Breast Cancer Surgery Options

Breast Cancer Surgery Options


I wanted to be able to videotape the
talk that I normally give patients when you first come see me with a
diagnosis of breast cancer. There’s so much information I need
to convey and so many decisions that need to be made, so it’s really nice to
have a resource to be able to go back to. So what I’m going to do is just
go through this spiel that I normally do with my patients. When I given this spiel, I ask them
to hold their questions till the very end because most the time, by the time
I get to the end of this spiel, I have answered almost
all of their questions. So first of all, the first and very
most important thing to understand is that breast cancer is a
really, really common disease. Almost 200,000 women were diagnosed with
breast cancer in the United States alone last year. The other good news, although I can’t
say it’s necessarily good news, but the good news is most women go on
to survive their breast cancer. So we never want the treatment
to be worse than the disease. We do know that the rate of breast cancer has finally started to decrease, and that probably has something to do with women stopping
hormone replacement therapy at a older ages. So they haven’t been exposed
to it for a long time. But there’s still a lot of breast cancer
in the United States. So first a little bit about breast
cancer biology. It’s really important to understand that breast cancers are
relatively slow-growing cancers. It works by doubling time so it goes from
one cell to two cells, two cells to four cells, etc. By the time we can detect a
breast cancer mammographically it’s usually about five millimeters
at a minimum and that means it’s probably been
growing for about five years. By the time we can pick
one up that we can feel, which is usually about
one centimeter, or ten millimeters, it’s probably been growing
for about 10 years. Now I don’t tell patients
this to get them upset that they should have picked this up last year,
or five years ago, or ten years ago. I tell them this so they understand that
there’s really not a huge rush. In fact, if somebody tells you, “you have breast cancer
and you need both breasts cut off tomorrow,” they just don’t understand the biology
of the disease. And I really want you to understand both the biology of the disease
and all your treatment options to have some time to think about that
before you make your decisions about which way you want to go. So let’s talk a little bit about risk
factors for breast cancer. First of all the two biggest risk factors for breast
cancer are being a woman and getting older, neither which we can really change. For most patients, those are
their only two risk factors. The other things that we talk about–
certainly there’s genetic risk. That accounts for only about five percent of the
breast cancers we see United States. There are also things like family history, early time that you started your period, early or late menopause. But once you have breast cancer
obviously all those are moot points. We do use some of those–especially family history–
to assess and help in your treatment planning. But they really aren’t things that help us much
once you’re diagnosed with breast cancer. When we talk about breast cancer I like
to divide it into treating the local disease, which is usually treated
with surgery and radiation, and treating the disease that might be beyond
local disease, so I call that systemic disease. and that’s when we use drugs
like chemotherapy, the stuff that makes your hair fall out,
makes you sick to your stomach, and hormonal therapy, usually a pill that
doesn’t really have many side effects. The most important thing from my
standpoint as a surgeon to understand is that your long-term survival is based on
characteristics of the tumor, not on the surgical option that you
choose for your breasts. So those four characteristics that help us
determine how good or bad your cancer is are the following:
Number one is size of the tumor. Number two is whether or not lymph nodes
have cancer in them. Number three is are there hormone
receptors on the cancer cells? So those are docking stations for the
hormones that your body makes. If you have those on your cancer cells,
the estrogen and progesterone that your body makes dock in there and then
they stimulate the cells to grow. Not all breast cancer cells have those
but it does give us useful information. And then the fourth thing is grade of
the tumor. So that means, what did the tumor cells look like
underneath the microscope? Now I like to explain this
because most women that we see with breast cancer have some
experience with teenagers. So I like to explain it like teenagers.
