As a woman, a pair of well-developed breasts represents the health and beauty of a woman and is the pride of every woman. However, for women who have unfortunately suffered from breast cancer and had to undergo mastectomy, their breasts are an unbearable pain in their hearts. In the past 10 years, the annual growth rate of breast cancer in China is 3% to 4%, which is higher than the global growth rate, and there are about 200,000 new cases every year nationwide.
After mastectomy, breast cancer patients are mostly missing their feminine features, and the resulting mental trauma is not less than the pain caused by cancer cells. Especially some young women lose their breasts early, even though their survival is prolonged, the psychological depression and marital crisis often lead to a serious decline in their quality of life, making it difficult to live a happy life or even worse than death.
The quality of survival, especially the psychological health of breast cancer patients, has increasingly attracted the attention of scholars. In order to improve the survival quality of patients, the current focus of medical development of breast cancer is to remove the tumor while preserving the breast as much as possible, and now breast-conserving treatment for breast cancer in developed countries has reached 50%~80% of all cases. However, in China, only 10% of breast cancer patients have undergone breast-conserving surgery, while the other 90% still choose the traditional one-size-fits-all model because of doctors’ or patients’ own concerns.
For modern women, the function of the breast is not limited to breastfeeding, but is an important part of maintaining a woman’s shape and confidence. As a result, the World Health Organization has designated October as International Breast Awareness Month, marked by the pink ribbon, to raise awareness of breast cancer among women.
We would like to remind women to take care of their breasts when they are healthy, but it is not advisable to sacrifice them easily to save their lives in case of breast cancer. Modern medicine has entered the era of breast conservation, which is able to extend the survival time of tumor patients while preserving the breast, thus improving the quality of life.
Breast cancer enters the era of breast conservation
In the past, both the classical surgery for breast cancer treatment, as well as the extended radical surgery and modified radical surgery, treated breast cancer at the heavy cost of removing the breast. The long and ugly scars will be left on women’s chests after surgery, and this eternal wound makes many female patients feel the loss of dignity and self-confidence of being a woman, and some of them even feel ashamed to see others.
In addition, extensive mastectomy and axillary lymph node dissection inevitably bring more surgical complications, the common ones being: postoperative scar tissue formation, which limits the range of upper limb movement; impaired lymphatic return circulation in the upper limbs, leading to upper limb swelling; and postoperative subcutaneous fluid accumulation or skin necrosis due to long surgical incisions and extensive subcutaneous freeing. However, the bad thing is that many experts found that not only the postoperative survival rate of patients did not improve significantly with the expansion of surgery, but also the quality of survival seriously decreased.
After six or seven decades of clinical research around the world, foreign scientists began to realize that breast cancer is a systemic disease, and expanding the scope of excision cannot cure the tumor; instead, over-treatment brings the patient possible physical damage and property loss. The correct approach should be moderate surgery, together with standardized radiotherapy and Chinese medicine, as well as other effective treatment methods, to carry out a multidisciplinary and comprehensive treatment, which can prolong the survival time and improve the quality of life of tumor patients.
In fact, foreign scholars began to conduct research on breast preservation in breast cancer as early as the early 1970s. After more than a decade, the initial conclusion in favor of breast conservation was reached. The results of six prospective randomized controlled studies conducted in several countries in the United States and Europe later confirmed that breast-conserving surgery is less invasive and less painful, and it preserves the integrity of breast shape while taking into account the functional recovery after surgery, and the survival rates after breast-conserving treatment for early-stage breast cancer and traditional surgery are basically the same.
Breast-conserving surgery creates a better quality of life for breast cancer patients, greatly reduces the psychological trauma of breast cancer patients, and enables them to face society and integrate into life with ease after recovery, which is conducive to improving the quality of life of patients.
In other words, breast-conserving surgery is not a sacrifice of life for beauty, and breast-conserving treatment is generally available as long as it is detected early and the conditions are suitable. Breast-conserving surgery has become a new option for patients with early and locally advanced breast cancer, and will become a scientific, standardized and more desirable treatment option for breast cancer.
