What is a mastectomy, and what is a lumpectomy?
The early indications of breast cancer are often quite subtle, although in this stage it may be revealed by routine mammograms. In some cases, no overt symptoms exist until the cancer is well advanced. Women between forty and fifty years of age without risk factors are advised to have a mammogram every two years. Women over fifty or in the high-risk category because of a family history of breast cancer should have a mammogram once every year. If palpation of the breast reveals a lump, then immediate mammography is indicated.
It is necessary to be constantly vigilant for any sign that an abnormality exists in the breast. Clear indications of possible breast cancer include lumps or thickening of the tissue in the breast or in the area under the arms. Symptoms such as discoloration of the breasts or dimpling, thickening, scaling, or puckering of one or both breasts may also arouse suspicion of breast cancer. A significant change in the shape of the breast or a swelling of it are also symptomatic. A bloody discharge from the nipple, scaly skin on the nipple or surrounding area, inversion of the nipple, or discoloration of the area surrounding the nipple may presage the presence of breast cancer.
Monthly palpation of the breasts, preferably seven or eight days after menstruation, may reveal lumps that could be harmless growths but that might be cancerous. This procedure is referred to as breast self-examination (BSE). Because the female breast contains many glands, it is not uncommon in some women for lumps to appear regularly—often profusely—particularly in the week prior to menstruation. Women with notably lumpy breasts are said to have fibrocystic breasts. Often, the lumps diminish in size in the week following menstruation. If they do not recede, however, then these lumps should be regarded with suspicion and the patient should be examined by a physician, preferably a surgeon, gynecologist, or oncologist.
Once a problem is detected, a number of procedures must be considered for dealing with it. The initial procedure in treating suspected breast cancer usually involves a mammogram to reveal irregularities in the breast. If the results of the mammogram are negative and the patient is still convinced that there is a lump in the breast, an ultrasound or sonographic examination may be indicated. In such tests, harmless sound waves are focused on the breast. These sound waves are reflected so that they create an image of formations within the breast. Although ultrasound cannot definitively indicate whether a lump is cancerous, it can at least verify whether a lump exists. It can also show whether the lump is hollow and filled with fluid, in which case it is usually a benign cyst rather than a cancerous growth.
If a growth is detected, the next, least-invasive means of determining whether it is cancerous is through a needle biopsy. In this procedure, the patient, under local anesthetic, has a hollow needle inserted into the growth. Fluids and cells are then harvested from it. If the growth is a cyst, a clear or light yellow fluid will be withdrawn, causing the cyst to collapse. This may be all the treatment required. In all cases, however, the substances withdrawn from the growth are examined by a pathologist for the presence of cancer cells.
Not all growths are so positioned that needle biopsies are possible. In such cases, a surgical biopsy is probably necessary. If the lump is small, then a lumpectomy, or the removal of the entire lump, may occur. Larger lumps often cannot be removed at this stage, so portions are excised for pathological examination. A pathologist carefully studies the tissue removed to determine whether it contains cancer cells.
In the past, biopsies often occurred while patients were anesthetized and, if the pathological report was positive for cancer, then a radical mastectomy was performed immediately while the patient was still under anesthetic. Since the late twentieth century, however, a two-step procedure has usually replaced this one-step method. If cancer is detected, then surgery is delayed, giving physicians the opportunity to consult with their patients about the treatments available to them.
The major decision in such cases usually is whether a total mastectomy or a partial mastectomy, commonly referred to as a lumpectomy, should be performed. Total mastectomy involves the total removal of the breast and the surrounding lymph nodes.
A radical mastectomy, done under general anesthetic, involves making a large, elliptical incision on the breast, including the nipple and often the entire breast. The incision normally extends into the armpit. All the breast tissue is excised, including the skin and the fat down to the chest muscles. The incision extends into the armpit to remove as much of the breast tissue as possible, including the lymph nodes, which may be cancerous. Once the bleeding has been controlled, a drainage tube is inserted and the incision is closed with sutures, clips, or adhesive substances.
This drastic form of treatment can be traumatic both physically and psychologically to patients. Many women fear the disfigurement that follows it. Some women, especially those with a family history of breast cancer, may decide that the total removal of the breast is their safest option. In some cases, to prevent future threats of breast cancer, they demand the removal of both breasts.
