The role of the surgeon in cancer care

The surgeon's role in modern cancer management has evolved beyond that of technician with a scalpel and now encompasses a wide ranging role in diagnosis, counselling, screening, prevention, resource management and palliative care as well as the traditional role of surgical excision. Many surgeons also have an active academic interest at teaching hospitals, conducting cancer research and teaching in associated medical schools. The UK has three established cancer screening programmes for breast, cervical and colorectal cancer, where surgeons are required to perform clinical assessment, diagnostic biopsies and plan surgical treatments. The multidisciplinary team remains the cornerstone of cancer treatment in the UK and each oncological subspecialty has regular meetings to discuss tailored cancer treatment for each individual. Alongside oncologists, radiologists, specialist nurses and pathologists, the surgeon is a key member of this team and in the decision making process. There are many different surgical techniques available for surgical treatment of cancer, many of which allow a minimally invasive approach including laparoscopic, endoscopic and robotic surgery. The progress of medical genetics and gene profiling now allows identification of ‘at-risk’ individuals for specific types of cancer where prophylactic or risk reducing surgery may be of benefit. Cancer treatment may result in disfigurement and loss of function, so reconstructive surgery is now an integral part of cancer management. Patients with advanced disease can often be helped by surgery to relieve symptoms and improve the quality of their remaining life and so the surgeon may play a key role in end-of-life care.     

The role of the surgeon in cancer care

The surgeon's role in modern cancer management has evolved beyond that of technician with a scalpel and now encompasses a wide ranging role in diagnosis, counselling, screening, prevention, resource management and palliative care as well as the traditional role of surgical excision. Many surgeons also have an active academic interest at teaching hospitals, conducting cancer research and teaching in associated medical schools. The UK has three established cancer screening programmes for breast, cervical and colorectal cancer, where surgeons are required to perform clinical assessment, diagnostic biopsies and plan surgical treatments. In addition to this there is also a screening programme in place for the early detection and treatment of abdominal aortic aneurysms. The multidisciplinary team (MDT) remains the cornerstone of cancer treatment in the UK and each oncological subspeciality has regular meetings to discuss tailored cancer treatment for each individual. Alongside oncologists, radiologists, specialist nurses and pathologists, the surgeon is a key member of this team and in the decision making process. There are many different surgical techniques available for surgical treatment of cancer, many of which allow a minimally invasive approach including laparoscopic, endoscopic and robotic surgery. The progress of medical genetics and gene profiling now allows identification of ‘at-risk’ individuals for specific types of cancer where prophylactic or risk reducing surgery may be of benefit. Cancer treatment may result in disfigurement and loss of function, so reconstructive surgery is now an integral part of cancer management. Patients with advanced disease can often be helped by surgery to relieve symptoms and improve the quality of their remaining life and so the surgeon may play a key role in end-of-life care.     

Breast Reconstruction after Bilateral Prophylactic Mastectomy in Women at High Risk for Breast Cancer

Abstract:  Several studies have shown the effectiveness of bilateral prophylactic mastectomies (BPM) at reducing the risk of developing breast cancer in women by more than 90%. A growing number of women at high risk for breast cancer are electing to undergo prophylactic mastectomy as part of a risk reduction strategy. This unique group of women frequently chooses to undergo reconstructive surgery as a part of their immediate treatment plan. Breast reconstruction after BPM has profound physiological and emotional impact on body image, sexuality, and quality of life. These factors should be taken into consideration and addressed when consulting the patient prior to BPM and reconstructive surgery. The timing of reconstructive surgery, the type of mastectomy performed, the reconstructive modalities available, and the possibility to preserve the nipple–areola complex, should all be discussed with the patient prior to surgery. In this article, we review our experience and the current existing literature on breast reconstruction for high-risk women after BPM.     

Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial)

Background

Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life.

Methods/design

In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described.

Conclusion

The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life.

