The then and now of treatment and surgery
Breast cancer is the most common cancer in women worldwide. Each year 1.3 million women are diagnosed with breast cancer and the incidence of breast cancer increases with age; more than 80 percent occur above age 50 and 35 percent above age 70.
There are many diagnostic modalities that are available to aid in the diagnosis of breast cancer. These include a digital mammogram with computer aid, ultra sound, (both screening and diagnostic), MRI, BRAC I & II testing, and physical examination. The goal is early diagnosis.
For years the diagnosis of breast cancer was determined with an open surgical procedure. Now the open surgical option is a rarity. The procedures of choice for the diagnosis of breast cancer are performed in the office: either ultra sound guided biopsy under local anesthesia or stereotactic biopsy under local anesthesia.
Today, the surgical options are discussed before going to surgery. Until 1970, the only option for the surgical treatment of breast cancer was radical mastectomy. The patient went to surgery for a breast biopsy, which was followed by mastectomy if the biopsy was positive for breast cancer. The patient received general anesthesia and did not know until recovery from anesthesia whether the mass was cancer or benign. The patient was unaware if she had a biopsy for benign disease or mastectomy.
When breast-conservative treatment (lumpectomy) was first done it was thought of as blasphemy. Today, a large majority of women with breast cancer undergo lumpectomy (breast saving) and sentinel node biopsy. The sentinel node is the first lymph node in the axillary (armpit) chain. The morbidity is far less for sentinel node biopsy compared to axillary dissection. Axillary dissection is reserved for women with positive nodes. New research has shown that there is a subset of women with minimally positive sentinel node who do not need axillary dissection. Mastectomy is mostly reserved for large or advanced breast cancers. Immediate or delayed reconstruction is available for mastectomy patients.
If conservative (breast saving) breast surgery is performed, then the patient will need radiation. There are two options for post-operative radiation: whole-breast irradiation for 6-7 weeks, or for a certain subset of women, accelerated partial-breast irradiation, which is performed twice a day for 5 days.
Since the 1970s, hormone-manipulating drugs have been available such as tamoxifen and now aromatase inhibitors. There are thousands of women alive today that would have been lost in the 70s if not for these drugs. The same goes for chemotherapy. That was unheard of in the 70s, but targeted antibody drugs are now available. Gene profiling analysis allows the individualized, appropriate use of chemotherapy. These advances save more lives.
Hopefully future research will give us the knowledge to eradicate this disease.
story by VINCENT G. CARIFI, MD
BIO: Dr. Vincent Carifi of Carifi Breast Care PA is a board-certified surgeon on staff at Heart of Florida Regional Medical Center and a Polk County Medical Association member. Dr. Carifi performs breast surgeries for cancer patients among many other surgeries. He’s been a general surgeon in the Central Florida area for more than 30 years and is certified in breast ultra sound and stereotactic biopsy techniques.