There’s three grades of breast cancer. Grade 1 is well differentiated,
grade 2 is moderately differentiated and grade 3 is poorly differentiated. So think of it as teenagers. Grade 1 is
that you left the house for two or three hours and your teenagers know exactly
when you’re going to get back. So they’re probably not going to try too much,
they’re not terribly aggressive about it. Grade 2, which frankly is the most common
run-of-the-mill breast cancer in women, means you left for more than a couple of hours, but
the teenagers are pretty sure when you’ll be home. Maybe you left overnight but they know you’re
going to be back early Saturday morning. Grade 3 is you left the teenagers
for a weekend and they don’t really know when you’re
coming back so they might be a little bit more
prone to try a few things. That’s how I like to explain those grades. So other things that we consider when
we’re trying to determine the treatment options for breast cancer patients are
the patient’s age. So really we kind of make a
dividing line at age 70 and that’s in part because patients
over age 70 tend not to do so well with the really harsh treatments and they don’t
have as much to gain in long-term survival. So if you’re 70, the chance of you
being alive 20 years from then is a little bit less than if you’re 40
when you’re diagnosed. We also look at HER2/neu.
That’s a receptor on the cell wall. We used to think if your tumor cells were
positive for HER2 that was really bad because it meant the cancer
is more aggressive. But in the last five years there’s a drug that was
developed to specifically target that receptor. It’s called trastuzumab, or Herceptin
is the trade name for it, and it specifically targets those receptors and kills
any cells that have those receptors on them. The good news is it’s rare for other cells
besides breast cancer cells to have HER2 on them. So it’s a very effective treatment. And then we also try to look at your
predicted life expectancy. Most women in their 40s are definitely
living another 20 years if not 40 years, although there’s an occasional
patient in their 50s and 60s that have other diseases that make
their life expectancy not so long. So we try to treat the whole patient. Once we determine and we see all the
characteristics of the tumor, then we try to think, “what of all these treatments that we have available
will you need for your breast cancer.” Most people need surgery, although there
are some exceptions to that. There are some people who
need radiation treatment, some people who need chemotherapy, and then some people
need hormonal therapy, and those four characteristics
help us determine that. Those characteristics also help us determine the
risk that you’re going die from this breast cancer. So chemotherapy is really the thing that
most people fear and chemotherapy again is the stuff that
makes you sick to your stomach, although if you take all our good
medicines to prevent that you probably won’t get sick to your stomach.
But it definitely makes your hair fall out. Why does it make your hair fall out?
Chemotherapy targets any fast dividing cells, which include the cells
that make your hair grow. That’s also what makes your stomach upset,
because the cells that line your gut, your stomach and things like that
turn over very quickly, like once a week. So those cells get killed and that’s what makes
you sick to your stomach and some other things. It also impacts your ability
to fight infections because your white and red
blood cells turn over very quickly. But these are the general guidelines for chemotherapy: in general we use these four
characteristics, and your age. So if you’re under age 70 right now
the recommendations are if your tumor is over two centimeters in size,
then almost everybody would recommend you have chemotherapy no matter what those
three other characteristics are. If your tumor is between one and two centimeters
then we think you should be considered for chemotherapy, and certainly if you are on the
younger side, we’re gonna push more for chemo. If your lymph nodes have tumor in them,
then almost everybody believes if you’re under age 70
you should have chemotherapy because that’s a sign that the tumor cells
might have gotten outside your breast. If you’ve got hormone receptors on your cells,
then we might ease up some the other things. Why? Because we have lots of good drugs
to either block those receptors or keep your body for making the hormone, so having the hormone receptors
on your cells is a good thing. And then we use grade with those other things.
If you’re on the borderline for chemotherapy and your tumor looks like
it’s the well-behaved teenagers, then we might be a little less likely to
send you on to chemotherapy. So we use all those. Now people get confused and they say, “well, if I have a mastectomy,
then I don’t need chemotherapy, right?” Wrong. Chemotherapy is something to
prolong your long-term survival. We use those four characteristics–size,
lymph node status, hormone status, and grade– to help us determine if
you need chemotherapy. And again, we treat the whole patient, so if
you’re older, you have a lot of medical problems, we might change some
of those recommendations. Now radiation therapy in general is used
to treat the local disease, and we’ll get into that more when
we talk about the surgical options. But over the years we’ve expanded
the use of radiation therapy. So we now sometimes will
recommend radiation therapy even beyond local treatment.
But again, I’ll get into that. So let’s go into the surgical therapy.
