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Health Matters
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  • breast cancer surgery – current practices and future trends


    breast-cancer-surgery-current-practices-and-future-trends

    Breast cancer has consistently remained the most common cancer among women in Singapore since the birth of our nation. The incidence has increased dramatically by more than 3-fold in this time period, regardless of age and ethnicity. Between the years 2013 and 2017, more than 2000 new breast cancers were diagnosed each year1.

    Despite this, there is much good news to share. Early diagnosis and detection through screening and public awareness, as well as the availability of better treatment modalities have led to a 60% improvement in survival rates in the last 50 years. 3 out of 4 breast cancers are now discovered at an early stage, which means patients are suitable for shorter and more tolerable treatment
    options1.

    First used in the late 19th century, surgery remains the cornerstone of breast cancer treatment2. The vast majority of early breast cancers are cured by surgery, while it continues to play a major role used together with other modalities like chemotherapy and radiotherapy in treating more advanced disease.

    We are experiencing a clear paradigm shift in breast cancer surgery. Removing the breast, or mastectomy, was for a very long time the only option that patients have. In recent years, rather than solely focusing on removing the tumour, far more emphasis has been placed in preserving the shape and form of the breast, while minimising potential long term complications3.
    It is now well established that cancer survival can, and should, go hand in hand with the overall physical and psychological wellbeing of the patient.

    Preserving the breast

    Lumpectomy, or removing the breast cancer together with a margin of healthy breast tissue, was conceived largely in response to the desire among patients to keep their breasts. Since the 1970s, clinical studies have confirmed that this option to be safe and feasible4, 5. It has to be emphasised that lumpectomy has to be paired with radiotherapy so that cure rates similar to mastectomy can be achieved.

    Up till recently, women with small breast sizes with relatively large tumours were often deemed as unsuitable for lumpectomy, as such a procedure often left a large defect leading to a poor cosmetic outcome. However, 3 recent developments have enabled more women to benefit from such a surgery.

    Firstly, the margins that are considered to be safe has dramatically reduced6. While early studies demanded removing a full quarter of the breast (quadrantectomy), successive studies have reduced this margin over the years. Currently, it is agreed that a microscopically clear margin is all that is needed. To achieve this, communication and coordination between the surgeon and the pathologist is of paramount importance.

    Surgery is often the first treatment that a breast cancer patient goes through, with a combination of chemotherapy, hormonal therapy and/or radiotherapy given thereafter. The realisation that giving chemotherapy first, known as neoadjuvant chemotherapy, prior to surgery can result in reducing the size of the cancer7. For certain subtypes of breast cancers such as Her2 positive and triple negative tumours which are more sensitive to chemotherapy, the response can be so dramatic that the cancer has completely disappeared by the time of surgery. Hence by reversing the order of surgery and chemotherapy, we can give patients the option of keeping their breast, rather than undergoing a mastectomy if surgery was undertaken at the onset.

    Finally, the emergence of new surgical techniques combining the principles of oncologic and plastic surgery has resulted in the new field of oncoplastic surgery. Careful consideration of factors, such as location of the tumour, size and shape of the breast, scar placement etc., prior to surgery results in optimal cosmetic outcome without compromising cancer clearance8. Such techniques involve filling the defect left after removing the cancer by adjacent healthy breast tissue or other nearby tissues such as fat or muscle. Another method called fat filling involves extracting fat from other parts of the body such as abdomen or thighs and injecting it into the affected breast.

    Constructing a new breast

    For some patients, particularly those with extensive or multifocal disease, mastectomy remains the best surgical option. However, they no longer have to lose a breast completely nor permanently. Post-mastectomy breast reconstruction is a proven technique which has become increasingly popular. Early concerns of it being a longer and more complex procedure has restricted its use to young and healthy patients. Nowadays, the improved surgical expertise together with advances in post-operative care have made this a good option in virtually all breast cancer patients9.

