1. What does locoregional treatment consist of?
- Local control of the cancer. The two techniques are mastectomy, which is the removal of the whole breast including the nipple or lumpectomy, which is also known as wide excision. The newer technique is wide excision, which is removal of the tumour with a margin of normal breast tissue. The rest of the breast is untouched to maintain good cosmesis.
- Axillary or Armpit Surgery
2. Is wide excision a safe option compared to mastectomy?
After wide excision, radiotherapy is given to the breast for 6 weeks. Research has shown that wide excision plus radiotherapy is a safe option as it also has a low recurrence rate.
3. Which patients are suitable for wide excision plus radiotherapy?
- Tumours less than 2 to 3 cm diameter
- Breast of a suitable size
- Tumour situated away from the nipple
4. Which patients are not suitable for wide excision plus radiotherapy?
- Young women (less than 30 years old) have a high recurrence rate after this procedure.
- Women with connective tissue disease are not suitable for radiotherapy.
- Pregnant women.
- 2 or more tumours within the same breast.
5. Why is axillary surgery required?
Axillary surgery is required to remove lymph glands (called nodes) for diagnostic and therapeutic purposes. Knowing whether the lymph glands are infiltrated by cancer is important in determining the stage of the cancer. Removal of the lymph nodes also prevents recurrence of the cancer in the axilla.
In this operation called axillary clearance or dissection, the surgeon removes all or most of the lymph nodes in the axilla. Some patients may after axillary dissection suffer from temporary shoulder stiffness and arm swelling (lymphoedema).
6. What is sentinel lymph node biopsy (SLN biopsy)?
Recent research has shown that 1 or 2 lymph nodes act as gateway to the axilla and if there is cancerous involvement of the axillary lymph nodes, they will be affected first (sentinel lymph nodes).
By identifying these sentinel nodes and biopsying one of them can determine whether the rest of the axillary lymph nodes are involved by the cancer.
Hence if the SLN biopsy is negative, there is no involvement of the axillary nodes and vice versa. Because of the limited extent of the surgery, SLN biopsy has fewer side effects compared to axillary dissection.
7. Is SLN biopsy suitable for all patients?
The SLN biopsy is a treatment option of patients with:
- Small tumours
- Non-palpable nodes in the axilla
It is not suitable for patients in which the chances of nodal involvement are high e.g. large tumours, palpable nodes. In such patients an axillary dissection should be performed.
It is also not suitable for patients in which the chances of nodal involvement are low e.g. non-invasive tumours. In such patients no axillary surgery is required.
8. Is SLN biopsy a safe option compared to axillary dissection?
This new technique is controversial and being evaluated. It is not recommended for routine use.
9. Is there any hope of ‘Saving The Breast’ after mastectomy?
Yes. The breast can be reconstructed and there is a new improved technique of breast reconstruction called Skin Sparing Mastectomy (SSM) and Reconstruction.
Points to note in breast reconstruction following mastectomy:
- Timing of Reconstruction
- Immediate: The Reconstruction is performed after the Mastectomy at the same operation. A new modified technique of mastectomy in which more skin is preserved, called Skin Sparing Mastectomy is performed and the breast is reconstructed with an artificial implant and a skin flap harvested from the back to cover the hole left after removal of the nipple.
- Delayed: The Reconstruction is performed at a second operation anytime after treatment for the breast cancer is completed. This is usually one year after the Mastectomy. The breast is reconstructed with either an artificial implant or skin and muscle flap from the abdomen (TRAM flap) or the back (Lat. Dorsi flap).
- Is reconstruction safe? The presence of an artificial implant or a reconstructed breast has not been found to interfere with the detection of local recurrence of the cancer or to increase the risk of local recurrence.
- What are the types of reconstruction? As discussed earlier the breast can be reconstructed using an artificial implant (usually silicon) or a skin-muscle flap from the woman’s body. The implant method is quicker (hence less expensive) but some women object to the presence of a foreign body inside them. There has been a lot of controversy whether a silicon implant can cause long-term side effects and the US Food & Drug Administration (FNA) banned the use of silicon implants for cosmetic purposes at one stage. The flap method is the natural method but it takes much longer (hence more expensive) and there may be some problems at the donor site.
- Is breast reconstruction popular? Not among Singapore women. Only 10% or less of our local women opt for reconstruction after mastectomy in a survey conducted and the reasons were:
- More worried about the cancer and less concerned about cosmesis
- ‘Extra’ surgery involved and the costs
- The lopsidedness after mastectomy is less in local women as the Asian breast is smaller
- Availability of external implants worn in the bra
Role of Radiotherapy
Radiotherapy is the use of radiation to treat breast cancer. Currently the most important indication for radiotherapy is local treatment of the conserved breast following a Lumpectomy for breast cancer. It is given over a 6-week period with daily outpatient treatment sessions. Side effects are usually tolerable, few and confined mainly to the treatment area. Another indication for RT is for women after Mastectomy in which the risk of local recurrence is high (lymph nodes +, large tumour > 4cm).
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