Chemotherapy

In the past, radical or modified mastectomy was the treatment of choice for breast cancer. Because these procedures removed the breast, underlying superficial muscle, and underarm lymph nodes, they were physically deforming surgeries with possible psychological effects. Every time they look in the mirror, these patients are reminded of their bout with cancer. However, a radical mastectomy is rarely needed today, and most newly diagnosed women are candidates for breast-conserving therapy. For those who are not, reconstructive surgery is now an option in most cases. Reconstructive surgery mitigates the physical and psychological effects of extensive surgery, especially when immediate reconstruction is done.

Women who are not candidates for breast-conservation treatment include those who have had prior radiation to the breast, who are pregnant, or who have a connective tissue disease such as lupus. Certain situations, such as two or more tumors in separate quadrants of the breast or failure to obtain margins free of tumor cells despite additional surgery, may also indicate the need for more extensive surgery. Breast size alone is not a reason that breast-conserving treatment cannot be done, but if the tumor is large and the breast is small, then, for cosmetic reasons, a mastectomy with reconstruction may be more desirable to some women. Your doctor will let you know if you are a good candidate for breast-conserving therapy. If you are, then you have a choice between breast-conserving therapy and mastectomy. (Insurance coverage is not a factor here; breast reconstruction is always covered when mastectomy is done to treat cancer.)

With early detection almost all early breast cancers can be treated with breast-conserving surgery and postoperative radiation. Only a lumpectomy and axillary node sampling are performed. Briefly, this means the tumor is removed, along with just enough surrounding breast tissue to insure clear margins, plus either a sentinel node procedure or complete axillary dissection.

Stage for stage, treatment results with breast-conservation surgery and radiation are similar to those for mastectomy alone. Doctors now have sufficient long-term follow-up to make this claim. Most women who are able to have breast-conserving therapy prefer this option for treatment because the surgery is less involved and the breast is spared. In some women the cosmetic results are so good that years later it is hard to tell which breast was treated.

Today, most women who are candidates for breast-conserving treatment choose breast conservation, while a smaller number may choose mastectomy. Personal preferences and lifestyle issues are important. Some women live in remote areas and, therefore, would need to travel long distances to a radiation facility, which may be a factor in their decision. Overall, it appears that in the United States, the rates at which women choose breast-sparing surgery vary greatly from region to region around the country. In other words, in some geographic areas breast-conserving therapy is underused. This underuse contrasts with some areas of Europe, such as England, where breast-conserving therapy rates are higher than found in many places in the United States.

Radiation

If you choose to have breast-conserving surgery for treatment of invasive breast cancer, then it is understood that you will have radiation to the breast. On the other hand, if you choose mastectomy, then radiation is recommended only in select cases.

Four to six weeks after the surgical wound has healed, or three to four weeks after completing all chemotherapy (if it is part of the treatment plan), then patients can begin a seven- to eight-week course of radiation. For the first five to six weeks, the entire breast is treated, and remaining treatments are delivered to boost the dose to the lumpectomy site because this is the location where any remaining cancer cells are most likely to reside.

You may ask if the postoperative radiation is necessary following lumpectomy. The answer is emphatically yes. Many studies have demonstrated recurrence rates of 50 percent or higher without it.

Currently, doctors are looking at a new procedure called mammocyte therapy. This entails inserting a catheter-like device at the lumpectomy site during surgery. In the following thirty-six to forty-eight hours, a high-intensity radioactive source is inserted, usually in three sessions. The major advantage of this treatment is that the patient does not have to go for an eight-week course of external treatment. At this time, this procedure is not appropriate for all patients, and many questions remain unanswered. For example, which patients do not require irradiation of the entire breast? Will the cosmetic results be satisfactory, because doctors are delivering a very high dose in a short time? Nonetheless, doctors do recommend this procedure to those patients with very small tumors or to those who are not overly concerned about cosmetic results. Doctors would not advise it for younger patients because they do not have long-term follow-up results. With breast cancer, it is standard to have a ten-year follow-up period, which doctors do not yet have for this treatment.

Most patients who have a mastectomy do not need radiation. However, it is given in some situations following mastectomy. These include: cells found on the margins of the removed breast, large tumors, and involvement of many lymph nodes. These recommendations are always evolving, so it is worthwhile to review options with a radiation oncologist.

The treatment is usually twenty-five to thirty treatments to the chest wall and axilla, plus an additional five or more booster doses to the scar, for a total of approximately 6,000 units. During treatment, the patient is in a supine position, with her arm out of the path of the beam. As much as possible, the beam passes through the breast while avoiding the lung and heart.

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