    Briefly, the affected breast is removed by the breast surgeon through a small, well concealed incision while preserving the overlying skin and nipple. The breast is then reconstructed by the plastic surgeon using either the patient’s own tissue, i.e. autologous flap, or an implant, or both. Autologous muscle-based flaps are harvested from the back (latissimus dorsi flap) or abdomen (rectus abdominis flap). More advanced, muscle sparing techniques are also available, the most common being the DIEP (deep inferior epigastric perforators) flap. Performing the breast reconstruction immediately after a mastectomy is the most convenient and cosmetically pleasing option.

    Women who carry have genetic mutations, such as BRCA gene mutation, which predispose them to developing breast cancer, prophylactic or preventive bilateral mastectomy with reconstruction reduces the risk of breast cancer by over 90% while providing a high quality of life10.

    Sampling the lymph nodes

    An integral component of breast cancer surgery involves checking the lymph nodes under the armpit, or axilla, to determine if the cancer has already spread.

    In the past, this would mean that all the lymph nodes are removed at the time of the surgery, a procedure known as axillary lymph node dissection. This was done regardless whether there was any evidence of spread at the time of diagnosis. In retrospect, this was unnecessary in 80% of patients with early breast cancer as there was evidence of no spread to the lymph nodes on histological examination. Even worse, patients often are left with permanent arm swelling (lymphoedema), numbness, stiffness of the shoulder and risk damage to the nerves and blood vessels of the arm.

    Sentinel lymph node biopsy, a highly selective and accurate method of checking the status of the axillary lymph nodes was first introduced in the 1990s11. This revolutionary technique requires the surgeon to identify and remove only the lymph nodes that are the first to be involved in case of cancer spread, i.e. the ‘sentry’ or sentinel lymph nodes. Only in cases where these lymph nodes were involved by cancer will an axillary lymph node dissection be necessary. It is no wonder that sentinel lymph node biopsy has quickly been adopted as the gold standard procedure for early breast cancer.

    Since then, the use of sentinel lymph nodes biopsy has been expanded further. For instance, in patients undergoing lumpectomy who have no more than 2 involved lymph nodes, an axillary lymph node dissection is no longer deemed necessary as the radiation given after surgery is enough to minimise the chance of tumour recurrence12. Another example is the use of sentinel lymph node biopsy in patients with proven lymph node metastases at diagnosis, but showed excellent response to neoadjuvant chemotherapy13.

    Future of surgery… or the lack of it

    In this age of disruptive innovation affecting every facet of our lives, the practice of medicine and surgery will not be spared. The current trend of ‘less is more’, reducing the extent of surgery while improving patient outcome, is relentless and quickening. In fact, we are already witnessing the beginning of the end of surgery as a treatment option for breast cancer patients. 3 prominent examples provide a tantalising glimpse into a ‘surgery-free’ future.

    Ongoing clinical trials on both side of the Atlantic, namely the COMET and LORIS studies involve treating patients with hormone sensitive, non-invasive or in-situ breast cancer with hormonal therapy alone14, 15. Prior to these trials, there are already proponents of a more conservative approach to treating in-situ breast cancer, as the main purpose of treating such conditions is to prevent it from developing into an invasive cancer. Still others felt that such cancers were the result of overdiagnosis following widespread breast cancer screening. They argued that without screening, these indolent tumours would have remained undetected and yet never lead to an adverse outcome.

    As mentioned earlier, we now know some breast cancer sub-types are exquisitely sensitive to chemotherapy, with complete responses increasingly possible given the advent of more effective drugs. Currently, surgery is still considered mandatory to ensure that all remaining cancer cells, if any, are removed after chemotherapy. With improved methods of imaging and biopsy, early feasibility studies are ongoing to determine if any remaining cancer can be accurately tested after chemotherapy using minimally invasive biopsy techniques16. In cases where no residual cancer are detected, surgery could soon prove to be a thing of the past.

    The third example examines if we can completely abandon any surgery for axillary lymph nodes. The ongoing SOUND clinical trial conducted in Italy hopes to prove that accurate pre-operative ultrasound, with the use of fine needle biopsy of axillary lymph nodes if necessary, prior to surgery for early breast cancers can safely replace the need for sentinel lymph node biopsy17. The findings of this study are expected to be announced in the next couple of years.

