When 32 year old, a HR consultant in an MNC, walked into my clinic, accompanied by her husband and parents, I could sense an air of hopelessness surrounding this good looking young lady. The papers that were laid in front of me carried a needle biopsy report, which confirmed the diagnosis of breast cancer. Fortunately, for her, the size of the lump was about 2cms and there were no lymph nodes that I could feel in the armpit. There was no evidence of spread to the other organs on imaging. She had come to me for a second opinion and I soon found out why. She had been advised a modified radical mastectomy (complete removal of the breast along with the lymph nodes in the armpit) and she wanted to know if she could keep her breast without compromising outcome. She was a successful career woman with everything going for her till yesterday and today she was grappling with this tough predicament- of losing an organ, an integral part of her femininity to cancer- it was almost cruel!.......... And there was really no choice then because the doctors treating her were also convinced that sacrificing the breast was the only chance of getting well.
The treatment of breast cancer has undergone significant evolution and this shows how outcomes have changed dramatically for the better. While curing the disease is a priority, maintaining quality of life is as important. The journey that has been covered before us is no less fascinating and the constant endeavor to make it better for the patient has driven the change.
Do you know that in the 20th century, mutilating surgeries in the form of amputation of the breast and then radical mastectomy (removal of the breast, muscles of the chest and the lymph nodes in the armpit) or the extended radical mastectomy(same as radical mastectomy but with the additional removal of lymph nodes inside the chest) remained in vogue for a larger part of the 20th century.
However, in the 1960s, the conviction that breast cancer was a systemic disease and not a local disease, prompted trials to address one question- ‘Are we doing too much? Radical mastectomy was replaced by modified radical mastectomy-“A procedure not as mutilating as radical mastectomy but still involved loss of an organ”. But, to a woman it meant much more than the loss of an organ as it entailed a psychological blow besides casting a shadow on her femininity.
Some smart minds in the medical field started questioning the necessity of performing such radical surgeries to get optimum results. There were trials conducted to compare mastectomy and breast conservation surgery in the 1970s. The conclusions were if breast conservation surgery (removal of the lump with a surrounding 1 cm margin of normal breast tissue) was followed by radiation therapy to the rest of the breast in selected patients, it required complete removal of breast. Finally, women with breast cancer had a choice.
With improvements in chemotherapy, radiation therapy, hormonal treatment and targeted therapy, breast conservation therapy has become a sole treatment choice in selected patients. While it is possible to conserve the breast in early stages of breast cancer, it is also possible to offer this treatment in patients with locally advanced breast cancer, where chemotherapy is administered first to shrink the tumor. If the tumor shrinks towards the centre and is marked while the patient is on chemotherapy, it may be possible to conserve the breast when surgery is performed after completion of chemotherapy.
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………..And that brings us back to the 32year old. An MR mammogram was done keeping in view her age and dense breasts. The MR mammogram showed a solitary 2cm lump in upper half of the breast with no significant lymph nodes in the armpit. With this newfound information, I offered her breast conservation surgery with oncoplasty (surgical technique to restore shape to the breast) and sentinel lymph node biopsy (few nodes in the armpit sampled instead of all nodes ). Her joy knew no bounds and she opted to go ahead with breast conservation surgery. The surgery went off well and fortunately for her, the sentinel node biopsy came back as negative for spread. She did not require all the nodes in the armpit to be removed with its attendant 20% risk of developing arm swelling. Her risk of arm swelling is probably less than 5% now. She was discharged the next day, without any tubes coming out of her body. She was complete in a sense………….and there was really no way to tell she had undergone surgery for breast cancer!