As Surgery for Breast Cancer Evolves, So Do Outcomes

Carla S. Fisher, MD, is an assistant professor of surgery at the Perelman School of Medicine and a breast surgeon. Dr. Fisher sees patients at the Rena Rowan Breast Center.

An article was published earlier this year in the Journal of the American Medical Association (JAMA) that challenged the current way we approach breast cancer treatment and surgery.

The article discusses the results of a randomized clinical trial that took place at many hospitals across the United States. In this trial, breast surgeons found that not every woman with breast cancer that has spread to the lymph nodes may need a full axillary (armpit area) lymph node dissection. As those of us in the medical community examine the results of this study and how they apply to our own patients, it seems appropriate to review a brief history of the evolution of surgery for breast cancer.

The history of the discovery and treatment of breast cancer is rich and one that has been documented back to the ancient Chinese and Egyptian cultures, as far back as 2600 BC. The most common forms of early treatment were medical remedies. In more “modern times,” beginning the 18th century, surgery became more common and well developed as a treatment for breast cancer. Surgery almost always involved removal of the entire breast (mastectomy).

Eventually, removal of all of the axillary lymph nodes and the pectoralis major muscle (one of the main muscles of the chest wall), a radical mastectomy, was also recommended. The surgery was always the same, regardless of the size of the breast cancer or presence of disease in the lymph nodes. This radical procedure, with some minor modifications, was practiced for over 70 years, well into the 20th century. In fact, many women may recall an aunt or grandmother who underwent a radical mastectomy with subsequent deformity of the chest wall.

Surgical techniques continued to become more refined and less morbid for the patient, but it was truly the discovery of the roles of radiation therapy, medical therapies (chemotherapy and endocrine treatment) and early detection (mammography) that propelled breast cancer treatment to where it is today. In the later part of the last century, breast conservation surgery was introduced. This surgery involved the removal of the cancer, without removal of the entire breast, followed by radiation therapy. Additionally, the sentinel lymph node biopsy technique was developed that allowed breast cancer staging without removal of all of the lymph nodes in the armpit area. If the sentinel nodes contained cancer only then would a full axillary dissection (removal) be performed in which the rest of the lymph nodes would be removed.

All of these surgical advances have given women with breast cancer more choices while maintaining or improving cancer care with less side effects and better cosmetic outcomes.

Now in 2011, we have evidence that suggests that even when breast cancer has spread to the axillary lymph nodes, we may not have to remove all of these lymph nodes. The important thing to point out is that while these findings are exciting and may represent a change for some women with breast cancer, the research and findings only apply to SOME women.

Not all women undergoing surgery for breast cancer will fall within the criteria used in this study, specifically women undergoing mastectomies. Younger women and women with certain types of breast cancer also may not qualify for this less aggressive surgery. What this study emphasizes, more than ever, is the importance of an informed discussion between patients, surgeons, medical and radiation oncologists.

At Penn, our multidisciplinary approach to breast cancer care gives us the opportunity to discuss the most up-to-date research, such as this recent publication, and determine how we can best apply it our patients.

Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.

The Abramson Cancer Center is pleased to present the Focus on Women's Cancers Conference featuring:

• 20th Life After Breast Cancer
• 10th Focus On Gynecologic Cancers
• Focus On Your Risk of Breast and Ovarian Cancer

Attend Penn Medicine’s Focus On Women’s Cancer Conference

Friday, October 28, 2011
7:30 am to 3:30 pm
Hilton Hotel, 4200 City Avenue, Philadelphia, PA 19131

Register and view the full agenda at The Abramson Cancer Center, or register by phone at 800-789-PENN(7366).

Please register for only one conference but feel free on the day of the conference to attend sessions at any of the 3 conferences.

Portions of the program will be livestreamed at PennMedicine.org/Abramson/WomensCancersLIVE on the day of the conference.

 

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Woman Beats Breast and Esophagael Cancer: Wants to Give Back

A 12-year breast cancer survivor, Gail Slappy was diagnosed with esophageal cancer in April 2009. Upon being diagnoses, Gail began receiving treatment at Penn Medicine's Abramson Cancer Center. When she retires from a teaching career this upcoming Spring, Gail plans on volunteering at the Abramson Cancer Center.

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My name is Gail Slappy. I’m a breast cancer survivor. In April of 2009 I was diagnosed with esophageal cancer.

I felt fullness in my chest that wouldn’t go away. After repeated attempts at diagnosing myself, I went to my primary care physician. She referred me to Gregory Ginsberg, MD, from Penn Gastroenterology.

Following an endoscopy, it was determined that I had a mass at the bottom of my esophagus leading into my stomach. Dr. Ginsberg informed me that I had esophageal cancer.
I thought to myself, “Oh no, not again!”

I’m a 12-year survivor of breast cancer. I was shocked that I was having another recurrence of cancer.

The multidisciplinary approach

Then, Dr. Ginsberg and I began to talk. I’m familiar with Dr. Ginsberg because he has been treating me over the years. He told me how he would handle my cancer treatment. Then, a team of doctors came in and discussed how I would be treated. The team consisted of Ursina Teitelbaum, MD, a hematology/oncologist; John Plastaras, MD, a radiation oncologist; and Ernest F. Rosato, MD, a surgeon. We all discussed how my case would be handled.

I felt quite relieved and confident that I was receiving the best treatment possible. There was a comprehensive team of doctors, and everyone was consulting with one another about my treatment.

Compassionate care

Throughout my experience at Penn Medicine's Abramson Cancer Center, I felt supported. Everyone was just so compassionate towards me and my care. I would receive phone calls at home asking how I was doing.

At my lowest point, I grew quite weak from the combination of radiation and chemotherapy. When I would go to receive therapy, everyone understood how I was feeling and treated me with the most compassion I could ever receive. One time, when I was receiving radiation, one of the radiation therapists talked to me so nicely. The nature of his voice and the way he spoke to me so calmly let me know I would be alright. It truly made all of the difference. He even said that I looked great even though I felt lousy and I probably looked lousy too! He was endearing and he helped me a great deal.

After I had my surgery, the nursing staff and the doctors in the hospital were so kind and gentle. They helped me through the whole process. Everyone was very concerned, very attentive, and genuinely interested in my care, my progress, and my recovery. People always asked what they could do to make me comfortable and how they could help me. That was the sentiment throughout my whole recovery at the hospital.

That’s why I like the comprehensive approach at the Abramson Cancer Center because everyone is in dialogue with one another. They are constantly updating each other on your condition, and making sure that you are okay.

Giving back
I’ve been recovering from my illness. I’m a teacher, and I plan to retire in June. Once I heal, I want to give back. I plan on volunteering at the Abramson Cancer Center. I want to help other individuals who may be diagnosed with cancer and help them get through it. I want them to know it’s not a death sentence or the end of the world. In spite of the seriousness of the illness, you can conquer it. You can be a champion.

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