    Conclusion

    Surgery continues to be a critical step in the treatment journey of breast cancer patients. We are witnessing a trend towards performing smaller and better timed surgery to provide durable cure while minimising avoidable complications. There is also increasing emphasis on optimising cosmetic outcomes which improve psychological wellbeing. Finally, surgery may be completely avoided in the future if current clinical trials prove successful.

    This article was contributed by Dr Ong Kong Wee, AIA Quality Heathcare Partner, and Medical Director of K W Ong Breast and General Surgery Clinic. To request an appointment with Dr Ong, please click here.

    References

    1. 50 years of Cancer Registration – Singapore Cancer Registry.
    2. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to January 1894. Halsted WS. Johns Hopkins Hospital Reports, Baltimore. 1894–95;4:297–350.
    3. Breast cancer: from "maximum tolerable" to "minimum effective" treatment. Veronesi U, Stafyla V, Luini A, Veronesi P.Front Oncol. 2012 Oct 8;2:125.
    4. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. Fisher B, et al. The New England Journal of Medicine. 2002. 347(16):1233-1241.
    5. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E.N Engl J Med. 2002 Oct 17;347(16):1227-32.
    6. Margins in breast cancer: How much is enough? Pilewskie M, Morrow M. Cancer. 2018 Apr 1;124(7):1335-1341.
    7. Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG Z1071 (Alliance) Prospective Multicenter Clinical Trial. Boughey JC, McCall LM, Ballman KV, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, Leitch AM, Flippo-Morton T, Hunt KK. Ann Surg. 2014 Oct;260(4):608-14; discussion 614-6.
    8. Long-term Results After Oncoplastic Surgery for Breast Cancer: A 10-year Follow-up. Clough KB, van la Parra RFD, Thygesen HH, Levy E, Russ E, Halabi NM, Sarfati I, Nos C. Ann Surg. 2018 Jul;268(1):165-171. 
    9. Long-term Patient-Reported Outcomes in Postmastectomy Breast Reconstruction. Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. JAMA Surg. 2018 Oct 1;153(10):891-899.
    10. Hartman LC, Schaid DJ, Woods JE, et al. Efficiacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999;340:77-84.
    11. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, Ashikaga T, Weaver DL, Mamounas EP, Jalovec LM, Frazier TG, Noyes RD, Robidoux A, Scarth HM, Wolmark N. Lancet Oncol. 2010 Oct;11(10):927-33. 
    12. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR, Ollila DW, Hansen NM, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, Hunt KK, Morrow M. JAMA. 2017 Sep 12;318(10):918-926.
    13. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Kuehn T, Bauerfeind I, Fehm T, Fleige B, Hausschild M, Helms G, Lebeau A, Liedtke C, von Minckwitz G, Nekljudova V, Schmatloch S, Schrenk P, Staebler A, Untch M. Lancet Oncol. 2013 Jun;14(7):609-18. doi: 10.1016/S1470-2045(13)70166-9.
    14. The COMET (Comparison of Operative versus Monitoring and Endocrine Therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS). Hwang ES, Hyslop T, Lynch T, Frank E, Pinto D, Basila D, Collyar D, Bennett A, Kaplan C, Rosenberg S, Thompson A, Weiss A, Partridge A. BMJ Open. 2019 Mar 12;9(3):e026797.
    15. Addressing overtreatment of screen detected DCIS; the LORIS trial. Francis A, Thomas J, Fallowfield L, Wallis M, Bartlett JM, Brookes C, Roberts T, Pirrie S, Gaunt C, Young J, Billingham L, Dodwell D, Hanby A, Pinder SE, Evans A, Reed M, Jenkins V, Matthews L, Wilcox M, Fairbrother P, Bowden S, Rea D. Eur J Cancer. 2015 Nov;51(16):2296-303.
    16. Nonoperative Management for Invasive Breast Cancer After Neoadjuvant Systemic Therapy: Conceptual Basis and Fundamental International Feasibility Clinical Trials. Kuerer HM, et al. Ann Surg Oncol. 2017. 
    17. Abandoning sentinel lymph node biopsy in early breast cancer? A new trial in progress at the European Institute of Oncology of Milan (SOUND: Sentinel nodevs Observation after axillary UltraSouND). Gentilini O, Veronesi U. Breast. 2012 Oct;21(5):678-81.

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