New approach reduces disfigurement from breast cancer surgery

New approach reduces disfigurement from breast cancer surgery

February 19th, 2017 by Steve Johnson in Local Regional News

POLL: Have you or someone you know had breast cancer?


› One in eight women in the United States will be diagnosed with breast cancer in her lifetime.

› Breast cancer is the most commonly diagnosed cancer in women.

› Breast cancer is the second leading cause of cancer death among women.

› Each year, it is estimated that more than 246,660 women in the United States will be diagnosed with breast cancer and more than 40,000 will die.

› Although breast cancer in men is rare, an estimated 2,600 men will be diagnosed with breast cancer and approximately 440 will die each year.

› On average, every two minutes, a woman is diagnosed with breast cancer and one woman will die of breast cancer every 13 minutes.

› More than 2.8 million breast cancer survivors are alive in the United States today.

Source: National Breast Cancer Foundation

Lisa Carlile has spent most of her professional life around women with breast cancer, but the news she got last May was still upsetting.

A mammogram had detected a tiny cancer. Now she had to make the decision she had watched so many other women make over 20-plus years she has prepared ultrasound and other breast images doctors use to determine if a woman has a tumor.

"Any kind of cancer diagnosis is devastating," Carlile said in an interview at CHI Memorial's MaryEllen Locher Breast Center, where she works.

But what to do about it? On the one hand, she wanted to be certain that the cancer was removed. But she also didn't want an operation that left her disfigured.

"We're a body-conscious society," she said. "You wonder, 'How am I going to feel about myself? How does my spouse feel?'"

But Carlile had an advantage. She works with Dr. Betsy Washburn, a breast cancer surgeon, and Dr. Mark Brzezienski, a plastic surgeon who does reconstructive surgery.

She opted for a bilateral mastectomy — removing both breasts — but with surgery to reconstruct her breasts at the same time.

Because her doctors went out of their way to keep the damage from the surgery to the minimum, she was left with only a small scar.

"I could not ask for a better result," she said, "because my scars are not visible, and that helps in the healing of emotional scars."

For decades, women who successfully battled breast cancer often were left disfigured, with most of their breasts cut off in an effort to remove any trace of a tumor. The idea was "you have to cut out as much as possible, they took the lymph nodes, all of the chest muscles," Washburn said.

"In the '70s, the attitude was 'women don't care, they just want to be cancer free,'" she said. "No, they care — we all care."

The scars were often deep, both physical and emotional, with some women dreading the probable surgical outcome almost as much as the possibility of dying from cancer.

But new surgical techniques, and improvements in reconstruction, have made those horror stories a thing of the past.

Now, "for the right woman, she could comfortably walk down the beach in a bikini, it is so much different than it was in the '70s and '80s," Brzezienski said. "I like to tell women, 'I defy anyone to recognize that you have had a bilateral mastectomy."

The first big improvement was lumpectomy, where instead of removing the entire breast, the surgeon tried to cut out only the cancerous tumor. But doctors didn't often know exactly what they would find inside the breast once they made an incision.

"When I started practice, women who had a lump would go into surgery, the surgeon would remove part of the lump, a pathologist would determine if it was cancer, and if it was, the woman would have a mastectomy," said Dr. Laura Witherspoon, a veteran breast cancer surgeon who primarily operates at Erlanger hospital. "She would go to sleep not knowing whether she would wake up with the breast."

But improvements in imaging now allow surgeons to see inside the breast and determine the size and location of the tumor in advance of the operation.

"We have a better ability to plan what we are going to do ahead of time," Witherspoon said.

New equipment and techniques allow surgeons to make an incision at the bottom of the breast, much as they would for breast enhancement surgery, and remove the tumor.

And surgeons are more aware that minimizing the damage to a woman's appearance can be important for treating her cancer.

"With a lot of cancer, you have a cure, you are physically not disfigured, and you can move past it into survivor mode," Washburn said. "With breast cancer, you can't get into survivor mode when every time you look at yourself, you are reminded that you have breast cancer. If we can get women past the image part of things, it is easier to get them into survivor mode."

Reconstruction techniques have improved, making the process much less onerous.

"In the past, you needed muscle from the abdomen and it was an eight-hour operation," Witherspoon said. "The patient had to go donate blood ahead of time, because there was so much blood loss that they needed blood transfusions. Now most of reconstruction is done with tissue expanders and implants, and recovery is quick — patients rarely need to spend more than one night in the hospital."

The minimally invasive surgery doesn't work for everyone. It is generally for patients with stage 1 or stage 2 cancer where the disease is still confined to the breasts or has spread only minimally to the lymph nodes.

Witherspoon said she herself was not a candidate for the minimally invasive surgery when she discovered she had breast cancer two years ago. Her cancer was showing up in several spots in her breasts, so more of the tissue needed to be removed. Her longtime friend Brzezienski was her plastic surgeon.

One group in particular benefiting from the less destructive techniques are women who do not have breast cancer, but who have a strong genetic predisposition to the disease, a situation highlighted by actress Angelina Jolie's decision based on her family history of breast cancer.

Jolie learned that she, too, was likely to have the disease, based on genetic testing, so she decided to have a double mastectomy to avoid the risk of getting cancer later.

Only a small percentage of all women have the most well-known genetic variation, less than 5 percent of breast cancer patients, but among them, more than 50 percent are likely to get the disease, and a significant number are also at risk for ovarian cancer.

"I find many young patients who have finished child-bearing are ready to reduce that risk the most they can," Washburn said. "We can reduce it to 1 percent with good surgery."

While a preventive mastectomy may seem drastic, the alternative has risks.

"We cannot guarantee them that we will catch their cancer early, even if we are watching them like a hawk," Witherspoon said. "And once they have it, there is the risk of it spreading or coming back."

Having a procedure that leaves minimal scarring is a big step forward.

"Now that women know these things are options, they realize that having breast cancer doesn't mean they have to be disfigured," Washburn said. "When they step out of the shower and look in the mirror, they can be happy with the cosmetic results."

Cancer survivor Carlile is convinced.

"You hear all of the horror stories, and I have seen those over the years," she said. "But I would imagine if we were in the same fitting room together, you would not be able to tell. I am extremely pleased."