After hearing the words “You have breast cancer,” the next thing you want to do is find out how to rid your body of that cancer.
Do you need surgery, chemotherapy, radiation? Will you be treated with a combination of these? Or, can you have a mastectomy and not have to worry about it ever again?
Dr. Nicolas Ajkay, a surgeon specializing in breast cancer at UofL Physicians – Surgical Oncology and UofL Brown Cancer Center, said, “Intuitively, patients believe more surgery is better. When you have cancer, you want to cut it out.”
While surgery is often required, having multiple surgeries or a more invasive surgery isn’t always the best scenario, depending on the particular diagnosis.
The go-to treatment for breast cancer prior to the 1970s was radical mastectomy. A surgeon would cut out all of the breast tissue, including the skin, muscle and lymph nodes surrounding the breast. “Even though the breast and everything around it had been removed, women were still losing their life to breast cancer,” Dr. Ajkay said.
Six large studies conducted in North America and Europe in the 1970s and 80s compared the radical mastectomy to a lumpectomy (removing only the tumor found in the breast), followed by radiation. Many patients were followed after either surgery for up to 20 years. The patients did equally well in terms of survival, but those who had breast conserving surgery didn’t have the pain and suffering associated with a radical mastectomy.
Surgeons quickly learned the extent of surgery isn’t equal to survival. In 1991, the National Institutes of Health said treatment for early stage breast cancer should conserve the breast whenever possible.
Dr. Ajkay says now, however, “the trend is swinging back. Forty-five years later, some think having a mastectomy and even a double mastectomy is best, thanks to celebrities and the media showcasing these particular choices.”
Dr. Ajkay recognized that in some cases this is the right course of treatment, but for others it’s “likely overtreatment.” Why? Because detection and treatments have improved so significantly.
“Outcomes have improved since the 1990s because breast cancer is detected earlier – cancers detected by mammography are usually smaller, giving women a better chance to begin with,” Dr. Ajkay said. “And treatment (radiation and chemotherapy) has improved allowing for smaller surgical operations, like getting a lumpectomy instead of a mastectomy. Less surgery can actually be more beneficial in certain cases.”
Dr. Harriet Eldredge-Hindy, a radiation oncologist at UofL Brown Cancer Center, points to past clinical trials for proof, such as one called Z11.
This trial found no significant difference between sampling the axillary lymph nodes (removing 1-4) or having all the axillary lymph nodes removed (10-20), for patients found to have a small amount of cancer in the axillary lymph nodes.
“In many women with early stage breast cancer, if you take away the extra surgery, you’re not getting any worse of an outcome,” Dr. Eldredge-Hindy said. “At UofL Brown Cancer Center we are able to tailor our therapies to decrease side effects like lymphedema, caused by extensive lymph node removal.”
There is currently a similar trial going on at UofL Brown Cancer Center for patients who present with cancer in the lymph nodes at the time of cancer diagnosis, but are found to have no cancer in the lymph nodes after receiving effective chemotherapy prior to surgery.
“The goal is to have individualized treatment for each patient,” Dr. Eldredge-Hindy said. “And we’re researching if that second surgery can be excluded for the benefit of our patients.”
UofL Brown Cancer Center has a team of breast cancer experts in different fields of medicine and surgery that meet weekly to discuss all patients with breast cancer and the appropriate combination and extent of treatments after surgery. “Following surgery we look at the tumor under a microscope and decide whether the patient needs more surgery or if radiation is a better course of action,” Dr. Eldredge-Hindy said.
“This meeting and collaborative approach makes the difference – we’re individualizing care to make it the best situation for our patients.”