During much of the 20th century, a diagnosis of advanced breast cancer meant extensive, physically debilitating surgery that removed the entire breast tissue as well as the underlying muscle and nearby lymph nodes.
Advances in the knowledge of breast cancer and innovations in therapy and surgery over the past 40 years have drastically reduced the number of radical mastectomies performed in the U.S., however, and today there are a variety of procedures and treatments that can be applied to breast cancer patients, leading to increased survival rates.
In this episode of Kentucky Health, host Dr. Wayne Tuckson speaks with a Louisville surgical oncologist to learn about the methods of diagnosing and treating breast cancer, as well as several other conditions that cause masses in the breast. Several slides depicting breast surgery, including one showing a radical mastectomy, are displayed during this program.
Dr. Nicolas Ajkay, M.D., is a surgical oncologist with University of Louisville Physicians and is affiliated with Norton Hospital and Jewish Hospital in Louisville.
“Breast cancer is the most common cancer in women,” Ajkay says. “One in eight women will develop breast cancer in her lifetime, so it is a very common concern.” Recent debates about how often a person should be screened for breast cancer, and about the most effective therapies, have kept breast cancer in the headlines as knowledge about the disease continues to evolve.
Rethinking Breast Cancer Screening
Ajkay says that traditionally, women were advised to begin getting a routine, annual mammogram starting at age 40. But in recent years there has been some dispute within the oncology field about whether the tests are revealing too many false positives. Ajkay says that now, some organizations are recommending women who have never had any problems with their breasts, and have no family history of the disease, to start getting mammograms at age 50, and to get them less frequently.
Another current conflict involves genetic testing for breast cancer, Ajkay says. About 10 percent of breast cancers have a hereditary component, he explains. There are specific genetic tumor markers that indicate an increased risk for both breast and ovarian cancers, and according to Ajkay, ovarian cancer is the main associated cancer that, if present in first-degree relatives, leads to a higher chance of a person developing breast cancer. “If a patient has breast cancer or has a family member with breast or ovarian cancer, they should be tested,” he says.
For women who find a suspicious mass or lump in their breast, no matter their age, Ajkay recommends scheduling a visit with their primary care physician. After examining the breast, the primary care physician will order a diagnostic mammogram, which is different than a routine screening mammogram. “That diagnostic mammogram usually comes with an ultrasound,” he says. “And at the end of that process, the radiology doctor will come out and tell you what was found.”
Once the suspicious area is isolated, diagnosis is done by inserting a needle into the breast, drawing some tissue, and then doing a biopsy. The radiologist and oncologist can then determine the type of cancer, the staging (whether and how far it has spread), and the preferred treatment.
“Breast cancers are a group of diseases that are stimulated by different elements,” Ajkay says. “Eighty percent of cancers are stimulated by estrogen, the female hormone. So if you understand that estrogen is stimulating the breast, targeting that stimulation is a great treatment.” Two other receptors also fuel breast cancer in women, Ajkay says: progesterone and growth hormone.
“Triple negative cancers are those cancers where we have not been able to identify a particular target,” he adds “They are not stimulated by estrogen, they are not stimulated by progesterone, and they are not stimulated by growth hormones. So those cancers are slightly more likely to come back and are a little bit more aggressive, but they do benefit from chemotherapy.”
Innovations in Surgical Techniques
Dr. Ajkay presents series of slides showing the evolution of surgical procedures for breast cancer. The radical mastectomy, commonly performed in the early and mid-20th century, removed the entire breast, the pectoral muscle, and the surrounding lymph nodes. It was a traumatic surgery that left patients unable to fully move their affected arm. Over time, research studies showed that performing radical mastectomies did not improve survival rates for patients with breast cancer.
“Patients continued to die, despite this very radical operation, with a lot of problems afterwards, making surgeons question whether these extensive operations were required,” Ajkay says. “And today, we know that this extensive operation is not necessary, so we don’t do it anymore.”
Today, surgeons have more options that spare much of the anatomy previously affected by a radical mastectomy. These include: a modified radical mastectomy, where the breast is removed but the muscle is left intact and the lymph nodes are spared if the cancer has not spread to them; a skin- or nipple-sparing mastectomy, which almost always is followed by breast reconstruction via plastic surgery; or a lumpectomy, which removes the specific lump or mass as well as a small amount of surrounding healthy tissue, and is usually accompanied by radiation of the entire breast.
A series of studies beginning in the 1970s followed patients who had mastectomies and ones who had lumpectomies, Ajkay says. Researchers tracked patients for up to 20 years and found no difference in survival rates among those who underwent a mastectomy or a lumpectomy.
“So essentially, having a mastectomy does not allow people to live longer,” he says. “What is allowing people to live longer is the right operation with removal of the cancer, radiation when it’s indicated, chemotherapy, medication through the vein to fight cancer when it’s indicated, and also hormone blockers, pills that block the effect of estrogen in cancers, that decrease the chances of the cancer coming back.”
Other Causes of Breast Problems
Ajkay also presents slides that depict other medical conditions that can cause a breast mass, breast pain or soreness, or nipple discharge. He points out that the majority of breast masses or lumps are benign, but says “a clearly separate lump in the breast that you can feel, that should raise attention” and be checked out by a primary care doctor.
Breast infections and nipple discharge are two common problems, Ajkay says. Most often, breast infections happen when a woman is lactating. Nipple discharge can be due to excessive lactation but can also happen due to a papilloma wart that blocks a milk duct in the breast. The latter produces a clear discharge and will require a visit to a breast specialist.
Other conditions Ajkay discusses are: chronic subareolar abscesses, small infected lumps in the areola surrounding the nipple that occur more often in women who smoke; and fibroadenomas, small, noncancerous tumors that occur most often in younger women. Fibroadenomas may be monitored and removed only if they cause pain or are growing.
