BEAUTY IS IN THEBEAUTY IS IN THE EYE OF THEEYE OF THE BEHOLDERBEHOLDER

Breast Cancer Surgery:Breast Cancer Surgery: Can I still keep my breast?p y

Dr shiryazdiDr shiryazdi

StatisticsStatisticsStatisticsStatistics

1 1 in in 9 9 womenwomen

Rising incidenceRising incidence

20102010 >> 22 500500 cancers diagnosed in Irelandcancers diagnosed in Ireland 2010 2010 > > 22,,500 500 cancers diagnosed in Irelandcancers diagnosed in Ireland

Outcome from breast cancer has improvedOutcome from breast cancer has improved

History of breast surgery• 1894 – Radical mastectomy by William

Halsted• 1967 – Modified Radical Mastectomy• 1981 – Breast conservation surgery1981 Breast conservation surgery

(lumpectomy and removal of axillary lymph nodes)lymph nodes)

• Studies have shown that there is no difference in the outcome in all these threedifference in the outcome in all these three types of surgery

HISTORICAL PERSPECTIVEHISTORICAL PERSPECTIVEHISTORICAL PERSPECTIVEHISTORICAL PERSPECTIVE

Ancient Eygptians Ancient Eygptians 33,,500500HippocratesHippocrates 460460 BCBC-- humoral diseasehumoral disease Hippocrates Hippocrates 460 460 BCBC humoral diseasehumoral disease

Breast Cancer considered systemicBreast Cancer considered systemic--surgery did not cure because this was a surgery did not cure because this was a su ge y d d ot cu e because t s as asu ge y d d ot cu e because t s as a

disease involving the entire bodydisease involving the entire body(H moral Theor )(H moral Theor ) (Humoral Theory)(Humoral Theory)

Move to Localised TheoryMove to Localised TheoryMove to Localised TheoryMove to Localised Theory

1717th Centuryth Century--Localised disease Localised disease potentially curable potentially curable

with surgerywith surgery

1919th Centuryth Century--1919th Centuryth CenturyHalsteadHalstead--Era of Era of

Radical MastectomyRadical MastectomyRadical MastectomyRadical Mastectomy

AnatomyAnatomyAnatomyAnatomy

Halstedian theoryHalstedian theory

Cancer spread Cancer spread anatomicallyanatomicallyanatomicallyanatomically

BreastBreast Lymphatics/Lymphatics/ BreastBreast-- Lymphatics/ Lymphatics/ direct invasion of direct invasion of

surrounding tissuessurrounding tissuessurrounding tissuessurrounding tissues

Oncology DevelopmentOncology DevelopmentOncology DevelopmentOncology Development

1895 1895 BeatsonBeatson--oopherectomyoopherectomy

18961896 Emile GrubbEmile Grubb--1896 1896 Emile GrubbEmile Grubbradiotherapyradiotherapy

ChemotherapyChemotherapy-- 2020thth

centurycenturycenturycentury

Influential Clinical TrialsInfluential Clinical TrialsInfluential Clinical TrialsInfluential Clinical Trials

NSABPNSABPMilanMilan MilanMilan

Breast Conservation and radiotherapyBreast Conservation and radiotherapyChemotherapy development and trialsChemotherapy development and trials Chemotherapy development and trialsChemotherapy development and trials

Modern Surgical PracticeModern Surgical PracticeModern Surgical PracticeModern Surgical Practice

Less invasive surgeryLess invasive surgery

More attention to cosmetic outcomesMore attention to cosmetic outcomes

Improved prognosisImproved prognosis

Oncological ApproachOncological ApproachOncological ApproachOncological Approach

Combining treatments:Combining treatments:Surgery/Chemotherapy/Radiotherapy/BiolSurgery/Chemotherapy/Radiotherapy/Biol Surgery/Chemotherapy/Radiotherapy/BiolSurgery/Chemotherapy/Radiotherapy/Biol

ogical treatmentsogical treatments

MultidisciplinaryMultidisciplinaryu t d sc p a yu t d sc p a y

“Tailored” approach“Tailored” approach

Breast Cancer Services in Breast Cancer Services in IrelandIreland

Specialist Cancer CentresSpecialist Cancer Centres Population of Population of 250250,,000000--300300,,000 000 per per

centrecentre 100100 --150150 new cancers p.a. per centrenew cancers p.a. per centre100 100 150 150 new cancers p.a. per centrenew cancers p.a. per centre High volume of cancer cases leads to High volume of cancer cases leads to

experienced personnelexperienced personnel

National Quality Assurance Standards for Symptomatic Breast Disease Services

(Ireland 2000)(Ireland 2000)

National Cancer Control National Cancer Control ProgrammeProgramme

Established Established 20062006

Cancer StrategyCancer Strategy

8 8 Cancer CentresCancer CentresWest: GUH and LimerickWest: GUH and Limerick

South:CUH and WaterfordSouth:CUH and WaterfordEast:Mater/Vincents, East:Mater/Vincents,

Beaumont and James’Beaumont and James’

Minimally invasive surgeryMinimally invasive surgeryMinimally invasive surgeryMinimally invasive surgery

1970 1970 Breast Breast conservationconservation

19901990’s Sentinel node’s Sentinel node19901990 s Sentinel node s Sentinel node biopsybiopsy

Wh i th diff h t tWhy is there no difference whatever type of surgery is done?

