By 80 years of age one in eight women will be diagnosed with breast cancer. Because of such high incidence it is not uncommon to have a family member or close friend who has been afflicted with the disease. For those recently diagnosed, currently receiving treatment, or continuing life after breast cancer, the impact could not be more direct. Breast reconstruction usually requires two to three operations and will take between four to twelve months to complete. Sometimes additional operations are required years after the original reconstruction. During the interval between breast reconstructive operations the patient may have breast asymmetry.
What is Breast Cancer?
Cancer is when a group of cells in the body grows out of control to form lumps of tissue called tumors or masses. In the breast, most of these tumors are harmless or benign. However, there are some tumors which are malignant or cancerous. A cancerous tumor not only grows in size to become palpable, it will eventually invade into the normal breast tissue and travel to the lymph nodes. Once it reaches the lymph nodes, it will further travel to other parts of the body such as the brain and lungs to cause problems with normal function.
Breast cancer imposes a direct impact on a woman’s life. Therefore early detection, routine screening exams, and prompt treatment are all necessary for best outcome.
Breasts come in a variety of sizes and shapes. Reconstructive options will vary depending on a patient’s anatomy and clinical circumstances.
The Cause of Breast Cancer
Unfortunately, there is not one single cause of breast cancer. Most cases occur sporadically, meaning at random. There have been many scientific studies comparing a large number women with and without breast cancer that have tried to identify common denominators. The vast majority of cases result of a combination of the following identified risk factors :
- Female gender, increasing age
- Obesity, sedentary lifestyle
- Older age at birth of first child
- Long exposure to estrogen (early menses and late menopause)
- Both alcohol and tobacco
Additionally, there are a few forms of hereditary cancer:
- Uncommon genetic cancer predispositions:
- BRCA1 and BRCA2 ( Tumor suppressor genes)
- Li-Fraumeni syndrome (p53 gene)
- Cowden’s disease (PTEN gene)
- Muir syndrome (MSH2 and MLH1)
BRCA is in a class of genes in our DNA known as a tumor suppressor gene. Commonly tested genes for breast cancer include BRCA1 and BRCA2. Mutations in these genes are associated with increased rates of hereditary ovarian and breast cancer. Other genetic forms of breast cancer include ATM gene, p53, CHEK2, CDH1, and PTEN but these are more rare and less tested for.
Men and Women who carry these genes are at high risk of developing breast cancer. With a strong family history of breast or ovarian cancer a person may consider genetic counseling to determine if gene testing should be performed. Genetic testing for BRCA1 and BRCA2 is often performed by obtaining a blood sample.
It is believed that 50% to 85% of women who carry BRCA1 will develop breast cancer during their life. With such a high risk for developing cancer the implications for those who test positive are great. While the risk for developing breast cancer are greatly elevated for those who carry a positive BRCA gene, not every woman who carries this gene mutation will develop breast cancer.
Following testing for genetic susceptibility to breast cancer counseling is performed so a person can better understand their risk and make appropriate treatment decisions.
BRCA gene carriers have several options they may choose following diagnosis. Consultation with medical and surgical oncologist is recommended so appropriate decisions can be made.
For woman know to have the BRCA gene breast screening is recommended by a breast specialist and imaging is often begun by age 25 to 30 with breast ultrasound and MRI. Clinical exams and breast imaging may also be performed more frequently at six month intervals.
Some women may choose to undergo prophylactic mastectomy ( removal of breast tissue) and oophorectomy (removal of ovaries) to minimize there risk of developing cancer.
For women who choose to undergo prophylactic mastectomy breast reconstruction is performed to restore the breast to a natural shape. Breast reconstruction can be performed with either implants or using a person’s own skin and fat obtained from the lower abdomen or hips.
The decision to undergo prophylactic mastectomy is personal and has significant implications. Following mastectomy the breast will never be exactly like what we are born with. The changes and risks associated with mastectomy and reconstruction are weighed against the risk of developing breast cancer.
BRCA and genetic predisposition to developing breast cancer poses a challenging question to women. Women in this circumstance are advised to maintain close surveillance for the development or may consider prophylactic mastectomy.
=Case Example =
Karisa’s mother, grand mother, and great grandmother all had breast cancer diagnosed at a young age as well as her materanl aunts. After counsiling with an oncologist she was told she had a high risk for developing cancer as well at a young age. She decided to proceed with prophylactic mastectomy.
Pre-op / Post-op view of bilateral Prophylactic Mastectomy. Reconstruction with Mastopexy followed by Tissue Expander and implant.
Diagnosis & Treatment
A new diagnosis of breast cancer can come from various events such as noting a mass in the breast, skin changes, or an abnormality on mammogram.
