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Because I've been thinking about it a lot lately, I want to do a general education post on how breast cancer treatment works as it relates to surgery. This post only refers to early stage and locally advanced breast cancer (stages I-III) and not metastatic (stage IV). Please to be excusing the way my fannish squee has been interrupted by cancer crap recently.
So here's the deal. The primary treatment for early stage and locally advanced breast cancer (stages I-III) is surgery. Under limited circumstances, like inflammatory breast cancer or a very large tumor, chemo may be used to shrink the cancer prior to surgery (what's called neo-adjuvant therapy), but the way you get rid of it is to cut it out. In most cases of early stage and many later stages of breast cancer, surgery alone has a decent shot of being curative all on its own. It is the single most powerful tool in the arsenal. If, for some reason, you could do either chemotherapy or surgery but not both, surgery would be the way to go every time.
Chemotherapy and radiation, when they are indicated, are what's called adjuvant therapy. It's what you do after the cancer has been cut out to catch any stray undetectable cancer cells and to hopefully keep it from coming back, or metastasizing to distant sites. When someone undergoing chemotherapy or radiation for breast cancer post surgery says they 'have cancer' what they usually mean is they are being treated for tiny cells that may or may not exist and that are not detectable, but the risk of assuming they aren't is too high not to flood the system with cancer killing agents. The risk is higher or lower depending on your stage and prognostic factors and many women will not undergo chemotherapy at all.
So what are your options for cutting it out? A single tumor that is smaller than five centimeters (or that has been shrunk by chemotherapy) and does not involve the chest wall or skin may be removed in a lumpectomy or a partial mastectomy. Basically, what happens is the cancer itself is removed along with surrounding tissue . If pathology reveals the margins of that tissue to be 'dirty' (containing cancer cells), a re-excision or a mastectomy will be performed to get 'clean' margins. Radiation is crucial to the success of a lumpectomy with invasive cancer, because the tissue left behind is high risk for the invisible cells we don't want to grow back.
Multiple tumors, tumors that are larger than 5 centimeters, or those involving the chest wall or skin are treated with a mastectomy. In addition, a mastectomy may be recommended for tumors with poor prognostic features, that are particularly aggressive, or that are considered likely to recur for any reason (a positive brca gene test, for example). A woman may also choose a mastectomy because she is simply not comfortable with the increased risk of a local recurrence (the risk for distant metastasis is about the same either way). A 'simple' mastectomy removes the cancer along with the entire breast, while a 'modified radical' mastectomy also scoops out a section of the lymph nodes under your arm. Which one will depend on whether or not there are any lymph nodes containing cancer. The goal is, again, to remove all the cancer with clean margins. If that is not possible due to extensive chest wall involvement, then you want to get as much of the cancer and surrounding tissue gone as you can. Leave no cancer cell behind, says the surgeon's knife.
Sometimes, even after treatment, there may be a local recurrence that is confined to the breast, lymph nodes, skin, or chest wall. If there are no distant metastasis present, the primary treatment is, once again, surgery. This time, however, the options are more limited and the standard of care is a mastectomy if one has not been performed previously. Why?
1. The previously radiated breast cannot be radiated again. We're trying to stop the cancer from coming back, not cause it, as repeated exposure to radiation is known to do. In addition, radiation damages skin and muscle. You can get away with that once, but do it twice and you are likely to cause severe and disabling complications.
2. This cancer has now proven beyond doubt it wants to come back. We might not be able to see those invisible cells, but now we know they are almost certainly there. Leaving them behind is not wise, especially since we can't even zap them anymore.
If a mastectomy has been previously done, the goal is the same, cut out the cancer with a clear margin in the surrounding tissue.
There are times when a patient is not a surgical candidate. As mentioned way at the top, generally metastatic cancer is not treated with surgery, as the goal is now palliative and not curative and not likely to gain any benefit worth the trauma of surgery. Or a person may not be able to tolerate surgery for a number of other reasons. But for a patient who is a surgical candidate, the knife is our very best friend, and we want it going after every last bit of tissue that either contains cancer or is highly likely to develop it.
Chemotherapy is a powerful thing. So is radiation. Neither one is very good at eliminating breast cancer entirely, and its best use is to mop up after the knife.
