Breast Cancer: The Complete Guide

HOW DO I KNOW WHICH TYPE OF SURGERY IS RIGHT FOR ME? Our basic job is to get rid of the cancer and prevent its spread and recurrence, if possible while preserving the breast. In order to accomplish that task, we have to understand the nature or pathology of the malignancy; its stage, including its size and how much it has spread; its location in the breast; and the size of the breast itself. We also have to give serious consideration to what you yourself prefer. The following sections describe the general circumstances under which each type of surgery is appropriate. Stage 0 Cancer Stage 0 cancers are noninfiltrating cancers confined to the lobules and ducts. Lobular carcinoma in situ (LCIS), generally speaking, requires no surgery after the biopsy. It should, however, be very carefully watched. Mammography and a physical examination by a doctor should be regularly scheduled because this in situ cancer is what we call a marker of great risk. Twenty percent of women with this symptom develop infiltrating cancers over a twenty-year period and there is a likelihood that both breasts are at risk. In the past, duct cell carcinoma in situ (DCIS) was usually discovered after a biopsy for a nipple discharge or ulceration. With the recent improvements in mammography, we are able to pick up very early abnormalities, and now over twenty percent of the women we treat for breast cancer have DCIS. To treat DCIS, we do a total mastectomy (without lymph node removal) or we do a lumpectomy followed by radiation therapy. Which procedure to choose poses a dilemma. We know that if we treat DCIS with mastectomy, we can achieve close to one hundred percent success. If we preserve the breast with a wide excision and radiotherapy, there is a one-percent-a-year recurrence rate. Of those women who have a recurrence, half can be successfully treated with mastectomy. The other half will have infiltrating disease. Some of them will be cured, but some lives will be lost. Many women and their doctors say, "If there is any risk of recurrence at all, do a mastectomy." Others decide that one percent a year is an acceptable risk. They are opting for as wide an excision as can be done to avoid deformity, along with radiation therapy. As we will see below, invasive cancers are treated with lumpectomy, node removal, and radiation. It seems paradoxical that cases of DCIS--that is, of noninvasive cancer--are often treated with mastectomy because of the one hundred percent cure rate. As one of my patients said, "Is the loss of my breast the reward I get for finding cancer before it has spread?" There are studies now under way to try to resolve this dichotomy, and to find out whether, in some cases of DCIS, wide excision alone is adequate treatment. In the meantime, if you have an in situ ductal cancer, you and your doctor will have to carefully discuss and weigh your treatment options We are not yet at the point where, as in early lobular cancers, we can monitor and observe and, at least, delay surgery. But treatment for intraductal carcinomas in situ can and should be individualized and the options carefully weighed as to their physical and emotional consequences. Stage I and Stage II Cancers The discussion of treatment for these cancers is best begun with a quote from "the horse's mouth," a conference convened by the National Institutes of Health (NIH) to evaluate available scientific information and to "resolve safety and efficacy issues related to biomedicHirshaut, Yashar is the author of 'Breast Cancer: The Complete Guide' with ISBN 9780553372038 and ISBN 0553372033.