Women have options with breast cancer surgery


Dr. Deanna Attai, a member of the board of directors for American Society of Breast Surgeons, in front of a cryoablation machine, which freezes some kinds of breast cancer tumors. (The Associated Press)

Published: Wednesday, May 22, 2013 at 2:39 p.m.
Last Modified: Wednesday, May 22, 2013 at 2:39 p.m.

Chicago

One of the world’s most glamorous women had an operation that once was terribly disfiguring — removal of both breasts. But new approaches are dramatically changing breast surgeries, whether to treat cancer or to prevent it as Angelina Jolie just chose to do. As Jolie said, “the results can be beautiful.”

Jolie revealed last Tuesday that she had a double mastectomy and reconstruction with implants because she carries a gene mutation that puts her at high risk of developing breast cancer.

For women who already have the disease, the choice used to be whether to have the lump or the whole breast removed. Now there are more options that allow faster treatment, smaller scars, fewer long-term side effects and better cosmetic results. It has led to a new specialty — “oncoplastic” surgery — combining oncology, which focuses on cancer treatment, and plastic surgery to restore appearance.

“Cosmetics is very important” and can help a woman recover psychologically as well as physically, said Dr. Deanna Attai, a Burbank, Calif., surgeon who is on the board of directors of the American Society of Breast Surgeons. Its annual meeting in Chicago earlier this month featured many of these new approaches.

Breast cancer is the most common cancer in women around the world. In the U.S. alone, about 230,000 new cases are diagnosed each year.

Most can be treated by just having the lump removed, but that requires radiation for weeks afterward to kill any stray cancer cells in the breast, plus frequent mammograms to watch for a recurrence.

Many women don’t want the worry or the radiation, and choose mastectomy even though they could have less drastic surgery. Mastectomy rates have been rising. Federal law requires insurers to cover reconstruction for mastectomy patients, and many of the improvements in surgery are aimed at making it less disfiguring. Here are some of the major trends:

— Immediate reconstruction: Doctors used to think it wasn’t good to start reconstruction until cancer treatment had ended — surgery, chemotherapy, radiation. Women would have a mastectomy, which usually involves taking the skin and the nipple along with all the breast tissue, followed by operations months later to rebuild the breast.

The new trend is immediate reconstruction, with the first steps started at the time of the mastectomy, either to place a tissue expander or an implant. In some cases, the whole thing can be done in one operation.

Nationally, about 25 percent to 30 percent of women get immediate reconstruction. At the Mayo Clinic, about half do, and at Georgetown, it’s about 80 percent.

— Sparing skin, nipples: Doctors usually take the skin when they do a mastectomy to make sure they leave no cancer behind. But in the last decade, they increasingly have left the skin in certain women with favorable tumor characteristics — and women having preventive mastectomies, such as Jolie. Attai compares it to removing the inside of an orange while leaving the peel intact.

Now they’re going the next step: preserving the nipple, which is even more at risk of being involved in cancer than the skin is. Only about 5 percent of women get this now, but eligibility could be expanded if it proves safe. The breast surgery society has a registry on nipple-sparing mastectomies that will track such women for 10 years.

— Freezing tumors: Attai, the California breast surgeon, is one of the researchers in a national study testing cryoablation. The technique uses a probe cooled with liquid nitrogen that turns tumors into ice balls of dead tissue that’s gradually absorbed by the body. This has been done since 2004 for benign breast tumors and the clinical trial is aimed at seeing if it’s safe for cancer treatment.

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