Treating Breast Tumors
The usual treatment for breast cancer is surgery - some form of mastectomy, or removal of all or part of the affected breast - either alone or in combination with radiation and/or chemo (drug) therapy. Although you will make the final decision about the extent of any breast surgery you consent to undergo, your decision should be based on your doctor's and surgeon's judgement, and on complete information about the likely benefits and possible consequences of each alternative.
Many surgeons have reassessed the standard operative approach to breast cancer after observing no significant decline in the per capita mortality from breast cancer over the past fifty years. According to an article appearing in Clinical Update, Autumn, 1987, published by the Mayo Clinic in Rochester Minnesota, two different approaches to the surgical treatment of breast cancer arose as a result of this reassessment. One approach, excision of the tumor itself with the dissection of axillary nodes and external radiation, and secondly, the modified radical mastectomy. The question being asked is, "Is the minimum possible operation always most desirable?"
The surgical procedure increasingly being performed in situation where the tissue surrounding the tumor is not involved, is called a lumpectomy. In this procedure the tumor the tumor including 1-2cm of surrounding (an uninvolved) tissue is removed. This is sometimes referred to as a tylectomy. The lymph nodes under the arm are almost always removed. Lumpectomy followed by radiation therapy is the treatment of choice now in those women with early stage breast cancer. Radiation therapy usually begins about two weeks after lymph node surgery and continues for 5 to 6 weeks. When the treatments are completed, an extra "boost" of radiation is usually given to the area where the tumor was located. Two long-term studies recently published and reported on the OB-GYN news June 1, 1995 issue, reinforce earlier studies that indicated a lumpectomy, followed by radiation, in patients with state I or II breast cancer, had similar survival rates at 10 years, as women who underwent mastectomy for their stage I or II disease.
Most mastectomies are generally one of 4 types. The surgical treatment of choice must be individualized to each patient. Though you have the final decision as to the extent of breast surgery you consent to, it should be based on your doctor's and surgeon's judgement, and on complete information about the likely benefits and possible consequences of each alternative.
|Segmental or mastectomy: Segmental or partial mastectomy (sometimes called quadrantectomy) is the resection of the tumor and some of the normal breast tissue surrounding the primary lesion. In almost all cases, radiation therapy follow surgery.|
Removes only the entire effected breast, leaving intact both the lymph nodes and pectoral muscles. Although opinions differ regarding the removal of lymph nodes from the armpit, many feel the simple mastectomy may be the best treatment for very old, debilitated patients.
|Modified radical mastectomy:
Removes the entire breast and lymph nodes from the armpit, leaving intact the chest muscles. It does not generally cause swelling or loss of mobility in the arm and hand; retaining the pectoral muscles reduces disfigurement and may facilitate later reconstructive surgery.
Radical mastectomy (also called Halsted radical mastectomy):
Was the standard surgical procedure for breast cancer at one time. Today, it is performed infrequently — usually only for very large or advanced tumors. In this procedure, the breast, the lymph nodes in the arm pit and the underlying pectoral muscles are removed.
Although mastectomy in some form is still the response to breast cancer chosen by many surgeons, it is important to know that it is not the only possible treatment. Breast cancers that have already spread through the bloodstream to other parts of the body may be better treated by early, intensive chemotherapy, according to researchers at the medical schools of Harvard, Yale, and the University of Pittsburgh; they believe that when drug treatment is introduced early in the course of the disease (rather than as a "last resort" following surgery and radiation) it is more easily tolerated and more effective at locating and destroying cancer cells which cannot be reached by other means. Similarly, early radiation of all lymph nodes surrounding the affected area may succeed better than attempts to remove all such nodes by surgery; many lymph nodes lie behind the breast bone and up the back and are difficult to remove. And a woman whose breast is mainly intact may withstand radiation better than one who has had a radical mastectomy, leaving extensive scars and only a thin layer of easily damaged skin covering her breastbone.
