In well-run comprehensive breast centre’s using
state of the art screening technology, the majority of women will be treated by
breast conserving therapy.
In large trials performed in the 70’s and 80’s
breast conserving therapy was shown to be equally effective in the treatment of
early breast cancer, as was a mastectomy.
Increasingly, additional treatments
such as chemotherapy and hormonal therapy, prolonged the patient’s survival.
Currently, of 100 patients with early stage breast cancer, about 80 are still
alive and well after 20 years.
According to Dr Rika Pienaar, an oncologist from
Cape Town, the survival of the patient is crucial. However, the cosmetic
outcome after the cancer treatment is an aspect that cannot be ignored.
Professor Justus Apffelstaedt from the University
of Stellenbosch says initial trials of breast conservation addressed mainly
safety issues and cosmetic outcome was only a secondary consideration. He says
mastectomies were performed to alleviate problems associated with late
radiation changes.
"The surgical outcome initially was often
acceptable. However, the necessary addition of radiotherapy in breast
conservation led to progressive scarring. After a few years then the scarring
made the cosmetic outcome rather poor," says Professor Frank Graewe, Head of
the Division of Plastic Surgery at the University of Stellenbosch.
There have been two significant developments that have
improved the cosmetic outcome remarkably. Progress in radiation planning and
new technology in radiation delivery cause much less scarring than in the past,
and new surgical techniques have been developed.
The aims of this integration are the uncompromised
safety in cancer treatment, while establishing an aesthetically pleasing breast
shape that can withstand radiotherapy with little long-term changes. This is
most readily achieved by a team approach including an oncologic surgeon, oncologist
and a plastic surgeon.
This approach, which combines cancer surgery and
plastic surgery in the same session, is named "oncoplastic" breast surgery.
Thirty years ago, breast cancer surgery was straightforward - it meant having a
mastectomy.
Nowadays, lumpectomies, tumor excisions,
segmentectomies, quadrantectomies, skin sparing mastectomies, mastectomies and
more, belong to the armamentarium of the oncologic surgeon.
Likewise, the
plastic surgeon has to have in his arsenal of procedures ranging from local
rearrangement of the breast gland after an excision of a tumor, a variety of
breast reduction techniques into which the tumor excisions are integrated, and
the reconstruction of the patients own tissue or new prostheses.
Professor Graewe says the plastic surgeon should be
familiar with all of the different techniques in order to provide an optimal
cosmetic outcome.
"For me as the senior member and convener of such a
team, it has been an eye-opener to see the iteration taking place between the
radiation oncologist and the plastic surgeon," says Professor Apffelstaedt.
Dr Pienaar concurs and says the combined clinics
and the new tools plastic surgeons have developed, provide the patient with a
reformed breast shape with excellent blood supply in which radiation is much
better tolerated.
The team of surgeons should all have a major
interest in breast cancer management in order to understand the complexities
involved. A good measure of this is the number of breast cancers they manage
annually.
More than 100 cases of breast cancer is a good indication, that the
team has the required volume to constantly achieve good outcomes.
Still, an unfortunate minority of women will
require a mastectomy. In these cases, immediate reconstruction is the standard treatment
with an emphasis on retaining the volume and shape of the breast.
In the newest
reconstruction techniques, only skin and fat with their own blood supply are
removed and used to form a new breast. Muscles are no loner sacrificed and the
recovery is swift.
As donor areas for the new breast, the lower belly or the
buttocks are used, which often have accumulated a little excess tissue in the
course of a good life. This, according to Prof Graewe, makes the newly formed
breast look and feel more natural.
Breast cancer management has come a long way since
the early days of breast conservation. It is the aim to restore women who are
afflicted by this dreaded disease, to a status as normal as possible as soon as
possible.
A combined approach of a radiation oncologist, a
surgical oncologist and a plastic surgeon all seeing the patient together and
making decisions with the patient and her family, comes close to this
ideal.
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