By Dr. Colleen Silva
Breast cancer treatment has changed dramatically in the past 25 years. In the late 1980s, when I entered the field of breast surgery, modified radical mastectomy was still the standard treatment. We removed the entire breast, all the lymph nodes under the arm, the nipple and much of the breast skin. Breast reconstruction was rare.
Today, we offer breast-conserving surgery to two out of three women with early-stage breast cancer. The partial mastectomy or lumpectomy has replaced the total mastectomy as the treatment of choice whenever possible. When mastectomy is required, we now perform a skin-sparing version of the procedure, sometimes even saving the nipple.
We also offer immediate breast reconstruction — a procedure that has been fully reimbursable by insurance since the federal government mandated coverage in 1998. Patients can choose saline or silicone implants or they can choose tissue transfers from their own lower abdomen, back or buttocks. Even if a woman had her mastectomy many years before the coverage mandate went into effect, she can still undergo breast reconstruction now and receive full reimbursement.
Until the mid-1990s, we advised all women diagnosed with breast cancer, regardless of how early or advanced it was, to have all their armpit lymph nodes removed. A common side effect of this procedure is permanent swelling in the arm. As many as 30 women out of every 100 ended up with this condition, known as lymphedema, which can have serious detrimental effects to a woman’s health.
We now know that we can safely limit lymph node removal in most cases to a select few nodes, the sentinel nodes, thereby reducing the number of women who will get lymphedema to 4 or 5 out of 100.
Women who have lumpectomies are typically advised to receive radiation therapy after they recover from surgery. Traditional radiation therapy was administered once a day for up to six weeks. Now in some cases the treatments can be finished in four weeks, or sometimes in one week, depending on other factors such as the stage of the cancer, the woman’s age and other related health issues.
We have now abandoned the philosophy that almost all breast cancer patients should undergo chemotherapy. We tailor the treatment recommendations to the individual patient based on details such as the size of the tumor, whether the cancer had spread to the lymph nodes or other organs and the genetic makeup of the woman’s specific cancer.
We have learned that not all breast cancers act the same. Some tumors may be larger but, based on their particular genetic makeup, will not likely come back or spread, making IV chemotherapy unnecessary. Some tumors may be very small but, based on their genetic traits, are likely to be aggressive, making chemotherapy important in attacking them effectively.
In the past, our understanding of breast cancer and how it spread was limited. Our discussions with patients about their cancer were pretty straightforward. Basically everyone had a modified radical mastectomy and everyone got chemotherapy.
As we learn more and more about how cancer begins, grows and spreads, our treatment recommendations change as well. It’s important to have a dedicated team of breast cancer specialists who are knowledgeable about these new advances. There are now special certifications that let patients know whether a medical institution’s breast cancer team and protocols are top tier. The University of Texas Medical Branch at Galveston is certified by the National Accreditation Program for Breast Centers.
The team includes breast surgeons, medical oncologists, radiation oncologists, plastic reconstructive surgeons, breast radiologists, pathologists, patient navigators, occupational therapy lymphedema specialists, oncology social workers and complementary medicine physician specialists, all of whom work together to create a customized treatment plan for each woman.
Breast Cancer Awareness Month is a great time to think about how much things have changed. Individualized treatment options and new team approaches to diagnosis add up to making a woman’s life after breast cancer more whole and healthy than ever before. It’s been gratifying to be a member of the breast-health field during this exciting time of important change. I can’t wait to see what further advances emerge in years to come.
Dr. Colleen Silva is the director of breast health at UTMB.