Overview: Breast CancerSurgical Treatment
Ms S Tormey
Consultant Breast Surgeon
MWRH Dooradoyle Limerick
Slainte an Chlair Meeting, Ennis
June 2011
Statistics

1 in 9 women

Rising incidence

2010 > 2,500 cancers diagnosed in Ireland

Outcome from breast cancer has improved
HISTORICAL PERSPECTIVE
Ancient Eygptians 3,500
 Hippocrates 460 BC- humoral disease

Breast Cancer considered systemicsurgery did not cure because this was a
disease involving the entire body
 (Humoral Theory)

Move to Localised Theory

17th CenturyLocalised disease
potentially curable
with surgery

19th CenturyHalstead-Era of
Radical Mastectomy
Anatomy

Halstedian theory

Cancer spread
anatomically

Breast- Lymphatics/
direct invasion of
surrounding tissues
Oncology Development

1895 Beatsonoopherectomy

1896 Emile Grubbradiotherapy

Chemotherapy- 20th
century
Influential Clinical Trials
NSABP
 Milan

Breast Conservation and radiotherapy
 Chemotherapy development and trials

Modern Surgical Practice

Less invasive surgery

More attention to cosmetic outcomes

Improved prognosis
Oncological Approach
Combining treatments:
 Surgery/Chemotherapy/Radiotherapy/Biol
ogical treatments


Multidisciplinary

“Tailored” approach
Breast Cancer Services in
Ireland
Specialist Cancer Centres



Population of 250,000-300,000 per
centre
100 -150 new cancers p.a. per centre
High volume of cancer cases leads to
experienced personnel
National Quality Assurance Standards for
Symptomatic Breast Disease Services
(Ireland 2000)
National Cancer Control
Programme

Established 2006

Cancer Strategy
8 Cancer Centres
West: GUH and Limerick
South:CUH and Waterford
East:Mater/Vincents,
Beaumont and James’

Minimally invasive surgery

1970 Breast
conservation

1990’s Sentinel node
biopsy
Breast Conservation/Oncoplastic
Surgery



.
Volume reduction
Scars
Symmetry
Oncoplastic/Reconstructive
Surgery

In past decade- evolving speciality

Preservation of the breast with a cosmetic
appearance, after oncological resection
(oncoplastic resection)

or reconstruction after mastectomy- either
immediate or delayed
Neoadjuvant Chemotherapy
Pre-op Chemotherapy
Negative Margins Negative Margins
Positive Margins
Reconstruction

Skin sparing
immediate

Nipple sparingimmediate
Who?
Multidiciplinary discussion
Factors influencing:
Breast size
Tumour size
Pathology
Age
Prerequisite before decisions:
Triple assessment and diagnosis
Triple Assessment

Triple assessment- gold standard

Clinical, Radiology, Pathology
Clinical Assessment

History and Examination

Clinical diagnosis
Accuracy- clinical breast examination is
reported to have sensitivity of 68-80%
Radiological Assessment

Mammography

Ultrasound- focal palpable area on clinical
assessment/focal area of pain
Mammography

Standard screening
tool for breast

Sensitivity increases
with age

Overall sensitivity
75%, but 54-58% <
40years, and 8194%> 65 yrs
YOUNG
WOMAN
POST
MENOPAUSAL
WOMAN
Ultrasound

Used to evaluate
focal areas in breastpalpable
lumps/painful areas,
or an area seen on
mammography

Low sensitivity and
specificity when used
for screening
Ultrasound Guided core biopsy

Increases accuracy

Current standard for
performing breast
biopsy in lesions
graded U3 or above
Same Day Service
TAC visit takes 2-3 hours to complete
 Results from imaging available at the end
of the visit
 Re visit the primary clinician for results


Second visit necessary for biopsy results
Multidisciplinary Meeting

Consists of symptomatic breast unit core personnel ie
surgeons, radiologist, pathologist, medical oncologist,
radiation oncologist, breast care nurses, radiographers

Held weekly

All imaging, and clinical assessment re visited, and
biopsy results
Consensual decision re outcome
All surgically excised breast cancer discussed- decisions
son treatment


Summary

Last 25 years- many large trials have led
to better outcomes

Current research- focus on understanding
cancer genes and cancer cell growth to
achieve potentially more targeted
“individualised” treatment