BREAST CANCER SURGERY- CONSERVATIVE OR RADICAL?

Surgery is an integral part of treatment for breast cancer. The timing and extent of surgery may vary depending upon the patient’s choice and stage at presentation but all operable breast cancer patients (patients in whom cancer is limited to the breast and axillary glands) do undergo surgery at some point of time.
Complete removal of the affected organ has been one of the oldest and most important principles of cancer surgery. In the early 20th century, surgery for breast cancer involved complete removal of the affected breast, underlying muscles along with draining lymph glands in the axilla (arm-pit)(Radical Mastectomy). With the improved understanding of disease biology and the advent of effective systemic therapy, this technique was modified to removal of only one muscle under the breast and finally, breast surgery without removing any underlying muscles (present-day-modified radical mastectomy). The extent of surgery for removal of glands in the axilla has also reduced from a complete clearance of nodes in the axilla to mapping of the diseased nodes by a special technique called sentinel node sampling and thus reducing the extent of axillary surgery. For almost 50 years, modified radical mastectomy was considered the standard surgery for breast cancer. In most patients, the incision of surgery is planned in such a way that the axillary gland removal can be done through the same incision. Patients accepted modified radical mastectomy because it was an important step towards curing the disease but most were unhappy with the associated disfigurement.
In the past 3 decades or so, a novel concept of ‘Breast salvage’ or breast conserving surgery has emerged and has become popular. This process involves removal of the cancerous lump with a margin of normal tissue and removal of the axillary glands through a separate incision. This surgery needs to be supplemented with radiotherapy to ensure a complete local treatment. Initially, this procedure was viewed with a lot of skepticism and was often criticized as a substandard cancer surgery. However, extensive studies revealed that breast conservation surgery, if performed by trained cancer surgeons and supplemented with radiotherapy is equally effective in controlling breast cancer as compared to complete removal of the breast or modified radical mastectomy. Hence, as of today, breast conserving surgery with radiotherapy (Breast conservation therapy) is as effective as a modified radical mastectomy. Radiation therapy to the breast is an integral part of breast salvage surgery. Patients who have undergone a breast conserving surgery are subjected to 5 weeks of radiotherapy (5 days a week) with additional radiotherapy to the affected area in the breast.
So how does one decide about the choice of surgery? Breast conserving surgery is largely driven by patient’s choice. If a woman wishes, breast salvage can be offered to most women with small tumours. Obviously, cancer control is the topmost priority and takes precedence over all other factors. Patients with multiple tumours in the same breast, large tumours, small size of the breast or tumours which have grown over the skin surface make breast salvage technically or the end result may not be cosmetically acceptable and hence in such situations complete removal of breast (modified radical mastectomy) is preferred. Patients who are not suitable for radiotherapy cannot be offered breast conserving surgery.
But the most important question is- Do our patients take informed decisions? After being diagnosed with cancer, most women are scared for life and the first reaction is “Remove the affected organ completely and eradicate the disease”. This often is a knee-jerk response which is understandable. Another statement often heard is- “You are the doctor, you decide what is best for me”. Breast salvage is a decision primarily based on patient’s choice. If the patient is undecided about the procedure, she should spend more time with her doctor to discuss the pros and cons of either types of surgery.
A few facts about breast conservation surgery need to be stressed here. Breast salvage is NOT an inferior surgery. As far as cancer control is concerned, it is equally effective as compared to removal of the complete breast provided it is followed up with radiotherapy. Secondly, breast salvage does not necessarily mean that a woman has an early stage disease. A lady with a small tumour in the breast may have several glands in the axilla which may be cancerous (> 3 glands makes it stage III disease) and still may be suitable for breast salvage. So breast saving surgery does not necessarily mean that additional treatment like chemotherapy or hormone therapy is not required. Radiation therapy after salvage surgery is compulsory. Radiation is available at only selected centres, there is an added cost for it, the treatment is prolonged (almost 6 weeks, 5 days a week) which may pose logistic challenges and it can cause some physical discomfort too.
Most patients in India expect their doctors to take decisions on their behalf. However, in the interest of the patient, the decision of breast salvage versus breast removal must be taken by the patient herself, and that too after due consideration has been given to the abovementioned facts. Opting for breast salvage just because it is technically feasible may not always be a good option. “It’s a small tumour, it will not be necessary to remove the breast completely, a small surgery to remove the lump will be sufficient” sounds `cool’ and very good indeed, but the (often) unsaid part of this `cool’ statement is “……and then 5 weeks of Radiotherapy costing INR XXX will be mandatory for you” !
A lady with a small breast lump and who does not want breast salvage can opt for complete removal of the breast and thereby save the trouble of radiotherapy. Radiotherapy after breast salvage can scar the breast and shrink the surrounding breast tissue. So the cosmetic end result needs to be visualized before planning this surgery. A normal sized breast on one side and a shrunken fibrotic breast on the other side provide a good cosmetic result to a patient and hence may not be acceptable. Instead, a complete breast removal followed by reconstruction of the breast by plastic surgery may be a better option.
Breast salvage surgery may be glamorized by some as the surgery for breast cancer and complete mastectomy as an old fashioned, inferior and maiming surgery but it would be prudent weigh the benefits, procedures involved and the end result before opting for either of the surgeries.

- Oncologist in Pune | Cancer Specialist | Dr. Chetan Deshmukh