Ashley Dowdy, PA, from West Cancer Center breaks down the surgical perspectives.
An abnormal mammography result, that necessitates a call back for further diagnostic testing, can be a frightening experience for patients, where nurses and advanced practitioners are frequently called upon to navigate patient fear and anxiety over what comes next. At this year’s West Oncology Conference for Advanced Patient Practitioners (APPs) and Nurses, Ashley Dowdy, a PA from West Cancer Center, outlined the major surgical options for patients with a new breast cancer diagnosis.
If not detected as a palpable mass, with modern advanced imaging techniques, many breast cancers may be detected by regular mammography screening. If an abnormality is found, whether by mammography or sonography, a core needle biopsy is the standard of care for diagnosis. This procedure, which is generally well tolerated by patients, uses sonography or stereotactic imaging techniques to locate the abnormality; the skin is then cleaned, numbed, and a larger, hollow needle is inserted to take samples of the abnormality for diagnostic testing. Importantly, a biopsy marker, roughly the size of a pinhead, is inserted in order to mark the location within the mass from which the biopsy samples were taken. If a diagnosis of breast cancer is made based on the biopsy, a breast MRI may also be indicated in some, but not all cases to assess the extent of disease.
Once a diagnosis of breast cancer is made, the anatomic tumor staging (TNM) system (Tumor size, Nodal involvement, and presence/absence of Metastasis) is used to assign a stage for the breast cancer. Additional biomarkers are also used, including tumor histologic grade, estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status, to further refine the staging. In addition, results of tumor genomic profiling tests, such as Oncotype Dx, may be useful to define treatment strategy in a newly diagnosed breast cancer.
Further Diagnostic Workup
Generally, whole body imaging to detect the presence of distant disease is not indicated by the major guidelines, unless there is a suspicion of distant metastatic disease based on the patient’s clinical signs and symptoms. If indicated, such workup might include bone scan for bone pain, or a chest or abdominal CT if pulmonary or abdominal symptoms are noted, respectively.
Breast cancer treatment typically involves a multidisciplinary team (MDT) management approach that includes surgeons, radiation oncologists, medical oncologists, and other specialists. Surgery is often the first step in treatment for most breast cancers, and surgical pathology can inform on the need for subsequent treatments/adjuvant therapy. In this regard, there are two main surgical options in breast cancer, lumpectomy (partial mastectomy), or simple/total mastectomy (complete breast removal). When discussing these options with patients, it is important to convey that there is no data to suggest that complete breast removal (mastectomy) confers any survival advantage over partial mastectomy (lumpectomy). There is, however a slightly higher risk for local recurrence with lumpectomy + radiation (5%) as compared to mastectomy (2%).
There are indications for mastectomy over lumpectomy, which include multicentric disease (i.e., multiple tumors), a large tumor size relative to the breast size (which may lead to a cosmetically unfavorable outcome), a central location of the tumor, which necessitates removal of the nipple/areolar complex, and whether the patient has any contraindications for radiation therapy, which is used along with lumpectomy. Some patients may also opt for mastectomy for personal reasons, despite being offered either option. Whole or partial breast radiation will generally be used as adjuvant therapy for patients having a lumpectomy, with some exception for women with hormone-responsive tumors over the age of 70 or if tumors are 3 cm or less in size. By comparison, radiation is generally not indicated for patients having a mastectomy with some exception for tumors over 5 cm, those with skin or chest wall involvement, those with positive surgical margins, or multiple positive lymph nodes.
Overall, surgeons should discuss both surgical options for breast cancer with their patients, again noting that survival with lumpectomy + radiation versus mastectomy alone are equivalent. It is also important to note that decisions regarding the use of systemic therapy (such as chemotherapy, HER2-blocking, or endocrine therapy) are completely independent of the surgical option that is chosen.
In lumpectomy (also defined as partial mastectomy), the tumor is removed from the breast along with some healthy tissue. The procedure aims to preserve cosmetic outcomes as much as possible, depending on tumor location, utilizing, in most cases a periareolar incision (around the nipple), or an inframammary incision (below the breast fold) with a transaxillary incision (under the arm). The goal of lumpectomy is to completely remove the tumor with clear and negative tumor margins (surrounding tissue). A clear margin is defined as no tumor tissue along the edge of the excision. Margins are generally cleared with lumpectomy in the vast majority of cases. If margins are positive, a re-excision may be attempted, but if a significant number are positive (e.g., 5 of 6 margins), or if one or more attempts are unsuccessful at clearing the margins, a mastectomy may be required.
Patients with locally advanced breast cancer, for example those with large tumors (T3, T4) or more extensive nodal involvement (N2, N3) are most likely ineligible for lumpectomy as an upfront treatment. Such patients may also not be candidates for immediate surgery, but rather may require neoadjuvant treatment, after which the tumor is reassessed to determine size and surgical plan. Mastectomy may be performed with or without subsequent reconstructive breast surgery, and may also be designed to save skin (skin-sparing) or the nipple tissue (nipple-sparing).
A simple mastectomy without reconstruction results in a flat chest wall that is suitable for fitting with a breast prosthesis to create symmetry. For mastectomy with reconstruction, there are two main types, implant-based and tissue flap, and reconstruction surgery can occur either immediately following mastectomy, or can be delayed. For an implant-based reconstruction, a saline filled expander is used to gradually create space for the implant, after which an implant is placed when sufficient space has been created and the chest tissue has relaxed and healed sufficiently, typically 2 to 6 months after the mastectomy. The ideal patient for an implant reconstruction would be generally healthy, a non-smoker, with small to moderate sized breasts and seeking a similar breast size to their original. In tissue flap reconstruction, an area of tissue is taken from another part of the body, typically the back, abdomen, or buttocks, and is used to replace the breast tissue that was removed.
It is important to note that any kind of reconstructive surgery, bras and prostheses, or any treatment that is designed to create symmetry in the breasts after a cancer, is generally covered by insurance based on the Women’s Heath and Cancer Rights Act (WHCRA).
Lymph Node Assessments
Lymph node assessment is also required for patients undergoing breast cancer surgery for invasive disease, and in some instances, with non-invasive disease, as a means to determine the extent of cancer spread (axillary staging), and as a guide for subsequent therapy. The technique of axillary lymph node dissection (removal of level I and II lymph nodes, typically 10 or more) is generally used less frequently at present due to the risk of significant complications such as lymphedema. Sentinel node mapping and biopsy, which involves injecting a dye to locate, map, and remove several lymph nodes (which would be the first to encounter any cancer that has spread) is a less invasive option with a lower risk for lymphedema. Sentinel node biopsy is appropriate for most patients without clinical lymph node involvement.
The surgical consult is an essential component in the multidisciplinary team management of early breast cancer, and typically the first step when patients have abnormal findings on mammography. Once a breast cancer has been diagnosed by biopsy, either a lumpectomy or mastectomy may be indicated, and the integration of modern surgical techniques with advances in radiotherapy and systemic treatments has allowed for less invasive surgical procedures. Collectively, this has resulted in less morbidity, better surgical outcomes, and improved survival for women with early breast cancer.
See more from the 2022 West Oncology APP here.
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