- Self Breast Exam
- Yearly Physical
- Mass, pain, skin change, nipple discharge
- Mammogram or ultrasound
- Incidental finding
“We need to urge women to actually do self exam and maintain regular screening with mammogram and physical exams.” JFC
Patients are often referred by their primary care physician or gynecologist to a general surgeon (also known as an oncologic surgeon) who will perform biopsy of the tumor.
Additional imaging (MRI, Petscan, CT scan) or blood tests may be obtained to direct what type of treatment is required.
Breast Cancer Treatment
- Surgery- removing the tumor
- Chemotherapy- using medicine to eradicate cancer cells
- Radiotherapy- using radiation beams to burn cancer cells
Surgical treatment includes lumpectomy or mastectomy. The term lumpectomy refers to partial removal of the breast (the lump), aiming to remove the entire tumor and a margin of surrounding healthy breast tissue. The term mastectomy refers to total removal of the breast tissue with the tumor contained. The nipple and or part of the underlying muscle may be removed based on the type and location of tumor.
Chemotherapy refers to the use of medications that are injected into the veins or taken orally over a period of time. It is a treatment that aims to kill cancer cells throughout the entire body as the drugs circulate in the bloodstream.
Radiotherapy is a treatment that uses radiation or high-energy x-rays to kill cancer cells. The general area of the tumor as well as possible areas of spread are treated.
The treatment of breast cancer generally includes a combination of surgery, chemotherapy and radiotherapy. Every patient is unique and treatment will depend on tumor size, location, possible spread, and patient medical conditions.
The oncologic surgeon develops and coordinates a treatment plan along with medical and radiation oncologists who direct chemotherapy and radiation respectively. The entire process can be quite complex and requires the expertise of different types of doctors focused on breast health.
Main Treatment Team
Surgical Oncologist/ General Surgeon- Removes the tumor
Medical Oncologist- Chemotherapy
Radiation Oncologist- Radiation Therapy
Primary Care Physician- General Surveillance
Plastic Surgeon- Reconstructs Breast
Breast Radiologist- Monitors mammograms/sonograms
Pathologist- Examines biopsied tissue microscopically
Genetic and Psychiatric Counselors
Diagnosis & Treatment | Anatomy
Normal breast anatomy consists of the skin, subcutaneous tissue, and breast glandular tissue overlying the pectoralis muscle. The breast tissue contains a network of ducts and lobules which converge towards the nipple.
Breast cancer originates from within breast tissue. The tumor is an abnormal growth of cells within the ductal or lobular tissue of the breast.
As breast cancer increases in tumor size the cancer is more likely to spread to surrounding organs and lymph nodes.
Removes a segment of the breast and requires radiation therapy. Selected lymph nodes are also taken to evaluate for spread of cancer.
Removes all breast tissue, nipple, areola, and skin from the breast. In addition to removing breast tissue, lymph nodes from the axilla are usually sampled to evaluate for spread of cancer. For some patients part or all of the nipple may be preserved.
Diagnosis & Treatment | Breast cancer staging
Stage 0 ( in situ cancer) In situ ductal or lobular carcinoma represents early breast cancer that has not become invasive through the breast ducts and lobules.
Stage I Breast cancer with tumor size two centimeters or smaller. The tumor involves surrounding tissue but has not spread beyond breast.
Stage IIA Tumor that has spread to axillary lymph nodes but less than two centimeters.
Stage IIB Tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes, OR tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.
Stage IIIA / Stage IIIB Advanced breast cancer with spread to axilla with adherent lymph nodes or tumors greater than 5 centimeters and lymph node involvement. Spread of tumor to surrounding structures like skin, muscle and chest wall.
Stage IV Distant spread of cancer to other organs of the body including lungs, liver, bones, and brain.
Breast reconstruction is provided by a variety of different procedures. A patient’s reconstructive options will be unique to her medical condition. To learn more about the different procedures, click on the following links:
The Beautiful After Breast Cancer Foundation | USA
Dr. John W. Antonetti is the founder of Clinique Dallas Plastic Surgery, he is also the Board Director and Chapter Manager for the Beautiful After Breast Cancer Foundation | USA (BABC).
The Beautiful ABC Foundation is a global, multi-disciplinary, organization devoted to the reconstruction of a patient’s life following a diagnosis of breast cancer.
We act as a medium through which patients can discover a comprehensive approach to breast cancer and find inspiration that a life of joy, beauty and well-being is possible after treatment.
In addition to providing objective, reliable information to both patients and physicians, we will work toward enhancing the sense of well-being by offering advanced teaching opportunities, lobbying medical, insurance and governmental bodies, investing in scientific research and providing financial aid to deserving individuals.
The Beautiful A.B.C Foundation has no political or religious agenda.
The BABC Foundation believes that the healing process for breast cancer involves the physical, emotional and intellectual reconstruction of a patient and the foundation aims to replace their hope with joy.