• Even when a breast cancer is 1 cm, cancer cells can go into the blood and lymphaticcells can go into the blood and lymphatic vessels and be carried to any part of the body

• Hence surgery alone usually cannot cure the• Hence surgery alone usually cannot cure the patient

• Systemic therapy such as chemotherapy or• Systemic therapy such as chemotherapy or hormone therapy will also be required

• However surgery is important to get rid of• However surgery is important to get rid of all obvious gross cancer

Survival after BCS and Mastectomy

Trial Endpoint Overall SurvivalCS&RT Mastect

Disease-free SurvivalCS&RT Mastect

NCI Milan 18 yrs 65% 65% N/A

Institut GustavRoussy

15 yrs 73% 65% N/A

NSABP B 06 12 rs 63% 59% 50% 49%NSABP B-06 12 yrs 63% 59% 50% 49%

NCI USA 10 yrs 77% 75% 72% 69%

EORTC 8 yrs 54% 61% N/A

D i h B t 79% 82% 70% 66%Danish BreastCancer Group

6 yrs 79% 82% 70% 66%

L l t ft l tLocal recurrence rates after lumpectomy +RT, lumpectomy alone and mastectomy

Trial Follow-up

LumpectomyAnd RT

Lumpectomyalone

MastectomyAnd RT alone

NSABP-B06 8 yrs 10% 39% 8%

EORTC 8 yrs 15% NA 9%

Jacobsen etal 10yrs 17% NA 9%

EuropeanEORTC/DBCG

10 yrs 10% NA 9%

Radiotherapy

• After lumpectomy, radiotherapy is essential, otherwise the local recurrence rate is unacceptably highp y g

• Without radiotherapy, the local recurrence can be as high as 40%recurrence can be as high as 40%

When can we try to save yourWhen can we try to save your breast?

• Size is the most important criteria. The lump must be small enough to be excisedlump must be small enough to be excised with a good margin of normal breast tissue

• The tumour must be a single lump with no disease elsewhere in the breast –mammogram before surgery is essentialmammogram before surgery is essential to rule out multifocal disease

• The patient must agree to radiotherapyThe patient must agree to radiotherapyand have no other diseases which make radiotherapy impossible

When can we try to save yourWhen can we try to save your breast?

• Counseling is very important• Decision-making should be a shared

decision ie the patient and the doctordecision ie the patient and the doctor together will decide what is best for the patientpatient

Mastectomy

• No physical handicap• The degree of

emotional handicap depends on the patient

Breast conservation surgery

• Breast contour is dpreserved

• Requires radiotherapy• Generally less

depression and better pbody image

Breast conservation surgery

• Occasionally may l fcause a lot of

distortion if the lump i l lis large or too close to the nipple

• In such cases, may require plastic surgery or a mastectomy is necessary

What if I cannot save myWhat if I cannot save my breast?

• If the lump is too big to be safely removed with a margin of normal tissue, or there are multiple cancers , pin the breast, and mastectomy is required immediate breastrequired, immediate breast reconstruction is possible and has been shown to be safebeen shown to be safe

Immediate breast reconstruction

• Takes longer operating itime

• Own body tissues can be used eg abdomen

• Psychologically less y g ydepression

I th f i b t if IIs there a way of saving my breast even if I have a big tumour?

• Primary chemotherapy may be able to h i k th t th t BCS bshrink the tumour so that BCS can be

done• Not standard practice, but can be safely

done if the patient wants BCS and is not willing to have a mastectomy

• Not advisable in Stage 3 locally advanced g ybreast cancer

What is Stage 3 locallyWhat is Stage 3 locally advanced breast cancer?

• Cancer involving the ki h h lskin or the whole

breast• Chemotherapy can be

given first to shrink it• Mastectomy after

chemotherapypy

Is breast conservation surgeryIs breast conservation surgery commonly carried out?y

• In UMMC, 30% of breast surgery is breast conservation surgery while the rest areconservation surgery while the rest are mastectomy

• In USA figures of BCS are more than 70%• In USA, figures of BCS are more than 70%

• Early detection is the most important• Early detection is the most important factor in determining whether your breast can be savedcan be saved

Follow up after breastFollow-up after breast conservation surgeryg y

• Mammogram at 6 months after radiotherapy

• Mammogram yearly afterwardsMammogram yearly afterwards• If local recurrence detected,

t t t b i d tmastectomy must be carried out

Conclusion

• Breast conservation surgery gives the t t tsame outcome as mastectomy

• Selection of patients important• Education and counseling of patients is

importantp• Awareness programmes should

emphasize that with early detection, YOUemphasize that with early detection, YOU CAN STILL KEEP YOUR BREAST