A lumpectomy, usually performed under local anesthetic, involves the removal only of cancerous tissue. The incision is made under the breast, and the lump, with surrounding tissue, is removed. The appearance of the breast remains much the same as it was before the surgery. In some cases, physicians recommend a quadrantectomy, which involves the removal of the cancerous tissue as well as significant amounts of the surrounding tissue. Quite often, the lymph nodes are removed as well. When this treatment is used, the breast will appear slightly smaller than it previously was, but it can be enhanced through plastic surgery.
Subcutaneous mastectomy is frequently indicated in situations in which the tumor is small. In this procedure, the surgeon makes an incision under the breast. Most of the skin and the nipple remain intact, although the milk ducts that lead into the nipple are cut. Following the surgery, sometimes immediately, a breast implant can be inserted, restoring the breast to its normal appearance. Mastectomy and lumpectomy are routinely followed by a course of radiation and/or chemotherapy designed to kill any fugitive cancer cells that the surgery has missed.
While the goal of mastectomy is to create as little scarring as possible, considerable scarring may occur, particularly with radical mastectomy, and the absence of one or both breasts usually requires significant psychological adjustments on the part of women who have undergone the procedure. The breast reconstruction performed by a plastic surgeon following a mastectomy is often accompanied by treatment from a psychologist or psychiatrist.
Some women with family histories of breast cancer, particularly if the disease has occurred in first-level relatives (mother or sisters), may opt for a mastectomy rather than a lumpectomy to relieve themselves of the fear of contracting the disease, although most oncologists make such women fully aware of other, less drastic procedures available to them.
Certainly a consideration in reaching a decision about whether to have a lumpectomy or the more drastic mastectomy must include many factors. High on the list of such factors is heredity. In many patients who suffer from this disease, BRCA1 and BRCA2, mutated genes, are an early indication that breast cancer may eventually occur. The BRCA gene is frequently present in the female members of families with histories of breast cancer and ovarian cancer. About 85 percent of women with the BRCA gene will develop breast cancer if they live a normal life span. Women who have the BRCA gene may decide to have a prophylactic mastectomy before symptoms occur, although many women in this situation prefer treatment with tamoxifen, which appears to hold breast cancer at bay.
Advances in treating cancers of all kinds progressed rapidly during the last half of the twentieth century, and even greater impetus characterizes current advances. The four major treatments—often used in combination with each other—are surgery, radiation therapy, chemotherapy, and hormonal therapy. In the treatment of breast cancer, radiation may be used initially to shrink existing tumors that, once reduced in size, will be removed surgically. However, when surgeons remove cancerous tumors, they also remove large numbers of surrounding cells that might be affected; such a procedure is usually followed by additional radiation aimed at killing any lingering cancer cells the surgery has missed.
The salient use of surgery in cases of breast cancer is to remove its source, not only clearing away any tumors that may be found but also removing additional cancerous tissue as well as lymph nodes that might be affected.
Cancer cells can exist either in the breast’s lobules, which contain the cells that produce milk, or in the ducts that carry the milk to the nipples. Cancer cells in either of these locations can be of two types, invasive or noninvasive (also called in situ). The major complication with invasive cancer is that it can and usually does metastasize, spreading often to the lymph nodes, into the lungs and to other parts of the body. In such cases, a radical mastectomy is indicated. It must be performed as quickly as possible and followed by a strenuous course that typically includes radiation or chemotherapy. Noninvasive cancer is less likely to metastasize, although it sometimes does. Lumpectomy or quadrantectomy is often used to treat such cancers, but these procedures must be followed by close monitoring over the rest of the patient’s life and by radiation or chemotherapy following surgery.
Chemotherapy is used less often than radiation in the postsurgical treatment of breast cancer but is occasionally used along with it. Some physicians use anticancer drugs to reduce the possibility of recurrence. This treatment, as well as hormone treatment, is designed to kill any fugitive cancer cells that have strayed from the immediate site of the cancer that has been removed. Whereas surgery and radiation are local, affecting only the part of the body being focused upon, chemotherapy is systemic: the drugs used in chemotherapy travel through the bloodstream to all parts of the body. The disadvantage of chemotherapy is that it nearly always has significant side effects. In rare cases, complications are so extreme that they result in death. Usually, chemotherapy is indicated only for women who have not yet undergone the menopause and whose tumors are an inch or larger in size. It may also be employed in cases in which the patient’s tumor shows signs of growing rapidly and aggressively invading and attacking other parts of the body.
