The incidence of breast cancer in China has been on the rise in recent years. According to the data published by China Anti-Cancer Association, breast cancer has become the most threatening malignant tumor for women in Shanghai, Beijing, Guangzhou and Tianjin. The incidence of breast cancer in Shanghai is 56.2 per 100,000 population and 45 per 100,000 population in Beijing, with an average annual growth rate of 3%, and after the age of 31, the incidence rate of breast cancer is rising steeply, with the highest incidence rate between the ages of 36 and 60, accounting for 80.51%. The highest incidence rate is between 41-45 years old, followed by 56-60 years old. The main reasons for the increase in the number of early-stage breast cancer patients are probably the changing urban lifestyle, environmental pollution, dietary pollution, psychological stress, and changes in hormone levels caused by internal and external factors. For example, many urban women have not married, given birth or breast-feeding by the older age.
Development trend of breast cancer surgical treatment
1. Total mastectomy is decreasing and breast-conserving treatment is increasing.
2. Regional lymph node dissection is limited to patients with metastatic lymph nodes.
Breast-conserving treatment has become the main treatment method for stage I and II breast cancer. Radical and extended radical mastectomy have become history. Modified radical mastectomy and axillary lymph node dissection is still an important surgical procedure, and breast cancer surgery has entered the era of radical breast-conserving surgery.
Treatment strategies for breast cancer
The treatment goal for early stage breast cancer (stage I/II) is to cure, and surgery is preferred to remove the tumor and the involved lymph nodes. Adjuvant treatment options such as radiotherapy, chemotherapy and endocrine are given according to TNM stage and hormone receptor status, with the aim of killing as many metastatic cancer cells as possible and reducing recurrence after surgery.
2. Locally advanced cancer (stage III) treatment aims to reduce the stage.
3.Advanced breast cancer (stage IV) is an incurable disease. The goal is palliative treatment, controlling the disease, giving treatment to relieve symptoms, ensuring patients have a better quality of life and prolonging survival time as much as possible. Treatment of advanced breast cancer requires systemic therapy: such as chemotherapy and endocrine therapy. Local surgical excision is not emphasized and local treatment is used to relieve symptoms.
Breast-conserving treatment is becoming more and more widely accepted and should be the treatment of choice for early-stage breast cancer, with half of breast cancer cases receiving breast-conserving treatment in Europe and America (about 50% of countries) and about 5% in China. In a few hospitals, it has reached more than 40%.
In 2005, a prospective multicenter study of breast-conserving surgery in China showed that breast-conserving surgery accounted for 9% of all breast cancer cases treated by surgery in the same period, and 19.5% of early-stage breast cancer cases eligible for breast-conserving treatment, which is much lower than that in Europe and the United States. The main reasons are.
1. The traditional aesthetic concept does not have a strong demand for breast conservation.
2. Doctors’ perception of breast conservation has not yet been fundamentally changed.
3, There are not many early cases, and the census is not well done.
4.The lack of radiotherapy equipment and anterior lymph node detection equipment.
5. Insufficient strength of pathology and economic cost.
The key also lies in the concept change of doctors and patients. Some early stage breast cancer patients and their family members think that the only way to cure the disease is to remove the breast, and it is possible that the breast is not cleanly cut, so they would rather have a large cut than breast conservation.
The concept of breast-conserving surgery
In 1990, breastconservation therapy (BCT) was officially recognized as a suitable and desirable method for the treatment of stage I and II breast cancer in the symposium on early breast cancer treatment held by the International Cancer Society. BCT cannot be interpreted as conservative breast treatment or conservative breast surgery according to its literal meaning; its true meaning is to treat stage I and II breast cancer in women by enlarged local excision of the lump and axillary lymph node dissection, followed by radiotherapy and chemotherapy.
Purpose of breast-conserving surgery
Breast-conserving surgery is a comprehensive treatment method based on surgery, radiotherapy and chemotherapy.
The purpose of breast-conserving surgery is twofold.
1. to achieve effective local control of the tumor.
2. The preserved breast should have cosmetic and functional value.
Indications for breast-conserving surgery
The “Clinical Study on Standardized Breast Conserving Treatment for Early Breast Cancer” stipulates that the primary tumor of breast cancer should be ≤3cm in diameter, the axillary lymph nodes should not be invaded, and there should be no distant metastasis. In Europe and the United States, the selection of breast-conserving surgery is wider than that in China, because women in western countries have large breasts and have urgent requirements for breast conservation, so breast-conserving surgery is also performed for tumors ≤5 cm in diameter. In China, it has also been reported that breast-conserving surgery is still feasible for those whose tumor diameter is ≥3cm-≤5cm, after 3~4 cycles of neoadjuvant chemotherapy to reduce the tumor diameter to 3cm or less.
Issues to be considered when choosing breast-conserving surgery cases
1. The distance between the tumor and the nipple is generally set at >2cm; the size of the tumor.
2.Appropriate proportion to the breast.
3.Age 20-60 years old.
4.Patients strongly request breast conservation and have the conditions to receive full treatment and lifelong follow-up.
5.Clinical axillary lymph nodes are negative.
6.Post-operative evaluation of the cosmetic effect of the shape.
Studies in Europe and the United States have shown that breast-conserving surgery is feasible for both invasive ductal carcinoma and invasive lobular carcinoma, and the status of axillary lymph nodes does not affect the development of breast-conserving surgery. China has been cautious about breast-conserving surgery, and most hospitals select patients with solitary, peripheral type of breast cancer ranging from 2-4 cm in diameter (mostly 2-3 cm).
Radiotherapy after breast-conserving surgery
Postoperative radiotherapy is an important treatment step to prevent local recurrence of breast cancer after breast-conserving surgery, and is an indispensable treatment tool in breast-conserving treatment. The timing of postoperative radiotherapy should be started as early as possible, no later than 6 weeks after surgery, otherwise it will affect the local control rate and long-term survival rate.
Chemotherapy and endocrine therapy after breast-conserving surgery
However, for those who are ≤35 years old, have ≥4 lymph node metastases, visible vascular tumor emboli on pathological examination, nuclear grade III, negative ER and PR, positive Her-2/neu, positive histone D, significantly increased S-phase cell count, micro-metastases found in bone marrow, etc., and have several of the above high-risk factors, systemic chemotherapy should be administered first, using a post-breast-conserving chemotherapy first → then The first chemotherapy after breast-conserving surgery should be followed by radiation therapy and then chemotherapy. Most of the chemotherapy regimens use CAF or paclitaxel regimens. If the receptor is positive, endocrine therapy is feasible. TAM drugs can be used for premenopausal patients and aromatase inhibitors can be used for postmenopausal patients.
Follow-up after breast-conserving treatment
The principle of breast-conserving treatment is not to reduce the long-term survival rate and not to increase the local recurrence rate, so the follow-up after treatment is particularly important. In addition to the items routinely examined, special attention should be paid to the local recurrence of the preserved breast. In addition to regular physical examination, mammography and breast ultrasound should be performed regularly, and once local recurrence is detected, simple mastectomy is also feasible. It is easy to see from the four major courses of surgical treatment of breast cancer that the general trend of surgical treatment of breast cancer is to tend to rationalize the scope of surgical resection and to emphasize the multidisciplinary systemic treatment.