Let’s start first with lymph nodes. The reason I wanna start first with that
is because that’s not always as much of a choice. We’re gonna push you
one way or the other. First of all, in my practice if I can determine
that you have tumor cells in your lymph nodes prior to your surgery, then you go
directly to an axillary node dissection. So that means the lymph nodes in your armpit. You
probably have 60 lymph nodes underneath your arm. We’re gonna try with an axillary lymph
node dissection to get 10 or 15. That’s not all of them, but why 10 or 15?
Because we think that would get adequate staging. The act of taking lymph nodes out from underneath
your arm does not provide you a survival benefit. So, why do more surgery when it
doesn’t impact your long-term survival. So I have two goals for taking out
lymph nodes from underneath the arm if we know there are
tumor cells in there. One is to get at least 10 lymph nodes
so we can be sure we’ve got an adequate sampling of those 60. And two is any lymph node that is
grossly positive for tumors. So what do I mean by that? Well I’ve done a
lot of these operations and we know that lymph nodes that are normal are generally kidney bean
shaped, they’re brown, and they’re soft. Lymph nodes is one place in breast cancer
where size doesn’t really matter but their consistency and their color
seem to be more predictive. So if I’m operating on someone and I know
they have tumor in their lymph nodes, I’m gonna feel for any hard ones
and take those out. Why? Because I want to provide local control,
so that they don’t end up with tumor growing through their skin later on. So 10 to 15 lymph node and
certainly anything that feels positive. So if we can’t prove that you have
tumor in your lymph nodes to begin with, which is most patients with
breast cancer… For most patients with breast cancer, it’s
picked up very early, it’s highly treatable. …then we do something called
the sentinel lymph node biopsy. Now you remember I said just a little
while ago that the act of taking lymph nodes out from underneath the arm
does not improve survival. So we’ve looked at this in
big clinical trials to see, Could we get by with taking out fewer lymph
nodes? And the answer seems to be yes, if we can target the exact
right lymph nodes to get. So that’s what the sentinel
lymph node technology does. I inject a dye into the breast on the day
of surgery. It’s a radio labeled dye. Some people also add in a blue dye. The dye helps me find the first
couple lymph nodes that the breast drains to. We know that if you’re going to have cancer
in any of the lymph nodes underneath your arm, 96% of the time it’ll be in
one of those sentinel lymph nodes. Now let’s not get confused.
Just because I can find a sentinel node doesn’t mean you have cancer in it. In fact, it just means we found the sentinel node.
Then we look at it very carefully to be sure it does or does not
have cancer in it. So for most patients we do what’s
called the sentinel lymph node biopsy and I take out the first few lymph nodes
that the breast drains to. I have a little hand-held Geiger
counter in the operating room that helps me find those lymph nodes. We send those off to the pathologist.
They do a frozen section. So while we’re still in the operating room, they
look to see, is there cancer in this lymph node. If there’s cancer in the lymph node, then
we need to take out about 10 lymph nodes. If there’s not cancer in the lymph node,
we stop. The average number of lymph nodes we take out for
sentinel lymph node biopsy is between two to three, and it could range from one to six but we really
try to only get that first few that we need. So for most patients,
we’ll look at lymph nodes. If you’re really old, we’re going to
change our treatment based on that. What’s really old? Well, I have to be careful
because as I get older, my parents get older, really old is not that old. But in general,
if you’re over age about 75 or if you’re younger than age 75
and your health is not so good then we won’t look at lymph nodes.