All hail the knife. More info? http://www.breastcancer.org/ , http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?dt=5 , http://www.cancer.gov/cancertopics/types/breast
So here's the deal. The primary treatment for early stage and locally advanced breast cancer (stages I-III) is surgery. Under limited circumstances, like inflammatory breast cancer or a very large tumor, chemo may be used to shrink the cancer prior to surgery (what's called neo-adjuvant therapy), but the way you get rid of it is to cut it out. In most cases of early stage and many later stages of breast cancer, surgery alone has a decent shot of being curative all on its own. It is the single most powerful tool in the arsenal. If, for some reason, you could do either chemotherapy or surgery but not both, surgery would be the way to go every time.
Chemotherapy and radiation, when they are indicated, are what's called adjuvant therapy. It's what you do after the cancer has been cut out to catch any stray undetectable cancer cells and to hopefully keep it from coming back, or metastasizing to distant sites. When someone undergoing chemotherapy or radiation for breast cancer post surgery says they 'have cancer' what they usually mean is they are being treated for tiny cells that may or may not exist and that are not detectable, but the risk of assuming they aren't is too high not to flood the system with cancer killing agents. The risk is higher or lower depending on your stage and prognostic factors and many women will not undergo chemotherapy at all.
So what are your options for cutting it out? A single tumor that is smaller than five centimeters (or that has been shrunk by chemotherapy) and does not involve the chest wall or skin may be removed in a lumpectomy or a partial mastectomy. Basically, what happens is the cancer itself is removed along with surrounding tissue . If pathology reveals the margins of that tissue to be 'dirty' (containing cancer cells), a re-excision or a mastectomy will be performed to get 'clean' margins. Radiation is crucial to the success of a lumpectomy with invasive cancer, because the tissue left behind is high risk for the invisible cells we don't want to grow back.
Multiple tumors, tumors that are larger than 5 centimeters, or those involving the chest wall or skin are treated with a mastectomy. In addition, a mastectomy may be recommended for tumors with poor prognostic features, that are particularly aggressive, or that are considered likely to recur for any reason (a positive brca gene test, for example). A woman may also choose a mastectomy because she is simply not comfortable with the increased risk of a local recurrence (the risk for distant metastasis is about the same either way). A 'simple' mastectomy removes the cancer along with the entire breast, while a 'modified radical' mastectomy also scoops out a section of the lymph nodes under your arm. Which one will depend on whether or not there are any lymph nodes containing cancer. The goal is, again, to remove all the cancer with clean margins. If that is not possible due to extensive chest wall involvement, then you want to get as much of the cancer and surrounding tissue gone as you can. Leave no cancer cell behind, says the surgeon's knife.
Sometimes, even after treatment, there may be a local recurrence that is confined to the breast, lymph nodes, skin, or chest wall. If there are no distant metastasis present, the primary treatment is, once again, surgery. This time, however, the options are more limited and the standard of care is a mastectomy if one has not been performed previously. Why?
1. The previously radiated breast cannot be radiated again. We're trying to stop the cancer from coming back, not cause it, as repeated exposure to radiation is known to do. In addition, radiation damages skin and muscle. You can get away with that once, but do it twice and you are likely to cause severe and disabling complications.
2. This cancer has now proven beyond doubt it wants to come back. We might not be able to see those invisible cells, but now we know they are almost certainly there. Leaving them behind is not wise, especially since we can't even zap them anymore.
If a mastectomy has been previously done, the goal is the same, cut out the cancer with a clear margin in the surrounding tissue.
There are times when a patient is not a surgical candidate. As mentioned way at the top, generally metastatic cancer is not treated with surgery, as the goal is now palliative and not curative and not likely to gain any benefit worth the trauma of surgery. Or a person may not be able to tolerate surgery for a number of other reasons. But for a patient who is a surgical candidate, the knife is our very best friend, and we want it going after every last bit of tissue that either contains cancer or is highly likely to develop it.
Chemotherapy is a powerful thing. So is radiation. Neither one is very good at eliminating breast cancer entirely, and its best use is to mop up after the knife.
All hail the knife. More info? http://www.breastcancer.org/ , http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?dt=5 , http://www.cancer.gov/cancertopics/types/breast
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Also: ::hugs::
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I am a big believer in being informed.
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