When breast tumors are detected in an early stage, before they have had a chance to invade surrounding lymph nodes, removal of the tumor and 1-2 cm of surrounding tissue, followed by radiation of the surrounding tissue can be equally effective. Results of lumpectomy followed by radiation, were first published in 1927. More recently, a team of surgeons pathologists, radiologists, and internists ant Massachusetts General Hospital in Boston, reported much the same thing — results of lumpectomy followed by radiation were equally as effective as mastectomy when the tumor was small with no evidence that surrounding tissue had been invaded.
An October 1988 article published in a medical newspaper OB-GYN NEWS reported "the issue of lumpectomy plus radiation, versus mastectomy, has been studied about as well as any medical treatment has been scrutinized." The findings show the survival of patients who had a wide excision of the tumor followed by radiation was indistinguishable from the survival of those who underwent mastectomy. Appropriate selection of patients combined with the proper surgical technique helps ensure survival equal to that of mastectomy.
Do not be reluctant or hesitate to discuss this alternative with your doctors.
There are also important psychological and cosmetic advantages to less drastic surgery — although reconstruction may be less difficult for a patient who has undergone total simple mastectomy than for one who has had a large tumor removed from a small breast.
Patients considered to be at high risk of cancer recurrence may receive additional treatment — often referred to as "adjuvant" therapy. This may also be true of patients who have a mastectomy for a very large tumor or whose lymph nodes in the chest and axilla (armpits) are affected.
Treatment using drugs that kill cancer cells circulating in parts of the body other
than the breasts is also improving the survival rates in some women. Scientists are
continually searching for drug combinations that most effectively kill the cancer
cells while still having the fewest unwanted side-effects.
The National Cancer Institute reported in a 1986 study a significant reduction in death among premenopausal women given chemotherapy in conjunction with surgery. Two more recent studies, one by the U.S. research team and another by a cancer research group in Italy, found there was "clear-cut survival advantage" for premenopausal woman under the age of 50 who were treated with chemotherapy and surgery. There is continued debate regarding the timing of chemo-therapy in order to obtain the best results. There is also no definite answer as to the choice of drugs, dose and duration of a treatment.
Studies involving postmenopausal women who were given the hormone tamoxifen in conjunction with surgery also reported a significant survival advantage according to the National Cancer Institute. Tamoxifen, a synthetic hormone, blocks the action of the female hormone estrogen. It was once thought that tamoxifen sped up bone loss in postmenopausal women but recent studies do not support this. As a matter of fact, it may actually offer some protection against bone loss.
While tamoxifen acts against the effects of estrogen in the breast tissue, it acts like estrogen in other systems of the body, according to Cancer Facts published by the national Cancer Institute (NCI). This means that many of the beneficial effects of estrogen replacement therapy such as lowering blood cholesterol and slowing bone loss will affect women who take tamoxifen.
The side effects of tamoxifen are similar to some of the symptoms of menopause. This includes hot flashes, irregular menstrual periods and vaginal discharge or bleeding. However, not all women taking tamoxifen have these symptoms.
Tamoxifen has also been shown to increase fertility thus all premenopausal women taking this medication should use some type of birth control. Oral contraceptives (birth control pills) however, should not be used since they may alter the effects of the tamoxifen.
There have been recent clinical studies indicating that women taking the recommended dose of tamoxifen have an increased risk of endometrial cancer (cancer of the lining of the uterus). All women receiving tamoxifen are advised to have pelvic examinations every six months. Close monitoring of women taking tamoxifen therapy is essential. If an overgrowth of endometrial tissue (hyperplasia) is found, the tamoxifen should be discontinued and appropriate treatment instituted.
Tamoxifen offers the hope of adding may years to a woman's life, confirming the belief of many physicians that the beneficial effects of tamoxifen warrants the increased risks of endometrial cancer. In a study conducted in Amsterdam, and reported in the English medical journal, Lancet 1994:343:448, Dutch investigators concluded "the clinical benefit of tamoxifen in controlling breast cancer far out weighs the modest increase in uterine cancer."
