The rules before surgical engagement

You have heard me say many a time, “It is your body not the doctors; participate in the decisions that affect your body. Take time to make decisions; breast cancer is not an emergency.”

• Do not have an operation in order to find out what something is; start with a friendly radiologist, and a core needle biopsy.
• Find out the cost of the biopsy, and don’t rush in; you can take your films elsewhere for another opinion.
• There are excellent government services that can also do core needle biopsies to help make diagnoses.
• Insist on being treated in a multi-disciplinary environment, and that    the team is composed of many independent doctors, so you are not being treated by doctors who merely inter-refer.
• If you are told that you have to see a certain doctor and if you don’t consult with that specific doctor, you can’t be treated in that unit…Run far away!

The good news is that we are lucky to have breasts, besides being envied by most men (even those that have breasts themselves). Breasts create in most of us, except those with small A cups, a front curve that gives us a shape.

The bad news is gravity hates women more than men, scientists can’t explain this. The effect is that our bodies tend to head south faster than the male body. The breast, this modified skin appendage, hangs on the pectoral muscles for dear life and is supported by thin netting, called Coopers ligaments (the suspensory ligaments of the breast). Charl had a tent called Cooper, needless to say it had an alarming droop!

The reason for sharing this information is that the bra’s role is to counteract gravity, and therefore the breast one sees under a T-shirt is not the same as the breast one sees squashed in a mammogram, and neither looks the same as the breast one sees when a patient is lying on an operating table.

I have been called by many a surgeon and registrar, to say they can no longer feel a lump (cancer) that they had felt before and were going to remove, now that their patient is lying on the operating table.

Lesson 1

The important lesson here is that when in doubt, the friendly radiologist should mark the area needed to be taken out prior to any surgery. This can be done by placing a fine wire into the lesion; by marking it with dye; or by using a nuclear medicine isotope. Please check with your surgeon before the surgery, how they can be absolutely sure that the correct area will be removed.

Lesson 2 

There is no reason to not place cosmetic incisions wherever possible,        when operating on the breasts. Most lumps can be taken out through the inframammary fold (the base of the breast); circumareolar (around the brown pigment area of the nipple); or within the fields of the plastic surgery cuts used for a breast lift.

I still see ladies coming in after surgical biopsies, where they have cuts on the décolletage (cleavage) and elsewhere, creating problems for future reconstruction should it be required, and with nasty scars on the breast.

Lesson 3

Once you remove 5% of the breast tissue; you need to use small reconstructive techniques so as not to have a divot (small hole) in your breast post-surgery. Most breast surgeries look good for the first month, as our bodies produce fluid that fills the holes and gaps. It is for this reason, that most breast specialists leave a drain in after operating on the breast.

Lesson 4

Breast cancer does not jump from one breast to another, ever! Cancer spreads elsewhere. The survival is equal, whether you have a breast-saving operation or a mastectomy. Remember to take your time with this decision…most women I see, 10 to 15 years after their cancer surgery, feel that not enough time was taken to makes these choices.

Breast cancer spreads and has the ability to kill by travelling elsewhere in the body.

Sure, there is a chance that cancer can reoccur locally (in the surrounding area where it was taken out). This ‘local recurrence’ does impact on who lives or dies with breast cancer.

Obviously, getting a local recurrence is devastating for a patient. For this reason, lots of breast specialists prefer a margin of “normal” tissue (like a moat) to be taken around the cancer. The amount/or margin various from unit to unit, and from doctor to doctor. How that margin is accessed also differs.

Some units are fortunate enough to have good pathology in theatre (intraoperative pathology) where as other units send the specimen to the lab, and wait (three to seven days) for the result, then counsel the patient as to whether the margin is acceptable by that unit’s policies, and if there is a  need for repeat surgery.

International guidelines, which are a bit like “one size fits all”, accept a tumour at the inked margin (on the margin), therefore a compelling reason should exist to go back to theatre. These decisions should be discussed in the multi-disciplinary unit meetings, and re-discussed in terms of pros and cons for the patients.

I am forever grateful to the superb quality and service offered by our pathologists in the unit; they come to theatre (at weird times); make difficult calls; and protect our patients from the need for redo surgery. The redo surgery rate in the unit is less than 1%.

Lesson 5

So who needs a mastectomy in this day and age? The simple answer is very few people. Certain types of cancers that involve the whole breast, namely inflammatory cancers and multi-centric cancers (cancers involving all quadrants of the breast), need a mastectomy.

Cancers that are difficult to visualise in the breast, such as Paget’s disease of the nipple; cancers that may be more extensive; extensive areas of ductal carcinoma in situ (DCIS) (sleeping cancer); and lobular cancers (cancers that can have mirror cancers in the other breast – rarely <20% of the time) are associated with women with strong family histories of breast cancer, or confirmed BRCA genetic, or other positive gene tests. All of these may result in your doctor discussing a mastectomy with you. These are all, however, relative indications. Today with the breast MRI, focused ultrasounds and clever radiology, an understanding of what is hiding in the breast is easier to visualise.

At the end of the day, the choice of surgery is a psychological decision not a scientific one; it is for this reason that women must take a great deal of time and thought when making this decision.

Factors that come into play here are stressors around going for follow-up mammograms and biopsies; fear of radiation; having a previous breast augmentation and having prostheses; family history and genetic factors.

However, before making this decision, the oncology rules are clear:

• The type of surgery does not prevent the need for chemotherapy (oncology treatment is the umbrella under which all other treatment sits).

• If cancer has spread to the glands, most units would recommend radiation treatment today.

• If a breast-saving surgery is chosen (lumpectomy, quadrantectomy or breast conservation), radiation treatment is almost always offered. The rule is breast-saving and radiation treatments always go hand-in-hand.

Mastectomies today are not the straight stripe cut across the chest wall. For a large number of women, a mastectomy is nipple- and skin-saving, with an immediate reconstruction as to which there are many options available. The choices are difficult to make. Read Chasing the Nirvana of the Perfect Breast Reconstruction.

The final chapter

Safety around surgery is paramount! Much to the horror of most surgeons,

I often teach that the physician is the tower; you can’t get on the plane or even take off unless the tower has cleared you for safety.

The anaesthetist is the pilot; I hate flying, and the critical safety issues are often about take off and landing (going to sleep and waking up). Insist on seeing the anaesthetist well before surgery. Does the unit have an anaesthetic clinic? This is of particular importance for patients who are going to have their surgery post-chemotherapy.

The surgeon is the flight attendant; they work long hours and deal with various issues and complaints i.e. the client interface. The choices they offer are either chicken or beef (breast-saving surgery or a mastectomy), with a few other limited options that you should have pre-booked prior to the flight. The surgeon is your crossing point, and friend, between the diagnosis and the treatment, and is an integral part of   the multi-disciplinary team.

It is your body not the doctors; participate in the decisions that affect your body. Take time to make decisions; breast cancer is not an emergency.