But if you’re under age 75, then we probably will. Okay. So that’s a lymph node status. Then we have to talk about what to do for local
treatment for the cancer that’s in your breast. Now I am going to emphasize this again
because it’s a really, really important concept. What surgery you choose for your breast
does not impact your long-term survival. That’s impacted by the four characteristic: size,
lymph node status, grade, and hormone status. So we know from big randomized trials
that were conducted 25-30 years ago now and published 25-year follow-up data
on those patients showing that no matter what surgery you choose
for your breast, your long-term survival is dependent on the characteristics of the
tumor, not what you do to your breasts. Those survival curves completely overlap. So what’s different is that
the less you do to the breast, the higher the risk of local
recurrence, so in the breast. So there are theoretically three options for what
to do with the cancer that’s in your breast. One is lumpectomy alone. So that means remove the tumor and a
rim of normal tissue around it. That rim needs to be about two millimeters
or like an eighth of an inch. Then no other local treatment
to the breast. The second option is lumpectomy
followed by radiation treatments. The third option is a mastectomy
with or without reconstruction. So again we know from these big studies,
no difference in long-term survival. So what’s the difference? If you do a lumpectomy alone and no
other local treatments to your breast, your risk of having recurrence in that breast
is 30-40% at twenty years. And so for most of our women, unless
you’re in your mid 70’s and above, you’re still going to be alive 20 years from now,
so that’s too high a recurrence rate to put up with. Now if you’re 85 when your breast cancer
is detected, it’s probably fine. Lumpectomy followed by radiation
treatments. Whenever we’ve added radiation treatments into local treatment for
breast cancer it reduces the recurrence rate by about half if not more. So that means
if you have a lumpectomy followed by radiation treatment, your risk of having
a local recurrence in your breast is about 15-20%. Turn those numbers around, look at the
glass as half-full instead of half-empty, that’s an 80-85% chance
it won’t come back in the breast. Those are pretty reasonable odds
for almost everyone. The trial that I am quoting these
numbers from was the American trial, and they allowed women into that trial with
tumors up to four centimeters, about that big. In the European trial that
was done at the same time, they only allowed women in with
tumors up to two centimeters and their risk of local recurrence
at 20 years was about 8-15%, so for my patients with the smaller tumors, two centimeter or less, I like to quote those numbers. So those are very reasonable rates. 85-90% chance
you won’t have cancer back in your breast. Those are pretty good numbers. If you have a mastectomy, whether
or not you have reconstruction, you think, “well doesn’t that take away
my risk of local recurrence totally, because you removed my breast?”
Not really. It’s about a 5% risk
of recurrence at 20 years. You have a chance of it coming back
on the chest wall, in the skin, or in the scar. And do we see that happen
at about 5%? Yeah, we do. And so there’s no way to really assure
yourself that it’s never coming back. So for a lot of women weighing the risk
of a 5% chance of recurrence verses 10% local recurrence,
no difference in overall survival, that really puts the decision of lumpectomy
versus mastectomy in their court. Because we know that outcomes are no different,
then we can take other things into account. What’s the breast going to look
like if we do a lumpectomy? What would be your outcomes if you had a
mastectomy with or without reconstruction? We can explore all those options. I never assume what someone’s
relationship is with their own breast. It’s very easy to say, “well if I ever
had breast cancer, I would do ABC.” Well, actually once you get breast cancer,
it becomes a little different because the breast is a body part and do you really want
to lose your breast if you don’t have to. Most people say no. But it’s a very personal decision and
I am not the one to make that. Now if there’s a medical reason
that I should make it, like there’s tumor in more than one quadrant,
then we might push for mastectomy. Or there are still cancers we can’t detect on mammogram or on ultrasound. And so if it’s one that we had trouble detecting,
then I might push more towards a mastectomy. Why? Because then I would have trouble detecting a recurrence probably. So there are certain situations
where we push you that way. The other thing is if you have a large tumor
compared to the size of your breast, I’m not going to be able to leave you
with a very nice looking breast so for cosmetic reasons I might
push you towards a mastectomy. But still it’s usually the woman’s decision. Now I use to say if you do a mastectomy,
you won’t need radiation. Remember we talked about
radiation a little bit ago? But there are three reasons why you would get
post mastectomy, so after mastectomy, radiation. If you have a tumor more than five centimeters,
we give radiation after mastectomy because the risk of having a local failure
or a tumor coming back on the chest wall is pretty high once you get up to
tumors bigger than five centimeters. Number two is if you have a close margin
that’s in a place where we can’t take more tissue like muscle or skin, then we
recommend radiation afterwards. The third thing came about in the late 1990s with the publication of two randomized
trials in different parts of the world. That radomized trial looked at
pre-menopausal women with breast cancer who had four or more positive lymph nodes.