Trial Registration Number

Netherlands Trial Register (NTR): NTR2579     

Progresses in the treatment of early breast cancer. A mini-review

The treatment of breast cancer has undergone continuous and profound changes over the last three decades; breast conservation therapy has been progressively validated as a safe alternative to radical mastectomy for patients with early stage breast cancer. Several large trials have shown that overall survival time of patients treated with conservative surgery and axillary dissection followed by radiation therapy is equivalent to that of patients treated with modified radical mastectomy, with better cosmetic outcomes and acceptable rates of local recurrence. Improvements in diagnostic work-up and the wider diffusion of screening programs have allowed the detection of smaller, often non palpable tumours, furtherly facilitating the widespread use of tumour localization and breast conserving techniques. Since the removal of negative lymph nodes is useless, eventually harmful and plays no therapeutic role in breast cancer patients, techniques for staging of the axilla have also gradually evolved toward less aggressive approaches, such as lymphatic mapping and sentinel node biopsy. The introduction of "onco-plastic techniques", that combine the concepts of oncological and plastic surgery of the breast, achieve the goal of allowing more extensive excisions while improving the aesthetic results, and eventually patient's quality of life. The present work will highlight potential benefits as well as unresolved issues of the above mentioned therapeutic options, with special emphasis on technical aspects of conservative surgery in the treatment of early breast cancers.     

Oncoplastic principles in breast conserving surgery

Oncoplastic surgery (OP) represents a major advance in breast cancer surgery. It is based on three principles: ideal oncology surgery with free margins and adequate local control of disease, immediate breast reconstruction and symmetry, with the transposition of plastic surgery techniques into breast cancer surgery. Its original focus was to improve the quality of life of patients undergoing oncological treatments that can be more effective from the aesthetic-functional point of view than the traditional breast conserving techniques. As it happens with all changes of paradigms, it brings new challenges for the traversal formation of all involved in the treatment of breast cancer. Besides that, it opens to new perspectives of surgical research related to the aesthetic results, quality of life and local control, as well as optimization of operative timing and reduction of both adverse effects and costs. The aim of this review was to present the principles of this approach and the main techniques applied, evaluating its indications and limits in conservative breast cancer surgery.     

The sentinel node biopsy under local anesthesia in breast cancer: advantages and problems, how the technique influenced the activity of a breast surgery department; update from the European Institute of Oncology with more than 1000 cases

Sentinel lymph node biopsy (SLNB) is a staging technique with a significant impact on patients' quality of life: the oncological effectiveness in a large number of patients affected by breast carcinoma has been already demonstrated, and the clinical research is now focusing on new indication for the biopsy and widespread adoption of the technique. At the European Institute of Oncology we are applying SLNB under local anesthesia: our aim is to improve the management of the disease with low costs for the structure and patients, and to improve patients' acceptance of breast cancer treatments. We are now discussing the impact of the SLNB under local anesthesia on the activity of a breast surgery department. We also present an update of our experience.     

Breast reconstruction: a review

Remarkable advances have been made in the field of breast reconstruction, especially since general surgeons, patients, and the community as a whole have become more knowledgeable and accepting. This has provided an impetus for plastic surgeons to develop better techniques, many of which are reviewed here. In general, less time now elapses between ablative and reconstructive surgery, and frequently reconstruction follows immediately. Procedures requiring fewer steps with less donor and recipient site morbidity are favored for both the mound and nipple areolar reconstruction. There is a definite trend toward submuscular implantation to minimize the negative effects of capsular contracture. With a deficiency of skin or muscle, the trend is toward using musculocutaneous flaps primarily, latissimus dorsi, and more recently the rectus abdominis flap. Occasionally, microvascular flap reconstruction is indicated for extensive chest wall defects, e.g., postirradiation injury. Reconstructed breasts are not capable of nourishment, frequently are not erogenous , and most often are not as pleasing to the eye as the contralateral breast. Yet reconstruction has, in the majority of cases, improved the quality of life for those women who have developed breast cancer and offered hope to those women in a high-risk category for developing breast cancer. To those ends, the search for the perfect breast reconstruction will continue.     

