In part two of our Cornerstone Treatments series, we’re looking at what research has shown us about breast cancer surgery, and where it might take us in the not too distance future, with expert insight from Professor Adele Francis, consultant breast surgeon at University Hospital Birmingham.
Surgery is the oldest effective treatment for breast cancer with reports of breast cancer surgery stretching as far back as around the 2nd Century AD.
Fast forward through the innovations of anaesthesia, antisepsis and a modern understanding of cell biology, and surgery remains the cornerstone of breast cancer treatment. Surgery is now also used for breast cancer prevention in women with a high risk of the disease.
However, surgery for breast cancer treatment still is a major undertaking for patients with general anaesthetic, hospital admissions, scars and sometimes complications. So research is needed to improve on how, when, and sometimes why surgery is done.
How is surgery used in the UK today?
Historically, most people with breast cancer had surgery before any other treatment. This is often still the case but increasingly it may be appropriate to have other treatments before surgery. This is known as neo-adjuvant treatment and can be given to shrink the cancer so that there is less cancer to remove with surgery.
During surgery, the cancer is removed from the breast and surgeons also look to see whether lymph nodes (glands) in the armpit contain breast cancer cells.
Breast cancer surgery is either a lumpectomy (also called wide local excision or breast conserving surgery), where only the breast cancer and a small layer, called a margin, of healthy tissue is removed, or a mastectomy, where the whole breast and usually the nipple is removed.
Women who are offered a mastectomy will be able to discuss breast reconstruction, or the option of being fitted for a breast prosthesis (artificial breast) if they are not having reconstruction surgery.
Surgery can also be used to help prevent breast cancer in women at high risk of the disease because of a genetic fault, and for people with secondary breast cancer, surgery can sometimes be used in other organs to relieve pain and other symptoms (e.g. surgery to strengthen bones when cancer has spread there), and to control secondary tumours.
How have we got there?
A lot of the changes to breast surgery that we’ve seen in the era of modern medicine have come from an evidence based move away from the ‘gut feeling’ that ‘more surgery is better’.
For example, the original ‘radical’ mastectomy, popularised in the late 1800s by surgeon William Halsted, involved removing the full breast intact with the skin, adjoining lymph nodes (glands) and the major muscle of the chest. This would leave women disfigured and either in pain or numb and with limited movement.
At a time without radiotherapy or chemotherapy it was deemed the best way to treat breast cancer patients but by the 1960s, surgeons were taking note of the huge impact this operation had on women’s quality of life and began to realise that an evidence based approach was required. Several important clinical studies led to lumpectomy, in combination with radiotherapy, being recognised as equally effective as a mastectomy for many patients.
The technique of sentinel node biopsy has also been developed, thanks to well-designed clinical trials. This is where only a few lymph nodes are taken for testing from the armpit (axilla) instead of removing all of the nodes which was previous practice. This helps minimise the chances of a patient’s arm swelling on the side of their surgery, called lymphoedema, which happens when fluid builds up in the arm because it can’t drain through the lymph nodes. Although the occurrence and impact of lymphoedema is less extensive now than it has been in the past.
Research and surgery – a new generation
Although surgery has come a long way from the Halstead mastectomy, there is still much that can be improved.
Key to improvements will be a shift in the culture of surgery, a field where there has not been a strong tradition of performing randomised clinical trials unlike in drug treatments, Professor Adele Francis explains.
An initiative that aims to encourage a culture of research within cancer surgery is the Royal College of Surgeons’ Clinical Research Initiative, in which Prof Francis is a Breast Surgical Specialty Lead, funded by Breast Cancer Now and the Association of Breast Surgery.
One of the challenges that Prof Francis and others are addressing is how we can make sure women have the least amount of surgery possible with the best survival outcomes, and whether some women can avoid surgery completely.
“This whole issue is that of ‘overtreatment’,” she explains. “It is very important that these complex issues are researched through clinical trials rather than brought in haphazardly across the UK.”