They randomized them, so flipped a coin. You either put them into post
mastectomy radiation or not. All the women got chemotherapy,
and what they found in both the trials was that the women who got radiation
had an improved long-term survival. So if you have positive lymph nodes, even
though the trials were done with lots of positive lymph nodes, we pretty much
think you should be considered for radiation. So we take all that into account when
we talk about what we’re gonna do. So if I’m pretty sure you’re going to be able to skip radiation with the mastectomy, I’ll tell you that, but I don’t ever promise it anymore because there are many reasons why you might get that. I wanna talk a little bit now
about reconstruction options. I won’t go in-depth into that but I’ll make the
point that we believe strongly from data that an immediate breast reconstruction
is oncologically safe, meaning it doesn’t increase
your risk of recurrence or increase your risk of dying
from your breast cancer. We believe strongly that any woman who wants
reconstruction, we should offer that to her, no matter whether they’re going to need
radiation after mastectomy or not. Because there are so many women who end up
in a post mastectomy radiation group, we first do a temporary reconstruction.
I would say 95% of the time, if you’re going to have an immediate reconstruction, we’re going do a temporary one first. In case there’s something that changes things and you do need radiation after mastectomy, we radiate you with the expander in, the
temporary reconstruction there, rather than other types of reconstruction
because we feel that outcomes are better. So that’s kinda the overview for
invasive breast cancer. There’s also a pre-invasive cancer.
That’s called duct carcinoma in situ. Pre-invasive cancer is treated a lot
like invasive cancer of the breast except, for the most part,
minus the lymph nodes. So pre-invasive cancer means that you
have cancer cells within the ducts, so the ducts that drain the milk,
but we don’t have any evidence that they’ve broken out
through the ducts. If we think you only have
pre-invasive cancer, then we treat it as if it were invasive cancer
as far as local treatments. So your options again are lumpectomy,
usually followed by radiation treatments or mastectomy with or without reconstruction. If you go the lumpectomy route with pre-invasive
cancer, we don’t check your lymph nodes. The reason is there should be no chance
that you have tumor in your lymph nodes and the risk of doing the
lymph node biopsy is higher than the chance that you would
have any bad news in there. If, however, you end up having a
mastectomy for your pre-invasive cancer, we do a sentinel lymph node biopsy at the
time of the mastectomy. The reason for that is usually
the reason you’re getting a mastectomy for pre-invasive cancer is
because you have a lot of it. It’s possible that there is some
little invasive cancer hiding amongst all of that pre-invasive cancer. If we find that out after
your breast is removed, we don’t have any way to do
the sentinel lymph node biopsy. Then we’re in a quandary, because it’s this
teeny tiny one millimeter invasive cancer. Do we really need to take out ten
lymph nodes when we’re pretty sure there’s not going to be anything in there?
So we do that ahead of time, just for the maybe 10 percent
chance that you have a small invasive cancer in there with
your pre-invasive cancer. Take home messages, because I know it’s hard to incorporate all this information. What I tell the patients and part of the
reason we wanted to do this video is it takes my residents and medical
students hearing this talk many times before they actually get it. So I want you
to be able to come back, we have a whole book we give you, but sometimes it’s
just better to hear it again. So important take-home messages: Number one is the characteristics of
the tumor. Those help us determine how good or bad your cancer is and
how much treatment you’ll need and whether that would
involve chemotherapy. The second take-home message is what you choose to do to your breast
has no impact on your long-term survival. There’s only one caveat to that.
If we took every woman’s breasts off at age 20, we could probably prevent breast cancer but to me
that seems a bit radical, so I don’t recommend that. If you have a strong family history we’ll
usually recommend that you go to genetic counseling and possibly get
genetic tested. The general overview I’ve given here
does not include patients who have a genetic mutation
as a cause for their cancer. Those patients have much higher risk of
getting another breast cancer so we tend to push them towards either more aggressive screening or even bilateral mastectomy. That’s almost another whole talk. But in general, we want you know
it’s the characteristics of the tumor that impacts your
long-term survival. What you do your breast is almost
always up to you, unless there’s some anatomic reason
we need to do something. The only other thing is if you
are one of those few people who recur their breast cancer
after lumpectomy and radiation, the standard treatment at that
time is mastectomy. So at this point I’m usually happy to
answer any questions.