Breast Cancer Awareness With modern options, 'less is more with breast cancer surgery'

Oct. 2—JOHNSTOWN, Pa. — For years, surgeons have been finding ways to avoid or at least reduce surgery in breast cancer diagnosis and treatment.

Thirty years ago, it often took a surgical biopsy to diagnose cancer.

If the biopsy showed cancer, a patient usually underwent a radical bilateral mastectomy to remove both breasts, with additional surgery to examine lymph nodes to see if the cancer had spread.

Today, most women can opt for breast conservation surgery, commonly known as a lumpectomy, to remove the cancer and save most of the breast tissue.

If the lumpectomy patient also receives some course of breast radiation therapy, the life expectancy and rate of serious complications are no different than mastectomy, breast surgeon Dr. Meaghan Marley said at the Conemaugh East Hills outpatient center in Richland Township.

"Both are equal from an oncological standpoint," Marley said. "The local recurrence is higher for lumpectomy but still very small, and it doesn't affect overall survival."

Lymph nodes are tiny bean-like glands that are part of the body's lymphatic system.

Doctors examine them to determine if the cancer has advanced beyond the breast.

Until the 1990s, most breast cancer patients got an axillary lymph node dissection, taking up to 30 lymph nodes from the armpit area. The procedure can disrupt the lymphatic system and cause swelling, or lymphedema, in the legs.

Since the 1990s, the standard of care has been to check lymph nodes most likely to be the first hit by cancer cells and check only those cells, requiring a much smaller incision.

"We use radio tracer blue dye," breast surgeon Dr. Renée Arlow said at the East Hills center.

She said that the dye is injected into the breast and tracked through the lymphatic system.

"We follow its trajectory through the lymphatic system of the breast," Arlow said. "The cancer is going to have that same path. We take out the lymph node that has the highest amount and those in the top 10%."

With axillary dissection, there's a 30% chance of lymphedema, but with axillary sentinel node biopsy, the chance is reduced to 5%.

Surgeons are also not removing as many abnormalities found in the breast. A radial scar and an intraductal papilloma are two usually benign growths found in the breast.

Once they are identified by biopsy, surgeons decide if the growth is a threat.

"We used to take the patient to the operating room and take all of those out," Arlow said. "Now there's a group of those that we observe. We don't take them out. The risk of upgrade is very, very low."

If the patient still has residual cancer after standard oncology treatments, surgeons will go back and do a full axillary lymph node dissection.

"That's the next big push," Arlow said, "to see if we actually need that."

Another advance makes the day of surgery shorter and less stressful, Dr. Trudi Brown said at the Joyce Murtha Breast Care Center in Windber.

The surgeons or radiologists use an image-guided catheter to place a tiny marker at the tumor site a few days before surgery. On the day of surgery, magnetic or radio-wave scanning equipment finds the marker and helps the surgeon see the tumor's precise location.

"It makes the day of the surgery more streamlined," Brown said. "I make the incision directly over the cancer and take out a much smaller piece of the breast, which is fantastic."

Without the markers, patients have to come in early on the day of surgery to have a wire inserted into the breast and directed to the tumor with imaging.

"It makes for a long day," Arlow said. "This avoids the patient having an annoying, barbaric wire sticking out of her breast. It's more comfortable for the patient."

Surgeons are starting to use techniques associated with plastic surgery to help preserve tissue and improve the cosmetic appearance following a lumpectomy.

"With oncoplasty, you are really trying to get good cosmetics and hide the scar," Arlow said. "We have done some minor tissue rearranging and oncoplasty has pushed that a little bit further."

The technique is not recommended if the ratio of tumor size to breast size is high, she added.

"We are definitely seeing less is more with breast cancer surgery," Arlow said.