Breast-conserving surgery in China is more than 80%
Breast-conserving treatment is not yet popular in China, and the percentage of breast-conserving surgery in large specialized hospitals is less than 20%, while that in large general hospitals is generally less than 5%. The vast majority of breast cancer patients are still treated by radical mastectomy. There are several reasons for this.
First of all, even surgeons in our country are not aware of the early detection and treatment of breast cancer, and they think that if they cannot feel the lump, it is fine. In fact, early breast cancer with a diameter of less than 1 cm is often not palpable and must be detected with the help of mammography or ultrasound. This results in some patients delaying early treatment.
In addition, most women do not know much about early detection and treatment of breast cancer, and many patients are too shy to talk about it when they find a suspicious lump in their breast, and only come to the doctor at the urging of their family members when the lump is very large or long after it is found, which is often at an advanced stage. In rural areas, the situation may be even worse. Therefore, there are many breast cancer patients in the middle and late stages, when they mostly need radical surgery.
Secondly, it has to do with doctors’ perception. Most doctors are not yet aware of the new concepts and technologies of breast cancer treatment such as breast-conserving treatment, and are accustomed to the traditional radical surgery. For example, there are still some misconceptions about breast cancer surgery, and it is generally believed that the bigger the surgery, the more complete the treatment effect, while breast-conserving surgery is not removing the whole breast tissue, and the treatment effect must not be as complete as breast-cutting surgery.
As a matter of fact, a standardized breast-conserving surgery can achieve the same long-term survival of 15-20 years as the traditional breast-cutting surgery. There are also many doctors who are afraid of the high recurrence rate of the tumor and think that if they do breast-conserving surgery and plastic breast augmentation, it will be more troublesome to deal with the recurrence, so they will just cut it off.
There are also reasons from patients’ side, such as low awareness of breast-conserving treatment, and many patients think that the bigger the surgery, the more thorough it is and the more curable it is. Many patients also believe that the larger the surgery, the more complete and curative it is. They are not confident about breast-conserving surgery and worry that the tumor will not be cleaned up if it is not completely removed. In our work, we often encounter patients who have just been diagnosed with breast cancer, with frightened and doubtful expressions, begging the surgeon to perform the surgery as soon as possible, and asking for all the breasts to be cut off, the bigger the surgery the better. Some patients may want to save their breasts, but after consultation, they may change their mind and ask for radical surgery.
Even if there is no lymph node metastasis in breast cancer patients, after radical surgery, 5% of patients still have local recurrence and 30% of patients die from breast cancer within 10 years. Therefore, radical treatment is relative and the current radical surgery is not literally radical. Therefore, whether breast cancer is radical or not does not depend on the surgical method, but on the early or late stage of the disease and the effectiveness and adequacy of systemic treatment.
In addition, the incidence of upper limb edema and dysfunction is much higher when comparing radical surgery with breast-conserving surgery, so it is obviously unwise to lose one breast unnecessarily without getting a curative effect.
It is worth reminding that in China, on the one hand, there is a lack of understanding and promotion of new concepts and technologies of breast-conserving treatment; on the other hand, some hospitals do not have a strict grasp of the indications for breast-conserving treatment and do not have the conditions for breast-conserving treatment, or even carry out breast-conserving treatment blindly without even the necessary examination and diagnosis, which may seriously damage the interests of patients. Therefore, if you have breast cancer, you must seek treatment from a breast cancer specialist in order to get a truly standardized and reasonable scientific diagnosis and treatment.
The earlier the breast-conserving treatment, the better the result
Breast-conserving surgery is as effective as radical surgery, but can all breast cancer patients undergo breast-conserving surgery? No, first of all, the earlier the treatment, the better the result. Generally speaking, the indications for breast-conserving surgery include
Tumor size There is no uniform definition at home and abroad. Most researchers believe that if the tumor size is 3~5 cm and the patient subjectively wants breast-conserving surgery, neoadjuvant chemotherapy should be administered before surgery, and breast-conserving surgery should be performed after the tumor shrinks to meet the indication of breast-conserving surgery.
Tumor location Most researchers believe that breast-conserving surgery should be performed for “peripheral” breast cancer with tumors 2-3 cm or more from the areola.
Axillary lymph node metastasis Most investigators believe that axillary lymph node metastasis is not a contraindication to breast-conserving surgery and that early cases with single, active lymph nodes ≤2 cm in diameter should be selected.
