Breast conservation vs mastectomy

In earlier years the discovery of a cancerous lump in the breast was very bad news for most women – usually they would have to undergo a mastectomy (removal of the breast), probably receive chemotherapy, and deal with all the emotional and physical tribulation that faces cancer patients.

However, modern science has shown drastic improvements in the survival rate and also the quality of life for breast cancer survivors.

In the 21st century, 80 out of 100 patients with early stage breast cancer are still alive and well after 20 years. “With the increasing survival of patients, quality of life issues become ever more important. One aspect crucial to the well-being of women is the cosmetic outcome of the cancer treatment,” explains Dr Rika Pienaar, an oncologist in Cape Town.

At comprehensive breast centres the majority of women are treated by breast conserving therapy.

“The initial trials of breast conservation primarily addressed safety issues and cosmetic outcome was only a secondary consideration” says Professor Justus Apffelstaedt of the University of Stellenbosch.

According to Professor Frank Graewe, Head of the Division of Plastic Surgery of the University of Stellenbosch: “The surgical outcome initially was often acceptable. However, the necessary addition of radiotherapy in breast conservation led to progressive scarring. After a few years the scarring made the cosmetic outcome rather poor.” At times, mastectomies had to be performed to alleviate problems associated with late radiation changes.

Two developments improved the cosmetic outcome markedly: progress in radiation planning and new technology in radiation delivery that cause much less scarring than in the past, and new surgical techniques that have been developed.

Where previously the aim was merely to eliminate the cancer, it is now understood that surgical treatments and radiotherapy must be integrated. 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 change.

Best results from a team approach
This is most readily achieved by a team approach of an oncologic surgeon, an oncologist and a plastic surgeon, all of whom have a specialised interest in breast cancer management in order to understand the complexities involved.

“For me as the senior member and convener of such a team, it has been an eye-opener how much interaction takes place particularly between the radiation oncologist and the plastic surgeon,” says Professor Apffelstaedt.

Concurs Dr Pienaar: “I have learned a lot in these combined clinics about the amazing new tools that plastic surgeons have developed. These now provide us with a reformed breast shape with excellent blood supply in which radiation is much better tolerated.”

This approach, which combines cancer surgery and plastic surgery in the same session, is called “oncoplastic” breast surgery. It was initially described in the 1990s and is undergoing continuous refinement. Thirty years ago, breast cancer surgery was easy: it meant mastectomy. Today, lumpectomies, tumor excisions, segmentectomies, quadrantectomies, skin-sparing mastectomies, mastectomies and a lot more are in the toolbox of the oncologic surgeon. Likewise, the plastic surgeon has to have in his arsenal procedures ranging from local rearrangement of the breast gland after an excision of a tumour, a variety of breast reduction techniques itegrating tumour excisions, to reconstructions with own tissue or prostheses.

“Experience has taught us that, in order to provide an optimal cosmetic outcome, the plastic surgeon should be familiar with all of these different techniques,” says Professor Graewe. Even then, an unfortunate minority of women will require a mastectomy.

In these cases immediate breast reconstruction is the standard of care. In the newest reconstruction techniques, only skin and fat with their own blood supply are removed and used to form a new breast. No muscles are 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.

But not only the volume and the shape of a breast are important. “I need an oncologic surgeon who can provide me with as much original skin as oncologically safe. This makes the newly formed breast look and above all feel more natural” says Prof. Graewe.

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.

By Frank Graewe, Professor and Head: Department of Plastic and Reconstructive Surgery, University of Stellenbosch; Justus Apffelstaedt, Associate Professor of Surgery, University of Stellenbosch and Head: Breast Clinic, Tygerberg Hospital; Dr. Rika Pienaar, Oncologist in Private Practice in Cape Town

March 2008

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