The impact of mastectomy, breast-conserving treatment and immediate breast reconstruction on the quality of life of Chinese women

Background : The psychosocial impact of breast surgery has been extensively studied in the Western population. There is a relative paucity of comparable data in Oriental women who are increasingly affected by cancer of the breast. The present study investigates the effects that different types of breast surgery have on the quality of life of Chinese women. Methods : Forty‐nine Chinese women with early breast cancer were interviewed at 6 months–2 years following their primary surgery (breast‐conserving treatment (BCT; 17 patients), mastectomy (15 patients) and mastectomy with immediate breast reconstruction (17 patients)). Aspects of quality of life measured included general psychological well‐being, body image, sexual functioning and social functioning. Results : Patients who received BCT had significantly better body image scores compared to mastectomy patients. They were less worried about their appearance, had more freedom in the choice of clothing, felt less upset by the change in their body and felt more accepted by their partners. The three groups did not differ significantly in the other aspects of quality of life measured. Conclusions : Compared to mastectomy or mastectomy and immediate breast reconstruction, the most significant benefit of BCT is the preservation of a better body image.     

早期乳腺癌手术的乳房轮廓保留策略

乳房轮廓保留(BCP)是指通过保乳手术(BCS),乳房切除即刻乳房重建(IBR)的外科策略,保留乳腺癌患者术后乳房的轮廓。随着乳腺外科技术的发展,乳腺癌患者的术后外形和生活质量获得了明显改善,最近的研究报道中,将BCP作为一项新的指标来衡量或评价乳腺癌治疗效果。在早期乳腺癌手术中,需要根据术前对乳腺癌患者全身情况和乳房肿瘤的全面评估以及乳房的形态特点,制定个体化的手术策略,合理提高乳腺癌术后的BCP率,改善患者的术后外形效果。结合我国女性乳房的形态特点,不仅可以通过BCS和IBR保留乳房轮廓,在部分乳腺癌患者中,保留乳头乳晕复合体乳房切除术也可作为保留乳房轮廓的术式选择,从而减少乳房缺失给患者带来的身心影响。     

直肠癌新辅助治疗后行保直肠手术的争议和前景

直肠癌治疗有3个目标,一是通过治疗,最大程度降低盆腔局部复发率,降低至5%以下更佳;二是尽可能减少急性或慢性并发症;三是保留良好的括约肌功能和生命质量。直肠癌新辅助治疗后保直肠手术作为一个新理念,在施行过程中仍存在很多争议,包括筛选标准、新辅助治疗方案、治疗方式、并发症、肿瘤学预后及生命质量等。笔者查阅文献并结合自身实践经验,对上述问题展开讨论,旨在为新辅助治疗后行保直肠手术的推广提供参考。     

Breast tomosynthesis: What do we know and where do we stand?

Digital breast tomosynthesis (DBT) is a new imaging technology that addresses the limitation caused by overlapping structures in conventional two-dimensional digital mammography owing to the acquisition of a series of low-dose projection images. This unique technique provides a dual benefit to patients screened for breast cancer. First, DBT increases the cancer detection rate mostly by highlighting architectural distortions and allowing better assessment of masses shape and margins. Second, DBT helps reduce recall rate by discarding asymmetries related to overlapping tissue. However, DBT is not included in the majority of cancer screening programs worldwide. Several issues still need to be addressed such as over-diagnosis and over-treatment, lack of reduction of interval breast cancer, quality control and storage, and radiation dose. In the diagnostic setting, DBT increases the diagnostic accuracy and reduces the number of indeterminate lesions in symptomatic women. Its aforementioned performances regarding asymmetries, masses and architectural distortions allow reducing the number of additional views while working-up a screening-detected lesion. Tumor size is also better assessed at DBT as well as multicentricity, two significant benefits in the staging of breast cancer. Finally, DBT allows a better analysis of scars and helps reduce the rate of indeterminate findings after surgery. Although somewhat limited by high breast density, DBT globally outperforms digital mammography in both screening and diagnostic breast imaging. Additional research is however needed, particularly on relevant screening outcomes. This review describes the main performances of breast DBT in breast cancer screening and diagnosis and the resulting consequences in both settings.     

