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Comprehensive Breast Care of San Diego
Treatment  
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TREATMENT
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Breast Surgery

Once you and your physician have determined that you are going to proceed with breast cancer surgery, there are many surgical options for you to consider. It is important at this time to work with your multidisciplinary team. The team at Comprehensive Breast Care Denver will assure that you and your family have the necessary professional and personal support during and after your treatment period.
 
The different types of breast cancer surgery that you may undergo are described in the following paragraphs. Your doctor will consult with the other members of the team and recommend the type of surgery that offers you the best chance of successful treatment, based on your specific diagnosis.

It is important to note that most medical and surgical procedures carry some risk. You must discuss the risks and benefits of different breast cancer treatments with your physician in order to choose the treatment that is most suitable for you.

Axillary Lymph Node Biopsy

The first place that breast cancer usually spreads is to the lymph nodes in the axillary area, better know as your armpit. The traditional way to determine if the cancer has spread, or metastasized, to this area was the complete removal of all of the lymph nodes (called a complete axillary node dissection). A pathologist examines the nodes after they are surgically removed.

Axillary Lymph Node Evaluation

Evaluating the lymph nodes is an important component of staging the breast cancer. The side effects of this procedure can include lymphedema, which causes your arms to retain fluid and swell. It occurs in 5 – 10% of all patients. Other side effects can include arm weakness and/or arm numbness above the elbow. These side effects may decrease over time.


Sentinel Lymph Node Biopsy

A newer method of axillary node evaluation is called a sentinel node biopsy. This biopsy can more accurately detect lymph node metastasis with less invasive surgery and fewer side effects than the traditional complete axillary dissection. A sentinel node biopsy is usually performed at the time of mastectomy, (breast removal), or partial mastectomy (lumpectomy). This procedure involves injecting a radioactive tracer before surgery and a blue dye during surgery. These substances trace or map where the lymph drains from your breast into your axillary lymph nodes. The sentinel nodes are identified and only these nodes are removed. The pathologist may examine these lymph nodes during surgery (frozen section analysis) to determine if the cancer has spread to the lymph nodes. If they are cancerous, a complete axillary dissection may be performed immediately. If the lymph nodes are free of cancer, there is no need for further axillary surgery and the surgeon will proceed with breast surgery. The pathologist performs further analysis of the lymph nodes after surgery to check for any microscopic presence of cancer. A complete axillary dissection may be performed at a later date pending the final analysis.

Mastectomy

Mastectomy is the medical term for removal of the breast. It refers to a number of different operations ranging from those that remove only a portion of the breast to those that remove all of the breast tissue, nipple areola complex, surrounding skin and underarm lymph nodes.


Modified Radical Mastectomy or Total Mastectomy with Axillary Node Dissection

This surgical procedure removes the breast, the axillary lymph nodes (underarm nodes), and the lining over the chest muscles. This is a treatment for more advanced stages of breast cancer with large tumors where lymph nodes are found to contain tumor cells as well.

Total or Simple Mastectomy

A total or simple mastectomy removes only the breast. The axillary tail of the breast is also removed and therefore, some lymph nodes may be removed along with the tissue. This procedure is used most often to treat breast cancers that have not metastasized and for women opting for a prophylactic mastectomy.

Skin-Sparing Mastectomy

This procedure refers to a total or simple mastectomy in which just the nipple areola complex and a minimal amount of skin is removed. Most women who are eligible for immediate breast reconstruction have a skin sparing mastectomy in order to preserve skin for reconstruction.

Nipple Sparing and Nipple Areola Sparing Mastectomy

This surgical procedure involves removing breast tissue and cancer while preserving the nipple and/or nipple areola complex. As there is little long-term data available on the procedure, only a very select group of patients are eligible for this surgery. Talk to your breast surgeon to learn more about this procedure.

Breast Conservation

A partial mastectomy or lumpectomy is the most common breast cancer surgery performed. It is now often referred to as breast conservation surgery. This procedure removes the tumor from the breast plus a wedge of normal tissue surrounding the tumor. A portion of normal breast tissue must be removed surrounding the tumor to ensure that the tumor has been completely removed. This extra portion is called a margin. Occasionallyhe skin and lining of the chest muscle below the tumor will need to be removed to obtain clear margins. This procedure can be followed by approximately six weeks of whole breast radiation (standard therapy) or partial breast radiation. Again, make sure you talk to your Comprehensive Breast Care physician about the options available to you.

Breast Reconstruction

Many breast cancer patients are very interested in reclaiming their natural physique and request reconstruction surgery. Some reconstructions can be performed immediately following a mastectomy, during the same operation. Other reconstructions may need to be performed at a later date, depending on the need for post surgical radiation in certain cases. If you are considering mastectomy as a treatment option, our breast surgeons will refer you to a plastic surgeon to discuss your reconstructive options. The plastic surgeon will be very experienced in breast reconstruction and will discuss the various options and recommend reconstructive surgery that will work best for you, your body and your treatment plan.

