentinel node biopsy, unnecessary axillary clearance can be avoided, thereby reducing the number of women with this complication.
Sentinel node biopsy involves removal of the first node receiving lymphatic drainage from an area of interest. It involves the injection of a radioactive and blue dye so that the ’hot’ blue node can be removed and carefully studied histologically for cancer cells.
With a positive sentinel node (containing cancer), a completion axillary clearance or radiotherapy to the axilla are undertaken. Further surgery gives more prognostic information about the number of nodes that contain cancer.
Early diagnosis of breast cancer
Early diagnosis as a result of ‘breast awareness’ and mammographic screening has meant that for most women, breast cancer is diagnosed at an early stage where the aim of treatment is cure rather than palliation.
In 2010-2011, the UK NHS Breast Screening Programme detected 14,725 cancers in women aged 45 and over, a rate of 7.8 cases per 1,000 women screened. Of these, 80 percent of the cancers were invasive. Most of the detected cancers were more small (less than 15 mm diameter) invasive or non-invasive cancers.
While the opponents of mammographic screening argue that more non-invasive cancers are picked up that would never cause any trouble and that women are put through unnecessary biopsies causing unnecessary anxiety, it remains a fact that earlier diagnosis of breast cancer leads to better survival outcomes.
Most women undergoing mammographic screening have a normal result. Only three to seven percent (higher number called back after first rather than subsequent screening mammogram) of women screened are called back for an assessment where further mammogram views are taken and a breast ultrasound performed. Most of these women can then be reassured that they do not have breast cancer. Forty percent of those called back for assessment go on to have a needle core test or fine needle aspirate.
With the advent of new and effective adjuvant therapies, less extensive surgery is more often possible. Upfront chemotherapy or endocrine treatment can be used to downsize large tumours to allow breast conservation surgery rather than mastectomy. Neoadjuvant therapies also allow switching of drugs if the response to the first regimen is poor.
New chemotherapeutic regimes, endocrine therapies (i.e. aromatase inhibitors like anastrazole, exemestane, letrozole), monoclonal antibodies (i.e. Herceptin), and radiotherapy as a single treatment intraoperatively (TARGIT), potentially make breast cancer treatment less invasive with more promising outcomes.
Chemotherapy is one of the most feared treatment modalities for breast cancer with women dreading the frequent hair loss, nausea and fatigue. While it is clear that most women with large, node positive oestrogen receptor negative cancers will benefit from having chemotherapy, it is often unclear as to as whether a woman with a relatively small node negative oestrogen receptor positive breast cancer should have chemotherapy. There is now the option for an assay of an individual woman’s cancer with the use of Oncotype DX (a multigene breast cancer assay) that can predict whether she would benefit from chemotherapy. This test has proved to be extremely valuable in selected cases, so much so that the cost of the assay is covered by most private health insurance companies.
Treating breast cancer is an ever-evolving specialty, with challenging aspects. We do now however have so many more tools to enable us to tailor treatment to fit each individualised patient according to their informed choice.