The treatment of breast cancer goes far beyond merely eliminating the cancer. Oncologists now understand that surgical treatments and radiotherapy must be integrated.
In well-run comprehensive breast centres 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.
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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 Stellenbosch University 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 Stellenbosch University.
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 patient's 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 longer 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 Professor 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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