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Doctors start to rethink some radical surgery


Journal Star (Peoria, IL)

05-07-13

May 05--PEORIA -- "Less is more" is a dominant theme in modern breast cancer treatment, said breast cancer surgeon Lynne Jalovec during an interview at her Peoria offices recently.

"We're finding that previously we did all this radical surgery, and now we're seeing that maybe our thoughts about cancer need to change," said Jalovec.

Three treatments Jalovec highlighted as part of that theme include a study that showed certain early-stage cancer patients do as well when a few sentinel lymph nodes are removed versus similar patients who have all the nodes removed in the affected area; new technologies being used in breast reconstruction, which allow it to be done immediately following mastectomy, eliminating a second surgery; and non-surgical common-sense health advice that can reduce the risk of recurrence by up to 50 percent.

Z0011 trial

Cancer is being detected earlier now than it was 20 years ago, a fact that is allowing surgeons to take a less invasive approach during most surgeries, Jalovec said.

"The average size of a tumor is much smaller than it was 20 years ago," she said. At that time tumors were typically found when they were an inch or larger. "Under a half an inch is typical now."

Breast cancer surgeons were glad when the Z0011 trial confirmed what they already suspected -- lumpectomy patients with minimal lymph node disease did just as well when only a few lymph nodes were removed as compared to similar patients who had all the nodes in the affected area removed.

Two years ago, if cancer was found in a single lymph node, all the nodes in the affected area were removed. Now patients who fit the criteria are allowed to keep the axillary lymph nodes if only two of the three sentinel nodes -- those closest in lymphatic flow to the cancer -- are cancer positive. If three or more sentinel nodes are positive, the axillary lymph nodes are still removed.

Eligible for this option are lumpectomy patients planning whole breast radiation after surgery. They must have early stage cancer and be clinically node negative, meaning the nodes are not noticeably enlarged when examined before surgery.

"This option leads us even further from unnecessary surgery on lumpectomy patients who have minimal lymph node disease," said Jalovec.

Leaving as many lymph nodes as possible lowers the chance the patient will develop lymphedema, a permanent condition that can range from minor to severe.

"When you take out lymph nodes you interrupt the lymphatic drainage in the arm," explained Jalovec. A healthy lymphatic system removes excess fluid and waste, destroys pathogens, and delivers nutrients and oxygen. But if the lymphatic system is damaged, fluids can pool and cause swelling.

Not everyone who has their axillary lymph nodes removed gets lymphedema, said Jalovec. An estimated 30 percent to 45 percent will have some degree of lymphedema, and 10 percent to 15 percent will have noticeable problems. Being overweight and having radiation after surgery are factors that make the condition more likely.

"The chance of having severe lymphedema has been improved by doing less lymph node surgery," said Jalovec. "We have clearly seen a reduction in lymphedema patients."

Quicker reconstruction

Breast reconstruction with silicone or saline implant used to mean two surgeries, but with new technologies plastic surgeons are now sometimes able to build a new breast using an implant immediately following breast removal.

The key to this procedure is The SPY Intraoperative Imaging System, which helps surgeons check the blood supply in the skin flaps that once covered the natural breast, said Jalovec.

"The skin has to have a good blood supply," she said. "Without the little SPY imaging camera you could not go direct to implant. This way we can pick which patients are appropriate for this procedure."

If the blood supply is deemed sufficient, the surgeon uses a product called AlloDerm Tissue Matrix to create a hammock to hold the implant. Derived from the skin of cadavers, AlloDerm has been processed to remove cells that can lead to tissue rejection. It is accepted by the body and allows the patient's own cells to grow through it, ultimately becoming part of the patient's body.

A portion of the pectoralis muscle is used to create the top of the implant pouch and is stitched to the AlloDerm hammock. Implant surgery for mastectomy patients used to require the insertion of an expander behind the pectoralis muscle of the chest wall. It could take weeks to stretch the muscle enough to accommodate the implant, and then required a second surgery for implant insertion, Jalovec said.

"The procedure saves the patient from a second surgery and the pain the tissue expanding process often caused," she said.

The surgeon later tattoos the reconstructed breast with an areola and carefully puckers the skin to form a nipple, Jalovec said. "Reconstructions look pretty darn good nowadays," she said.

Good health, good results

The least invasive procedure is no procedure -- breast cancer survivors are given a set of health guidelines to help them keep cancer from recurring.

"Achieving and maintaining your ideal body weight can lower breast cancer recurrence by half," said Jalovec.

Patients should eat healthy, stop smoking, and stop or limit alcohol consumption to a single drink a day, Jalovec said.

"We all know what we should be doing," said Jalovec. "Instead of waiting until we have cancer, we should do it before."

Jalovec also stressed the importance of early detection.

"Patients where the cancer is found earlier have more choices and are less likely to have the axillary lymph nodes removed," she said.

In spite of recent controversial government recommendations that women should wait until 50 to get their first mammogram, Jalovec stresses that yearly mammogram screening should begin at 40.

"If you are due and you have no insurance, there's a program in Peoria County that is administered through the Heartland Community Clinic," she said. The Illinois Breast and Cervical Cancer Program is administered for uninsured women in other counties through the various health departments.

Leslie Renken can be reached at 686-3250 or lrenken@pjstar.com. Follow her on Twitter, @LeslieRenken, and Pinterest, larenken.

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(c)2013 Journal Star (Peoria, Ill.)

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Copyright Journal Star (Peoria, IL) 2013

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