Breast-conserving surgery requires a single focal breast cancer. Multifocal and multicentric breast cancer is a contraindication to breast-conserving surgery.
In addition, the availability of radiotherapy is a necessary condition for breast-conserving surgery. Therefore, breast cancer patients with combined collagen vascular diseases such as scleroderma and active lupus erythematosus are contraindicated for breast-conserving surgery because they cannot tolerate radiotherapy.
Regular breast examination is the only effective way to detect breast cancer at an early stage, and women over 45 years of age in the United States have an annual breast examination. In China, breast cancer is usually detected late, so it is necessary to raise the awareness of regular breast cancer examination to detect breast cancer as early as possible.
Nowadays, the early diagnosis technology of breast cancer is developing rapidly, and some advanced technology such as digital mammography can detect tumor at an early stage, even when the lump cannot be touched. It is recommended that people with family history of breast cancer, high-fat diet, endocrine and reproductive system history, late marriage, late childbearing and no breastfeeding, etc. should strengthen their screening efforts.
Neoadjuvant chemotherapy helps breast conservation
The number of breast-conserving surgery reflects the level of medical treatment and the progress of social civilization. However, not every breast cancer patient is suitable for breast-conserving surgery. Due to the size of the tumor and other reasons, some patients cannot realize the desire of breast preservation.
The traditional treatment model for breast cancer is to apply chemotherapy (chemotherapy for short), also known as adjuvant chemotherapy, after surgery. In contrast, we now start chemotherapy, known as neoadjuvant chemotherapy, before surgery. It is now widely believed that tumor cells can enter the circulatory system and trigger hematogenous metastasis in the early stage of breast cancer, and it is possible that hematogenous metastasis occurs earlier than lymphatic metastasis. It is therefore reasonable to assume that some breast cancer patients have micrometastatic lesions before the start of treatment, and that these lesions are the source of recurrent metastases later.
Some studies have shown that preoperative chemotherapy targeting these lesions can significantly improve the overall outcome of breast cancer patients. More importantly, neoadjuvant chemotherapy can significantly reduce the number of total mastectomies performed and increase the rate of breast conservation. This advantage is even more evident in cases with tumor diameter ≥5 cm. According to overseas statistics, approximately 23% of patients receiving neoadjuvant chemotherapy were spared from planned total mastectomy due to tumor “downgrading”.
Studies have also shown that surgical removal of the primary lesion may stimulate accelerated growth of micrometastases prior to effective systemic therapy, and that preoperative chemotherapy can prevent and inhibit this.
Comprehensive postoperative treatment is essential
After a patient undergoes breast-conserving surgery, he or she has only taken the first step in treatment. The comprehensive treatment after breast-conserving surgery (i.e., local radiotherapy and systemic chemotherapy, endocrine therapy, gene therapy, and immune adjuvant therapy) should still be given high priority because it is a strong guarantee of the efficacy of breast-conserving surgery. For example, radiotherapy after breast-conserving surgery has become an important part of comprehensive breast-conserving treatment.
Generally, radiotherapy can be started 1 week after stitches are removed from the incision, and no later than 6 weeks after surgery. Postoperative systemic adjuvant therapy (e.g., chemotherapy, endocrine therapy, and biologic targeted therapy) can further reduce the local recurrence rate. The specific measures depend on the surgical approach and pathological findings and are tailored to each patient’s specific condition.
After surgery, patients should also check their breasts regularly (usually once every three months), pay attention to whether there are new nodes around the incision and the whole breast, and pay attention to lung, liver, bone, etc., which are prone to metastasis, and perform mammography, ultrasound, whole-body bone scan, etc., if necessary, in order to detect recurrence or metastasis early and take corresponding treatment measures in time.
Breast-conserving surgery is a major development in the treatment of breast cancer, a change in the concept of treatment, and can be said to be a new leap in the history of breast surgery. However, to ensure the success of the surgery, in addition to strict control of the indications for the surgery, the operating hospital must have the relevant equipment and technology for breast-conserving surgery. In addition, breast-conserving surgery should be performed with full patient understanding and guaranteed postoperative follow-up, otherwise the surgical outcome will be affected.