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Is a mastectomy required or are there other options for breast cancer?

Breast cancer is a treatable disease and early diagnosis significantly improves the survival rate.  Many women now have the option of preserving their breasts. Two Mediclinic experts explain surgical and non-surgical treatment options.

Breast cancer is the most common cancer in women worldwide, affecting 1.5 million women annually and resulting in more than 500 000 deaths per year, according to the World Health Organization.

Thanks to screening technology, earlier detection and treatment is possible. Until the mid-1980s, mastectomy was the standard treatment for any stage of breast cancer, but attitudes have changed. Now women may have the option to choose between total removal (mastectomy) and breast-conserving surgery (lumpectomy).

This depends on the size of the tumour and other factors, such as whether the cancer has spread, but a lumpectomy followed by radiation treatment is believed to be equally effective compared to a mastectomy.

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Cutting out the risk

A mastectomy is not only a consideration when cancer already exists, but where there is a higher risk of developing cancer in the future. “Risk reduction surgery is a reasonable option only where a risk exists,” says oncology surgeon at Mediclinic Panorama, Dr Etienne Myburgh.

Dr Myburgh explains that there are various categories of risk in terms of a woman developing cancer. Someone who carries one of the high-risk genes (BRCA1 and 2, and P10, etc.) would be in the category with the highest genetic susceptibility for actually developing cancer.

“If I know that someone has a genetic risk for developing cancer, I think it is a reasonable option to look at risk reduction surgery to maintain their quality of life,” says Dr Myburgh.

Non-surgical treatments

Targeted therapy
This is a fairly novel approach that uses a new class of medications that can target certain parts of the cancer cell. “Some women have an excess of a certain protein called HER2 that makes cancer more aggressive”, says Dr Mariza Tunmer, a specialist radiation oncologist at the Wits Donald Gordon Medical Centre in Johannesburg. “Herceptin® (Trastuzumab) is a medication that’s been approved to target this type of breast cancer.” Dr Tunmer adds that there are also other types of targeted therapies.

Radiation therapy
Radiation is commonly used after breast cancer surgery to reduce the risk of recurrence.

Chemotherapy medications (oral or intravenous)
Chemotherapy is often used either before or after surgery to lower the risk of the cancer coming back. Chemotherapy may also treat cells that have spread to other parts of the body, even if these are too small to be visible on tests like X-rays, ultrasounds or scans.

Hormone therapy
Some kinds of breast cancer need certain hormones, like oestrogen, to grow. Hormone therapy blocks the effects of these hormones and reduces the chances of the cancer coming back. Hormone therapy is often also used after surgery, chemotherapy and radiotherapy to lower the risk of recurrence.

Immunotherapy

This is a form of cancer therapy that boosts the body’s immune system in the fight against tumours. According to Dr Tunmer, some of these are already approved for other cancers but are still being tested in breast cancer patients.

What to consider before opting for a lumpectomy

Although a lumpectomy can preserve much of the appearance and sensation of the breast, and recovery is generally easier than a mastectomy, it does have a few downsides:

  • After surgery most patients would have to undergo 3-6 weeks of radiation therapy and there are side effects such as fatigue, loss of appetite and a skin reaction.
  • Radiotherapy may also affect the timing of plastic surgery.
  • There is a risk of additional surgery being required after a lumpectomy – if further tissue needs removal. This can only be established after the lumpectomy as the pathology can take a few weeks to be analysed.
  • If the cancer does recur, then mastectomy is generally the standard treatment as the breast usually cannot tolerate further radiation in the same area.

What to consider before opting for a mastectomy

  • Radiation may still be necessary, depending on the margins at surgery, the tumour size and whether or not lymph nodes were involved.
  • The surgery is more extensive and recovery often takes longer.
  • There are the emotional and psychological aspects of losing an entire breast, and this may affect a woman’s sexuality.
  • Reconstruction means more surgery.

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