Saturday, October 28, 2006

What's the goal of surgery for a woman who has early-stage disease

For early-stage disease, the goal of surgery is to remove all of the cancer with clear margins around it and to determine the risk of spread by looking at the status of the lymph nodes under the armpit.

In the early days of breast cancer surgery, the procedure of choice was a mastectomy. But the National Surgical Adjuvant Breast and Bowel Project (NSABP) conducted a series of randomized studies that showed that just as many women could be cured with a lumpectomy and radiation therapy as could be cured with mastectomy. Women who choose lumpectomy need the radiation because it lowers the risk of local recurrence in the breast.

Does everyone require radiation therapy after lumpectomy?There is a movement afoot to look very carefully at some subgroups of people who may not need radiation after a lumpectomy. For example, researchers are looking at women with DCIS (ductal carcinoma in situ), which is a precancer that remains confined to the ducts, so we don't call it an invasive cancer. It does not have the potential, that we know of, to spread distantly beyond the breast.

As the degree of invasiveness of the cancer goes down and as the age of the patient goes up, the risk of recurrence is lower. Hence, the potential gains from radiation may be smaller.

How do women decide between mastectomy and lumpectomy?

The choice of mastectomy vs. lumpectomy is a fairly difficult one for some people. On the one hand, the mastectomy is over with quickly. You can choose to do reconstruction right away or at a later date. On the other hand, the lumpectomy allows you to preserve the breast, but generally requires four to six weeks of postoperative radiation therapy five days a week.
Some variables are technical. For example, if there is a large cancer in a small breast and the cosmetic result of a lumpectomy will be unacceptable, doctors and patients may select mastectomy. But there can be a large cancer in a woman with a very large breast that's amenable to lumpectomy.

In addition, patients who live far from a radiation center, who have economic issues with coming for treatment every day, may elect to have a mastectomy simply so they're not having to come to the hospital for six weeks for daily treatments. So there are many factors that can influence this decision and not all of them are medical.

Do women have a lot of anxiety over local recurrence following a lumpectomy? I think there is a lot of anxiety over recurrence in the breast, although we try to counsel people that that's not the major issue. In the end, what matters is whether the cancer spreads throughout the body or not. In the rare case of a local recurrence in the preserved breast, one can treat that with mastectomy.

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