Less treatment to lymph nodes
Surgeons want to do everything to avoid the irreversible side effect of lymphoedema by giving as little treatment as possible to the lymph nodes but they still need to know if lymph nodes contain cancer cells. One clinical trial which is aimed at reducing unnecessary lymph node surgery whilst still giving optimal treatment is called the POSNOC trial, led by Mr Amit Goyal, Consultant Surgeon at the Royal Derby Hospital.
“When cancer cells are found in one or two lymph nodes during a first surgery, women are currently offered a second surgery or radiotherapy to remove or destroy cancer in the rest of the lymph nodes in the armpit – increasing the risk of getting side effects like lymphoedema, pain and numbness,” Prof Francis explains.
“However, there is no evidence that this armpit treatment is necessary for patients who are receiving chemotherapy or anti-hormone drugs.
“The POSNOC trial will determine if we can avoid treating the lymph nodes in some cases and so save some women the risk of lymphoedema.”
Is not having surgery an option?
Although studies looking at lymph nodes could help eliminate a second round of surgery, there are other trials concerned with whether some women need surgery at all.
It’s important to be clear there are only a couple of scenarios where researchers are considering whether women can avoid surgery. These are when women have a diagnosis of low or low-intermediate grade ductal carcinoma in situ (DCIS) or when chemotherapy and targeted treatment before surgery have worked so well that there’s no cancer remaining (a pathological complete response).
Ductal carcinoma in situ (DCIS), is generally diagnosed by dots of calcium detected by mammograms, and before routine breast screening was introduced DCIS was hardly ever diagnosed. DCIS has always been treated by surgery, which is controversial because we can’t yet identify whose DCIS will become invasive breast cancer and whose would not cause them harm during their lifetime. Because of this, the Independent Review of Breast Cancer Screening, published in 2012, recommended research to see which patients with DCIS require treatment and who can avoid it.
To address this issue of overtreating some DCIS cases, a trial called LORIS has been launched randomise patients with low risk DCIS detected on mammography to receive either “active monitoring” – regular checks for any changes to their DCIS - or standard surgery. This is an approach similar to that used in some early prostate cancers where active surveillance without treatment is used. LORIS is one of several worldwide trials of active monitoring for DCIS.
In the second scenario of there being no evidence of the tumour following neo-adjuvant chemotherapy or targeted treatment, patients currently have surgery to remove the area where the cancer was before treatment to confirm there is no cancer left. To determine if the cancer is no longer there without operating, a trial called NOSTRA is opening in the UK in 2017 to see if biopsies after chemotherapy can safely determine if the cancer has all gone. If so, these patients may safely be able to have only radiotherapy after the initial chemotherapy, rather than surgery to remove something that is no longer there as well as radiotherapy.
A psychological perspective
As well as minimizing the amount of breast cancer surgery that people have, along with its side effects, research is also underway to limit the psychological impact of surgery.
Professor Diana Harcourt, at the University of the West of England, Bristol, is using Breast Cancer Now funding to develop a programme which helps women to better identify and explain their expected outcomes from reconstruction surgery.
The aim of this work is to help ensure women having reconstruction are better prepared for, and satisfied with, the outcomes of surgery, to help improve their longer term quality of life.
What does the future look like?
So, what is the ultimate goal for breast cancer surgery? “The priorities for breast surgical oncologists are to work in a multidisciplinary way to cure breast cancers whilst simultaneously reducing or ceasing operative treatment that is not required,” says Prof Francis.
“Participation in clinical trials is the route to successfully implementing these goals in the shortest time possible.”
If you’re interested in any of the trials mentioned in this blog please follow the links for more information and speak to your doctor about whether you are eligible for the trial, as well as its potential risks and benefits. To find more clinical trials for breast cancer one option is searching Cancer Research UK’s Find a clinical Trial database
If you want to find more about the research surrounding key treatments, check out the first instalment of our series, Cornerstone Treatments - Chemotherapy, and keep an eye out for our final blog on radiotherapy coming soon.