Breast cancer surgery – measure twice, cut once

Prof Carol-Ann Benn and Dr Lucienne van Schalkwyk share five reasons why you should not rush into breast cancer surgery.

You may have heard of the proverb “Measure twice, cut once.” But, did you know that the Russian version of this proverb warns to measure seven times before cutting? 

The proverb makes sense in a concrete way: if you fail to properly measure a piece of fabric or wood for a project, you will waste both time and money. It also makes sense in an abstract way: if you fail to plan before you act in any other aspect of life, the consequences could be disastrous.

Another saying with a similar meaning is “Marry in haste and repent at leisure.” Choosing a medical care team when having a stressful diagnosis is a like a marriage.

Once diagnosed with breast cancer, your first impulse may be to get the surgery done and sorted as soon as possible. A little like seeing a spider on your shoulder and wanting to brush it off at speed.

While the thought of delaying your breast cancer surgery for a few days, or a week, may make you very anxious, the reality is that in today’s era of personalised oncology care, the more information you and your treating team have, the better. 

Better in that it helps to plan and perform successful breast cancer surgery. We, as surgeons, have but one opportunity to get things right. Tipex does not work so well in this scenario. So, let’s get it right the first time.

Know thy enemy

Not all breast cancers are the same. Some are very aggressive, while others grow slowly and are relatively well-behaved. Some are like lions, some like kittens. So, we will deal with them differently. 

To determine the behaviour of your specific cancer, we need the results of the receptor studies, which are special stains performed on your needle biopsy by the pathologist. These tests may take three to four days to complete. 

In certain cases, surgeons may even ask the pathologist to take a second look at the biopsy to make sure that the kitten really is a kitten. 

For certain breast cancer subtypes, we would recommend starting with chemotherapy before surgery. These decisions should always be discussed by a multi-disciplinary breast cancer care team of specialists.

Picture perfect

Your surgeon will have a look at the images of your mammogram and ultrasound. Therefore, it’s super important to bring these along to your consultation, otherwise it’s like operating in the dark. 

Sometimes it’s necessary to request further tests, such as a breast MRI. 

The MRI scan provides high-resolution images of the breast, which makes it easier to evaluate the characteristics of the tumour itself (size, distance from skin or muscle, abnormal glands). 

We can use the breast MRI as a kind of road map for surgery. We also use it to have a closer look at the opposite breast. The MRI scan can sometimes pick up suspicious areas in the opposite breast which may have been invisible on the mammogram and may have to be biopsied. 

The MRI is especially helpful for women who have dense breast tissue, because abnormal areas can ‘hide’ behind the dense tissue on a mammogram. 

We might also need to ask the radiologist to place a marker into the tumour for us, which will act as a GPS to guide us to the tumour when we perform the surgery.

Plastic fantastic

No matter how you feel about having the cancer removed; a consultation with a reconstructive surgeon should always happen prior to undergoing surgery. This is not plastic surgery. But, taking a surgical bite out of the breast leaves a divot. 

Remember, once surgery is done, it becomes more difficult to reconstruct later. You’ll have a much better idea of the different reconstructive options available and their pros and cons once you’ve consulted with an expert in the field. This will enable you to make an informed decision.

(G)land reform

The sentinel lymph node is the first gland downstream from the tumour, and for breast cancer it’s usually located in the armpit on the same side as the cancer. 

Because the tumour has to spread via the sentinel node to get to the rest of the glands, we know that if we remove the sentinel and it’s negative, there is a good chance that the rest of the glands will also be negative. 

Taking a biopsy of the sentinel lymph node before the final breast cancer surgery provides us with helpful information that can change how we manage the cancer significantly. 

If the sentinel lymph node has no cancer in it, we know that it’s not necessary to remove any other glands from under the arm, which decreases the development of lymphoedema (a chronically swollen arm). If the gland is positive, we may decide to start with chemotherapy instead of surgery, which can often clear the cancer from the glands. 

We also know that patients with any glands affected will require radiation, which has an influence on the type of reconstruction and so on. 

As you can see, the information contained in one tiny gland can have a huge effect on surgery and further treatment.

Your mind: your best (breast) friend and worst enemy

Last, but not least – the emotional and practical difficulties around breast cancer surgery should not be underestimated. Have you had enough time to calmly consider your surgical and reconstructive options? Make sure you ask your team all the questions that have been weighing on you, and make sure you are satisfied with the answers. Have you had time to discuss your diagnosis with your family, and to make peace with it yourself? Have you planned for assistance after your surgery (who will look after your children, manage the household chores, etc.)? Is the financial aspect of the surgery and treatment all sorted out? 

Taking the time to sort through these issues (sometimes with the help of a qualified professional) will help you to tackle the treatment journey in the best possible frame of mind.

Prof Carol-Ann Benn heads up internationally accredited, multi-disciplinary breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

MEET OUR EXPERT – Prof Carol-Ann Benn

Prof Carol-Ann Benn heads up breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established Breast Health Foundation.

Dr Lucienne van Schalkwyk is a general surgeon with a special interest in breast surgery. Her practice manages the entire spectrum of benign and malignant breast disease, and her specific interests include breast conserving surgery and oncoplastic surgical techniques.

MEET OUR EXPERT – Dr Lucienne van Schalkwyk

Dr Lucienne van Schalkwyk is a general surgeon with a special interest in breast surgery. Her practice manages the entire spectrum of benign and malignant breast disease, and her specific interests include breast conserving surgery and oncoplastic surgical techniques.

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