University of Pennsylvania Health System

Focus on Cancer

Monday, October 17, 2011

As Surgery for Breast Cancer Evolves, So Do Outcomes


Carla S. Fisher, MD, is an assistant professor of surgery at the Perelman School of Medicine and a breast surgeon. Dr. Fisher sees patients at the Rena Rowan Breast Center.

An article was published earlier this year in the Journal of the American Medical Association (JAMA) that challenged the current way we approach breast cancer treatment and surgery.

The article discusses the results of a randomized clinical trial that took place at many hospitals across the United States. In this trial, breast surgeons found that not every woman with breast cancer that has spread to the lymph nodes may need a full axillary (armpit area) lymph node dissection. As those of us in the medical community examine the results of this study and how they apply to our own patients, it seems appropriate to review a brief history of the evolution of surgery for breast cancer.

The history of the discovery and treatment of breast cancer is rich and one that has been documented back to the ancient Chinese and Egyptian cultures, as far back as 2600 BC. The most common forms of early treatment were medical remedies. In more “modern times,” beginning the 18th century, surgery became more common and well developed as a treatment for breast cancer. Surgery almost always involved removal of the entire breast (mastectomy).

Eventually, removal of all of the axillary lymph nodes and the pectoralis major muscle (one of the main muscles of the chest wall), a radical mastectomy, was also recommended. The surgery was always the same, regardless of the size of the breast cancer or presence of disease in the lymph nodes. This radical procedure, with some minor modifications, was practiced for over 70 years, well into the 20th century. In fact, many women may recall an aunt or grandmother who underwent a radical mastectomy with subsequent deformity of the chest wall.

Surgical techniques continued to become more refined and less morbid for the patient, but it was truly the discovery of the roles of radiation therapy, medical therapies (chemotherapy and endocrine treatment) and early detection (mammography) that propelled breast cancer treatment to where it is today. In the later part of the last century, breast conservation surgery was introduced. This surgery involved the removal of the cancer, without removal of the entire breast, followed by radiation therapy. Additionally, the sentinel lymph node biopsy technique was developed that allowed breast cancer staging without removal of all of the lymph nodes in the armpit area. If the sentinel nodes contained cancer only then would a full axillary dissection (removal) be performed in which the rest of the lymph nodes would be removed.

All of these surgical advances have given women with breast cancer more choices while maintaining or improving cancer care with less side effects and better cosmetic outcomes.

Now in 2011, we have evidence that suggests that even when breast cancer has spread to the axillary lymph nodes, we may not have to remove all of these lymph nodes. The important thing to point out is that while these findings are exciting and may represent a change for some women with breast cancer, the research and findings only apply to SOME women.

Not all women undergoing surgery for breast cancer will fall within the criteria used in this study, specifically women undergoing mastectomies. Younger women and women with certain types of breast cancer also may not qualify for this less aggressive surgery. What this study emphasizes, more than ever, is the importance of an informed discussion between patients, surgeons, medical and radiation oncologists.

At Penn, our multidisciplinary approach to breast cancer care gives us the opportunity to discuss the most up-to-date research, such as this recent publication, and determine how we can best apply it our patients.

Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.

The Abramson Cancer Center is pleased to present the Focus on Women's Cancers Conference featuring:

Friday, October 28, 2011
7:30 am to 3:30 pm
Hilton Hotel, 4200 City Avenue, Philadelphia, PA 19131

Register and view the full agenda at The Abramson Cancer Center, or register by phone at 800-789-PENN(7366).

Please register for only one conference but feel free on the day of the conference to attend sessions at any of the 3 conferences.


Portions of the program will be livestreamed at PennMedicine.org/Abramson/WomensCancersLIVE on the day of the conference.
 

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