For most women, breast conservation will be the treatment of choice since it is less traumatic, and the survival results are identical to survival rates with mastectomy. However, not all women are candidates for breast conservation, and some women prefer mastectomy.
Women considering breast conservation must have a clear understanding of the issue of ' margins". The goal in breast conservation is to remove the tumor with a surrounding rim of normal tissue. Obtaining a clear margin can be a challenge. Although the surgeon attempts to take out the entire tumor at the time of the initial surgery, in some cases the tumor cells, which are not visible during the surgery, are found to extend to the edge (margin) of the lumpectomy specimen, and a second operation is required. Fortunately, the vast majority of women who initially choose breast conservation will ultimately achieve a good to excellent cosmetic result. Long-term survival is equal to that with mastectomy.
Some women are either not candidates for breast conservation or choose mastectomy for personal reasons.
Giving chemotherapy first (neoadjuvant therapy) is becoming a more common option. In the past, chemotherapy was given before surgery in situations where the tumor was too large to permit a mastectomy. The chemotherapy was given first to shrink the tumor so that a mastectomy could be successfully performed. It is now becoming common practice to give chemotherapy first to shrink the tumors so that less tissue is taken at the time of the lumpectomy, which leads to improved cosmetic results. We have had extensive experience with this approach and have now saved hundreds of breasts that in the past would have required a mastectomy.
A 6-8 week course of irradiation therapy will be recommended for women undergoing lumpectomy (radiation therapy may be safely avoided in selected women with small, non-invasive cancers). The purpose of radiation is to eliminate any remaining cancer cells in the breast following lumpectomy, and it is very effective in lowering the rate of cancer recurrence in the breast.There is now an alternative to standard radiation therapy which can be accomplished in 5 days .
Radiation is painless and takes only a few minutes to perform. It is much like a simple chest x-ray in that a beam of energy goes through the body without the patient being aware that anything is happening. With breast irradiation the energy beam is much stronger then the energy for a chest x-ray. The most common side effect of breast irradiation is redness to the skin. There is no hair loss or nausea with breast irradiation as there is with chemotherapy.
Lymph node removal will be recommended for most women with breast cancer. Lymph nodes are lima bean shaped structures that vary in size from that of a pea to the size of a marble. A primary function of a lymph node is to filter unwanted materials from the body, and this includes cancer cells. In fact, if breast cancer cells break off from the main tumor, the first place they are likely to go to the lymph nodes under the arm . One of the most important indicators of prognosis is the status of the axillary lymph nodes (i.e. no nodes involved means good prognosis; the more nodes involved, the worse the prognosis). For this reason it was standard therapy in the past to remove all of the lymph nodes under the arm at the time of the removal of the breast cancer to determine prognosis.
It is now standard practice to remove only the first draining lymph node (sentinel lymph node) at this time of the lumpectomy or mastectomy, and have it examined under the microscope. If the lymph node is free of cancer cells , no other lymph nodes are removed. By limiting the number of nodes removed, recovery is accelerated and risk of complications such as lymphedema are minimized.
One of the first questions a woman asks after learning she has breast cancer is: " Am I going to live?" , in other words, " what is my prognosis?" When a woman asks her physician this basic question, she is often frustrated with the vagueness of the response. The problem is that the treating physician does not have enough information following the initial biopsy to make an accurate prediction of survival. Until the tumor and lymph nodes have been removed and analyzed, an accurate prediction of survival is not possible. The most important predictors of survival are the size of the invasive component of the tumor and the status of the regional lymph nodes (when there is no invasive tumor, i.e. only DCIS, the survival rate is 100%). When the invasive tumor is less than 11 mm in diameter and the nodes are negative, the 10 year survival approaches 95%, and if you make it ten years, consider yourself cured. As the tumor enlarges and the number of involved lymph nodes increases, the potential for cure is reduced. However, dramatic improvements have been made in medical treatment of breast cancer (i.e. chemotherapy and hormone therapy) and many new treatments are on the horizon. There is now reason for optimism in even the most advanced cases.