Breast Conservation–A Paradigm Shift
The incidence of breast cancer is rapidly increasing in India and has overtaken cancer of cervix in Indian women in metropolitan cities. One in 22 Indian women are likely to develop breast cancer during their lifetime. Breast cancer is a disease of old age with the peak incidence in the fifth and sixth decades – but in India the disease is seen a decade earlier, probably due to shorter longevity of life in Indian women (about 62 years as per Indian census), as compared to their counterparts in the USA.
Statistically, breast cancer is more common among unmarried women, nulliparous women and those who did not breast-fed their babies. Smoking, alcohol drinking and high fat diet intake are attributed to the causation of breast cancer and its high incidence among the women residing in metropolitan cities of India, where a Western lifestyle seems to be taking hold.
In India, nearly 50 per cent of breast cancer patients present with locally advanced disease. The main reasons for this late presentation are illiteracy, poverty, lack of awareness, feeling of shame, ignorance coupled with lack of health education. Absence of pain in the early stages adds to the cause of delay in seeking medical advice.
Surgical treatment of breast cancer has changed significantly in recent years from radical to conservative approach. The surgical treatment of breast cancer must be determined for each woman on an individual basis. Breast cancer patients are twice more likely to be offered breast-conserving surgery (BCS) if treated by surgeons at a dedicated cancer center than by surgeons in the private practice, according to a national survey of breast specialists conducted by the American Society of Breast Diseases. In this study only 19% of surgeons used BCS in their practice while the remaining 81% performed mastectomy irrespective of the stage of the disease.
Patients may have an initial gut preference for mastectomy as a way to “take it all out as quickly as possible”. Women tend to prefer mastectomy more often than their surgeons do because of this feeling. But, studies following thousands of women for more than 20 years follow-up show that there is no difference in overall survival in mastectomy over breast conserving therapy. Hence, proper counseling is very important. Only a surgeon, who is convinced him/herself, can propagate the idea and convince the patient for breast conservation.
Women whose breasts are preserved have fewer episodes of depression, anxiety and insomnia. A recent multicentre study of patients with early-stage breast cancer found women who undergo breast conservation therapy have improved body image, higher satisfaction with treatment and no additional risk of recurrence compared with women treated with mastectomy. Careful selection of the patient for breast conservation is very important for a successful outcome.
Indications for breast conserving surgery (BCS):
1. Patient’s desire for breast conservation.
2. Tumor less than 4 cm in size (T1 or T2).
3. Good Breast vs. tumor volume ratio.
4. Availability of radiotherapy and mammographic facilities.
5. Patients with N0 or N1 axillary nodes.
6. Non-pendulous breast to allow a uniform radiation dosage distribution.
Contraindications for BCS:
1. Multicentric breast cancer.
2. Diffuse malignant looking micro calcifications on mammogram
3. Matted (N2) axillary lymph nodes.
4. Recurrence in a previously conserved breast.
5. Collagen vascular disease.
6. Early pregnancy.
7. H/o previous irradiation to chest wall.
8. Positive surgical margins
Relative Contraindications for BCS:
1. Tumor size >5 cm. (T3)
2. High risk of residual tumor or surgical margin positivity on resection.
3. Large tumor in a small breast.
4. Poor histological differentiation.
5. Extensive intraductal component (>25% of tumor is DCIS)
Breast Reconstruction
Reconstruction should be offered to all women who undergo a total mastectomy or whose breast conservation surgery (BCS) leaves an unacceptable cosmetic deformity. Immediate reconstruction is more convenient for patients, less expensive, and limits exposure to anesthesia risk. The aesthetic results tend to be better and the patient does not have to live with a deformity, even temporarily.
Reconstructive surgery can be delayed or performed immediately by either breast implants or autologous tissue. The most commonly used autologous flaps are the TRAM (transverse rectus abdominis myocutaneous) flap, the latissimus dorsi flap or free flaps.
Breast-conserving surgery is a treatment modality for early-stage breast cancer that causes less physical disfigurement and psychological trauma to the patient. Many prospective randomized trials have demonstrated that overall and disease-free survival rates for early-stage breast cancer are equivalent after mastectomy or BCS with postoperative radiotherapy.
Patients with a central sub(retro)areolar cancer or Paget’s disease of the nipple that require resection of Nipple-Areolar complex (NAC), can also be treated with breast conservation with acceptable cosmesis.
In conclusion, breast-conserving surgery combined with radiation is now well established as the preferred local-regional treatment for a majority of patients with early stage (stage 0, stage I, and stage II) breast cancers. Properly selected patients can expect equivalent long-term survival from the disease, yet avoid mastectomy with all the negative physical and psychological aspects of that more radical, ablative procedure. Not all patients, however, are considered appropriate candidates for a breast-conserving approach.
For more information you can visit Best Cancer Hospital in India
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