Breast is an extremely important secondary sexual characteristic of women, the source of human life and the main symbol of female charm. However, breast cancer is one of the common malignant tumors in women, and the incidence rate of breast cancer in Shanghai was as high as 60.1 per 100,000 in 2007. Breast cancer patients not only have the psychological burden of malignant tumors in general, but also suffer from the psychological shock of losing the breast, which is a very important female sex symbol, sometimes more than the cancer itself. After the removal of breast, some patients often feel that they have lost their femininity and are no longer a complete woman, which may also affect the couple’s life and family harmony to a certain extent.
Breast-cancer-preserving surgery has been gradually developed and perfected in the 1980s, and has now become the preferred procedure for early-stage breast cancer in Europe and the United States, with its advantages of balancing the efficacy of breast cancer and the quality of life of patients. The NSABPB-06 and Milan trial in the United States and Italy both showed no difference in survival between radical surgery and breast-conserving surgery after more than 20 years of follow-up, and many prospective and retrospective studies have supported breast-conserving treatment as the standard of care for stage I and II breast cancer. Breast-conserving treatment in China is still limited to large hospitals and breast specialists in large cities due to the misconceptions of both doctors and patients about breast-conserving treatment, breast characteristics of Asian population and relatively few early clinical cases. At present, breast-conserving treatment is not yet popular in China. Breast-conserving treatment is not yet popular in China, and the treatment protocols are inconsistent and the efficacy varies greatly.
Based on evidence-based medicine, clinical practice and the national conditions of China, I think that breast cancer patients need to answer the following three questions when choosing breast-conserving treatment.
I. Can we preserve the breast?
Indications.
(1) Tumor size: breast tumor length diameter ≤ 3 cm.
(2) Tumor location: the tumor is located in the peripheral quadrant with the edge ≥ 2 cm from the edge of the areola.
(3) Pathological type: invasive breast cancer.
(4) Clinical examination without regional lymph nodes and distant organ metastasis.
(5) Adequate volume of the breast and the ability to maintain the cosmetic result after surgery.
(6) The completion of breast preservation treatment plan, including postoperative radiotherapy, can be guaranteed.
Contraindications.
(1) Multicentric breast cancer or scattered malignant calcified foci.
(2) Previous high-dose radiotherapy to the chest wall.
(3) Collagen vascular disease, active connective tissue disease (e.g. lupus erythematosus).
(4) Breast cancer during pregnancy.
In the United States, the indications for breast-conserving surgery are wider, but in China, the history of breast-conserving treatment is shorter and the selection of cases is more cautious. In the early stage of breast-conserving surgery in Europe and the United States, the size of the tumor was one of the main qualifying factors for breast-conserving surgery, but later the attention was shifted to the ratio of tumor to breast size. The cosmetic effect of breast shape after breast preservation surgery is related to the size of the breast, the size of the tumor, the depth of the tumor and the quadrant in which the tumor is located, and the amount of breast excision is the decisive factor affecting the shape of the preserved breast.
2.Want to keep the breast or not
The patient’s strong desire to preserve the breast is the key to the success of breast preservation surgery and subsequent treatment. The patient and family (especially the spouse) should be fully understood before surgery and the patient’s right to informed consent should be respected. In clinical practice, we often encounter patients with good conditions for breast preservation who are determined to give up breast preservation treatment. In clinical practice, professional women and white-collar workers attach more importance to their image and are more willing to keep their breasts, probably because they are younger, have higher education and a higher sense of self-worth, and pay more attention to physical beauty, which may cause psychological imbalance when their image is damaged.
C. Whether follow-up treatment is possible
Breast cancer treatment requires a multidisciplinary approach, and not a single surgical procedure can solve all problems. Patients with breast-conserving surgery should have undergone post-operative radiotherapy (mandatory), chemotherapy and endocrine therapy according to the recipient’s condition, and post-operative follow-up should be carried out on schedule. If, for any reason, follow-up treatment cannot be guaranteed and additional medical costs cannot be covered, they should be fully informed.
There is no single surgical procedure that is suitable for different types and stages of breast cancer. Therefore, the surgical procedure should be chosen according to the specific stage of the disease, the tumor site, the surgeon’s practice, the condition of adjuvant treatment in the medical unit, and the condition of follow-up. Breast-conserving treatment should be based on the principle of not decreasing the survival rate and not increasing the recurrence rate. In choosing the treatment plan, we should take into account the efficacy and quality of life, and consider the advantages and disadvantages of breast-conserving treatment comprehensively to improve the effect of breast-conserving treatment. Whether the selection of breast-conserving cases is appropriate or not will directly affect the efficacy and the postoperative breast shape, and the indications for breast-conserving surgery should be strictly controlled.