Breast Radiation

One of the post-surgical treatments of breast cancer includes breast radiation (x-ray). Radiation has been used in conjunction with surgery to treat breast cancer for decades. New techniques allow your treatment team to assess your needs and provide different types and durations of radiation treatment.

Whole Breast Radiation

Radiation therapy usually follows a lumpectomy and/or chemotherapy, as part of breast cancer treatment. Whole breast radiation has been shown to reduce the risk of cancer recurrence in the treated breast and to increase the likelihood of long-term survival. Several weeks after a breast cancer has been surgically removed and the lymph nodes have been evaluated, whole breast radiation can begin. If chemotherapy is given, whole breast radiation usually begins after the completion of chemotherapy. During external radiation therapy, a machine called a linear accelerator beams x-rays to the breast and possibly the underarm lymph nodes and chest region. The goal is for the x-rays to kill any remaining cancer cells in the area. Radiation treatment usually involves two separate steps:

1 ) External radiation to the entire breast and surrounding area, five days per week for about six weeks. Each treatment takes only minutes.

2 ) “Boost” radiation therapy to the biopsy site only, for five additional days only.

Partial Breast Radiation

The standard therapy for whole breast radiation directs the x-rays to the entire breast as well as a boost to the tumor bed to decrease the chance of local cancer recurrence. A newer method, partial breast radiation, treats only a portion of the breast with radiation. The external x-ray beam targets only the site of the lumpectomy and a small area around it with HDR (High Dose Radiation). We are currently studying the use of partial breast radiation for treating small, Stage I breast cancers, those that have a low risk of local recurrence. This treatment lasts for only 1-3 weeks as opposed to 6 weeks.

Another approach to partial breast radiation is called brachytherapy. Brachytherapy involves the precise placement of radiation inside the previous site of the tumor. One such treatment involves placement of a catheter into the lumpectomy site. Radiation is then given through the device twice a day for five days, making this method more convenient and possibly better tolerated than traditional radiation therapy.

Partial breast radiation to the lumpectomy cavity performed at time of surgery immediately after the tumor is removed is called intraoperative radiation. The advantage over traditional radiation is that intraoperative radiation can eliminate the need for multiple weeks of adjuvant radiation after surgery. Although still under investigation, the studies show promising results.

Am I A Candidate For Partial Breast Radiation?

Please speak with your physicians to determine which method of breast radiation would be most beneficial to you. Criteria for partial breast radiation typically include:

  • Patients older than 50 years old
  • Tumor size less than 2 cm
  • Negative lymph nodes
  • No invasive lobular cancer
  • No extensive ductal carcinoma in situ (DCIS)

Chemotherapy

Some patients will benefit from additional treatment with medicines called chemotherapy. Chemotherapy given after surgery is called adjuvant therapy, and is given to potentially lower the risk that cancer will come back. Adjuvant therapy can take many forms but typically refers to the use of chemotherapy or hormonal therapy. Numerous factors are taken into consideration to determine if you are a candidate for adjuvant therapy. There are currently several tests on the market that may be used to help determine your risk of cancer recurrence. Some common tests used in treatment planning include Oncotype Dx, MammaPrint, BluePrint, TargetPrint, and TheraPrint.

For more information go to: www.agendia.com and www.genomichealth.com

Clinical Trials

1. Nipple Sparing Mastectomy Registry: A registry through the American Society of Breast Surgeons for patients undergoing nipple sparing mastectomies.

2. ABLATE: A prospective study evaluating intraoperative radiofrequency ablation after breast lumpectomy to extend the margins in the treatment of breast cancer. A second objective is to evaluate results of radiofrequency ablation when radiation is omitted.

3. RFID: (RadioFrequency Identification): A prospective, single-arm, multicenter clinical study to evaluate the safety and performance of the Health Beacons Radiofrequency Identification (RFID) Localization System for marking and retrieving non-palpable breast lesions. The goal is to determine if the RFID can replace the need for wire localizations of breast tumors in lumpectomies.

4. NBRST: (Neoadjuvant Breast Registry Symphony Trial): This is a prospective observational, case-only, study linking MammaPrint, BluePrint, TargetPrint, TheraPrint and possible additional profiles of interest to treatment response, Recurrence Free Survival (RFS) and Distant Metastases Free Survival (DMFS). Only patients who receive neo-adjuvant therapy can participate. For this project, approximately 20-30 institutions in the U.S. will be invited to contribute clinical patient data from enrolled patients after a MammaPrint, TargetPrint, BluePrint and TheraPrint test has been successfully performed and the patient has started neo-adjuvant therapy. Treatment is at the discretion of the physician, adhering to NCCN approved regimens or a recognized alternative.

DIAGNOSIS

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