Contributions of Surgery to Breast Cancer Survivorship

Posted By SHL Librarian

Presented by: Irene Wapnir, MD
Associate Professor, Surgery
Stanford University Medical Center
Date: January 13, 2011

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Lecture Overview:

A new focus on survivor’s quality of life has led to improvements in mastectomy techniques, reconstruction, and preserving fertility.

One look at the statistics surrounding breast cancer shows that this disease touches innumerable lives. After skin cancer, it is the most common type of cancer affecting women in the United States, according to the most recent American Cancer Society data. Each year roughly 40,000 women die from breast cancer.

Yet the outlook is not as bleak as these figures might lead one to believe. Advances in detection and diagnostic techniques, surgery, treatments and reconstruction have come a long way in not only finding and treating breast cancer, but also improving the health and well-being of survivors. In a presentation sponsored by the Stanford Health Library, Irene Wapnir, MD, chief of breast surgery at Stanford Medical Center, laid out some of the recent advances in her area of expertise over the past couple decades.

“From a surgical perspective, we have many more tools in our shed,” said Wapnir, who also is an associate professor at the Stanford School of Medicine. “Compared to decades ago, women today have many more choices.”

Advances in detection have led to a marked increase in the number of breast cancer cases, especially noninvasive breast cancer. Noninvasive describes a cancer that remains localized to the milk ducts and lobules of the breast. Invasive cancer, on the other hand, spreads beyond the ducts and lobules into the tissue of the breast.

Since 1983, when widespread use of mammographic screening began, invasive breast cancer cases increased by 35%, while the number of noninvasive cases skyrocketed by 500%, Wapnir said. The improvement in screening technology has let far fewer cases evade detection and made it possible to begin treatment earlier.

Magnetic resonance imaging, or MRI, is a newer, cutting-edge imaging technique. It is still considered a supplemental tool to mammography or ultrasound imaging and is used selectively. Like many imaging technologies, it has some shortcomings Dr Wapnir noted, as it can overestimate or underestimate the size of a breast cancer.

The ability to preserve the breast via a lumpectomy represents a significant advancement in the field of breast cancer. More and more women safely opted for lumpectomy beginning in the 1980s. The longterm outcomes of this breast conserving therapy have been equal to treatment by mastectomy, Dr. Wapnir said.

Mastectomies have played a central role in the treatment of breast cancer for over 100 years. Not only can mastectomies leave cosmetic and psychological scars, but they can create physical limitations too, when combined with the removal of lymph nodes under the arms (so-called axillary nodes). As the understanding of breast cancer advanced over time, surgical techniques were moderated and, as a result, the muscles in the chest wall are now routinely preserved.

Over the past five to 10 years, there has been a resurgence in the number of women choosing a mastectomy, a trend that has puzzled many surgeons, including Dr Wapnir. Fear of recurrence and the need for continued surveillance and intense clinical and radiologic screening could be the driving force behind this behavior.

“The burden of breast imaging is real,” Dr. Wapnir said. “For many patients, the mere possibility of a recurrence or the appearance of a new  cancer, albeit small, is psychologically difficult.”

A study by the National Cancer Institute found that prophylactic mastectomies in high-risk women can reduce the risk of developing cancer by 90%. In this type of surgery, a patient (often one who has had breast cancer in one side) chooses to remove a healthy breast to prevent the occurrence of cancer in their future. Women who have a family history of breast cancer or have breast cancer are increasingly choosing prophylactic mastectomies.

The scars left behind by a mastectomy are rarely purely physical.

“We have made strides in general to reverse the disfiguring impact of mastectomies,” Wapnir said.

Dramatic advances have occurred in reconstructive techniques over the past few decades. In some cases, tissue expanders can be used to retain a shape akin to that of the removed breast. Similarly, a myocutaneous flap (skin, fat and muscle tissue) taken from another part of a patient’s body can be attached to the breast site, using sophisticated microsurgical techniques that hook up the blood supply to the moved tissue. Various nipple reconstruction and now nipple-sparing mastectomies have expanded the procedures available to women.

The Sentinel Node
Removal of lymph nodes in the armpit (axilla) is part of breast cancer treatment. But the extent of lymph node removal has changed over the past 15 years, according to Dr. Wapnir. A relatively new technique focuses on the so-called sentinel lymph node. Lymphatic channels  of the breast tend to drain to one or more nodes under the arm first. As the name suggests, the sentinel node is the one that can set off the alarm that cancer has spread. If a biopsy of the sentinel node is negative, removal of additional axillary lymph nodes can be avoided.

Preserving Fertility
One of the potential side effects of chemotherapy and radiation therapy is a reduction in a patient’s fertility. This is important to women of childbearing age. Preserving a patient’s eggs through methods of in vitro fertilization and cryopreservation can be offered, Dr. Wapnir said. These procedures can be done quickly, without significantly delaying the start of cancer treatments.

“Women should be supported in a desire to do this,” she said.

Attitudes towards Stage IV Cancer
When cancer metastasizes, or spreads to other parts of a patient’s body such as bones or organs, the treatment approach usually turns to relieving symptoms and extending the lifetime of the patient. Yet even with this most advanced stage of cancer (stage IV), attitudes are evolving.

“We are getting better at treating metastasis. We view stage IV with less futility,” Dr. Wapnir said. “That’s an important change.”

Strides in detection and treatment have greatly improved survival rates for cancer patients. Clinical trials are key to defining new treatments for breast cancer, says Dr Wapnir, an active investigator. Every advance brings us one step closer to finding a cure to this very complex disease.

“Our long term goal is to cure all types of breast cancer,” she said.

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About Dr. Wapnir:

Stanford Cancer Center