In one of the largest analyses of breast cancer patients ever conducted, benefits of tamoxifen, either alone or in combination with chemotherapy, increased the life expectancy of breast cancer patients even after a relatively brief series of treatments had ended. Tamoxifen treatment appears even more effective in the second five-year period. Analysis of this large study indicated women treated with tamoxifen, with or without chemotherapy, had fewer recurrences and lived longer than these who did not receive this treatment.
Tamoxifen also appears to offer protection against the development of new cancer in the opposite breast. This protection was not seen with chemotherapy only.
Long-term effects of tamoxifen in premenopausal women have not been studies until recently. Current studies suggest that it can produce as good an effect in women under 50 years old as chemotherapy, which is more toxic and produces more debilitating side effects.
A medical alert issued by the National Cancer Institute's Information Service, and mailed to cancer specialists around the country, recommends tamoxifen, used in the treatment of early stages of breast cancer, be treatment include hot flashes, slight nausea and changes in the menstrual cycle, but practically no serious side effects in post menopausal women.
Chemotherapy and/or hormonal therapy for patients at high risk are not controversial. With the in-depth analysis of a study, reported in 1992, experts believe tamoxifen therapy with or without chemotherapy, may also be indicated in women in whom cancer is caught in the early stage.
Doctors may prescribe chemotherapy, hormonal therapy, or a combination of the two. Chemotherapy can cause a variety of unpleasant side effects, which in most people, disappear when the medication is discontinued. A small percentage of patients may suffer serious delayed effects. Patients are closely monitored and the dosage adjusted to minimize the risk.
These potential treatment alternatives should make you more aware than ever of the extreme importance of early detection of any possible breast cancer by BSE and your doctor's diagnosis. Today, the 5 year survival rate for localized breast cancer has risen to 96%.
If the cancer has spread to areas near the breast, the survival rate drops to 69%; for those where cancer has spread to distant areas, the survival rate drops to only 18%.
If breast cancer is not invasive the survival rate nears 100% according to "Cancer Facts and Figures — 1996," published by the American Cancer Society. An appalling and frightening fact is that, on the average, women wait five to six months between finding breast lumps and consulting their doctors. And, of course, delay reduces your chances for minimal surgery and possible reconstruction. Remember that finding a lump needn't automatically mean losing a breast; but not finding a breast cancer, or not reporting it, cold mean losing your life.
To date, there are still some key questions which have no answers. Research is continuing to more accurately identify "high risk" patients. This, coupled with insights from clinical studies that ate on-going should, in time, help eliminate the uncertainty of women facing breast cancer treatment.
Discuss these alternative treatments with your surgeon and/or family physician. According to Dr. Marsha McNeese, of M.D. Anderson Cancer Center in Houston, Texas, it not necessary to rush into surgery. She does not advocate postponing surgery for any length of time. Dr. McNeese does feel a woman should not be pressured into making an immediate decision. Rather, she should discuss the alternatives with her doctor(s).
Breast cancer specialists stress that for most patients, the decision of whether or not to have mastectomy should be strictly a matter of personal choice.
If you have a mastectomy
Rehabilitation: Your doctor will supervise your surgical recovery, including any necessary follow-up care such as radiation treatments, hormone or drug therapy. Generally, within a month or two after a mastectomy you will be physically able to resume a normal productive life.
Your mental and emotional rehabilitation, also, may be greatly aided by the help and encouragement of another sort of "expert" in mastectomy — A Reach to Recovery volunteer. At the request of you and your surgeon, you may be visited in the hospital by a woman who has also had a mastectomy; she has had special training, provided by professionals, enabling her to offer you both psychological support and practical advice to help you adjust successfully to your post-surgical life. Having survives and overcome her own experience with breast cancer and the loss of a breast, she is well qualified to offer you believable encouragement.
Your Reach and Recovery volunteer will answer your non-medical questions about post-recovery exercise, activity and "coping". She will advise you on where to buy (or how to make) prostheses (artificial breast forms) and appropriate and attractive clothing, including lingerie and bathing suits. Perhaps most important, she is living proof that you can feel and be as vital, active and physically attractive after a mastectomy as before.
Follow this link
to see information about Breast Reconstruction.