Related to chemotherapy is hormonal therapy. Hormones are chemicals produced by the body for various purposes. For example, when one is under sudden, undue stress, the body produces adrenaline, which provides a rush of energy and causes the heartbeat to accelerate. In women, the body produces estrogen every month during the menstrual cycle. Estrogen causes the cells in the milk ducts and lobules to grow in preparation for pregnancy. This chemical stimulates the growth of normal cells but can also stimulate the growth of cancer cells. Hormonal therapy is systemic. It involves introducing into the bloodstream a synthetic chemical, usually tamoxifen, which makes it impossible for the body’s natural estrogen to find its way to cancer cells that would be nourished by it. A complete biopsy report can determine whether hormonal therapy is appropriate in individual cases.
Until the middle of the twentieth century, a diagnosis of cancer, particularly of breast cancer, was viewed as a death sentence. Diagnosis generally occurred after the cancer had metastasized. In the first half of the century, general practitioners were much more prevalent than the specialists who, working as a team, are now generally mustered to provide cancer treatment once a diagnosis is made.
With the proliferation of sophisticated medical equipment, including the highly sensitive X-ray machines used in mammography and the various forms of ultrasound and sonograph equipment that are part of nearly every hospital’s arsenal of diagnostic equipment, an increasing number of cancers are discovered before they become symptomatic, so that they can be treated with considerable success.
Historically, mastectomies have been performed for centuries. President John Adams’s daughter underwent this excruciating surgery early in the nineteenth century, enduring this procedure without the benefit of anesthesia. As was usually true in such cases, the surgery extended her life for only a little while because her cancer was discovered in an advanced stage and had metastasized.
By the late nineteenth and early twentieth centuries, accepted treatment for breast cancer was a radical mastectomy that involved the removal of the affected breast and of as many surrounding cancer cells and lymph nodes as possible. William Halsted, a pioneer in the field of breast cancer surgery and a professor of surgery at the highly respected Johns Hopkins University Medical School, championed the cause of the radical mastectomy, which he viewed as a procedure that could extend substantially the survival of his patients. Little was said about curing breast cancer patients of their cancers. The radical surgery that physicians across the country performed following Halsted’s lead was viewed simply as a means of adding months or years to the life of the cancer patient. Until 1970, about 70 percent of women in the United States who had breast cancer were subjected to radical mastectomy.
Several factors brought about a major change in the treatment of breast cancer during the 1960s and 1970s, when social activism was very much in the forefront of American life. Feminists pointed out that most of the surgeons treating breast cancer were men. As an increasing number of women entered medical schools and eventually established medical practices, greater attention was paid to treating breast cancer in less disfiguring ways than had been common earlier.
Along with this change came advances in medical technology that made early diagnosis and more focused treatment a reality. As the chemical treatment of all cancers came to be better understood and more widely employed, the focus was more on preventing and curing cancer than on merely prolonging the lives of those who suffered from it.
Laboratory tests for detecting a woman’s predisposition for breast cancer have become increasingly sophisticated and accurate. Where the BRCA1 or BRCA2 gene is present, the possibility of developing breast cancer is greatly increased; women shown to possess this gene have been made more vigilant than ever before in monitoring their conditions and in seeking immediate medical intervention if even the slightest symptom appears.
Shortly after the end of World War II, some oncologists rejected Halsted’s emphasis on radical mastectomy. Surgeon Jerome Urban garnered numerous followers in his call for superradical surgeries in cancer cases. His procedures involved the removal of ribs, various internal organs, and even limbs in order to find and destroy every cancer cell. Surgeon Bernard Fisher stood in opposition to Urban, championing the effectiveness of smaller surgeries, such as the simple mastectomy, which involved the removal of one breast but not of all the lymph nodes and, in some cases, the lumpectomy, involving the removal only of the tumor and its surrounding cells.
The lumpectomy has gained acceptance through the intervening years. It is less disfiguring than either the radical or the simple mastectomy, leaving only a small scar on the underside of the breast. In cases where lumpectomy is viewed as a viable option, survival rates and cure rates are comparable to those of patients who have undergone more radical surgery.
Advances in medical science are accelerating substantially. Stem cell research offers great promise in the treatment and cure of diseases such as breast cancer. Researchers appear to be on the threshold of developing cells designed to destroy specific errant cells, such as those that cause cancer, while leaving healthy cells intact.
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