Evaluation of the treatment of cancer of the breast with a suggestion for its modification

In the treatment of cancer of the breast, we have reached a place where the prospects of reducing the early mortality or extending the span of life seems to have reached an impasse, unless we can better apply the tools at our disposal.Much has been accomplished by publicizing the prevalence and curability of cancer in its early stages, and while these efforts should be continued, no great impression will be made in the vital statistics by this alone.No longer should carcinoma of the breast be so designated without miscroscopical examination of the tissue, and compilation of cases treated without such verification should not be given printer's space. The punch biopsy only in its positive reports of carcinoma is entitled to any consideration from a diagnostic standpoint, and it would be far better if the method were abandoned altogether. Brodus has definitely established the value of grading cancer, and every effort should be made to get in line with his observations.We have two methods of attacking cancer of the breast, irradiation and surgery, and it is very questionable if we have exhausted the possibilities of the two, particularly as a dual method of attack. There has been too much half-hearted cooperation between the surgeon and roentgenologist. Irradiation alone has not lived up to the expectations; or possibly too much was anticipated, no doubt predicated upon a limited experience or a few outstanding cases. If the methods of treatment by irradiation now in vogue have failed materially to increase the number of cures or prolong life, possibly the utilization of this potent therapeutic measure can be better adapted and coordinated with surgery.It is conceded that irradiation inhibits many malignant growths, and any treatment that can arrest the propagation of cancer cells has a place in the treatment of cancer. Combined with surgery, irradiation can play an important part in the treatment of cancer of the breast.Preoperatively, a short period of intensive treatment by x-ray or radium, should be followed immediately by radical surgery. Irradiation alone, or delayed surgery after irradiation has not been justified by the end results. Postoperative irradiation has been rather “hit or miss” in its application, no effort apparently having been made to standardize the treatment in dosage, periodicity in relation to the operation or careful tabulation in regard to the extent, type or grade of cancer, except in few of the centers in which this problem is a matter of major importance. Unfortunately perhaps, most of the cases are not treated in the best organized clinics.The postoperative treatment of cancer of the breast, we believe, needs coordinating. Irradiation should be carried out early in the convalescence of the patient and repeated at two-year intervals regardless of recurrence or in the absence of recurrence, over a period of four to six years, assuming the patient survives.Notations as to the type and grade of cancer, metastasis, local recurrences are essential to supply data that can be applied to formulate future treatment of carcinoma of the breast.Until we utilize irradiation in an intelligent manner in combination with surgery, we shall just muddle along in a therapeutic rut. It is incumbent upon us to apply, with a sense of responsibility, all those measures that we have in our hands and not casually wait for some genius to throw in our laps a specific “carcinomastat.” This program will require years to consummate, but it will be worth the labor.     

Case series: pedicled vertical rectus myocutaneous flaps for cover of breast and perineal defects��a 2-year review in our centre

Colorectal carcinoma is the most common cancer afflicting both Singaporean men and women; whereas, breast carcinoma is the most frequent female-specific cancer according to the report published by the Singapore Cancer Registry on cancer trends from 2003 to 2007. As such, breast and perineal defects requiring soft tissue cover is a challenging occurrence after initial tumour surgery by the breast and colorectal surgeons, especially for fungating breast tumours and very low colorectal carcinomas, respectively. In Tan Tock Seng Hospital prior to 2007, many of these patients may have had their wounds skin-grafted or allowed to heal by secondary intention. This often involved prolonged hospital stay, difficult wound care and significant morbidity as well as a negative impact on the quality of life for these patients. Pedicled vertical rectus myocutaneous (VRAM) flaps were then introduced for cover of these defects as an effective method of reducing these negative aspects of patient care. This case series aims to review the efficacy of the VRAM flap in achieving this within a 2-year period. Over this period, the VRAM flap has shown to decrease length of hospital stay, reduction of the duration to commencement of adjuvant therapy, and also decrease in the difficulty of wound care as well as the complication rate.     

Radiotherapy for breast cancer in the 21st Century

Radiotherapy has undergone significant technological advances during the last 20 years, although their use in breast cancer was relatively limited until recently. The major recent changes in the use of radiotherapy for breast cancer have been the following: the establishment of partial breast irradiation (PBI) as an option for therapy in early stage disease; the revival of hypofractionated therapies for breast only therapy; the clearer definition of the role of post-mastectomy irradiation; and the continuing investigation as to which patients having conservative surgery do not need radiation therapy. Intensity-modulated radiotherapy is still not widely accepted to be medically necessary in breast cancer, but ongoing studies may demonstrate that it will prove to be useful in treating node-positive breast cancer when wide-field nodal targets need to be included in the treatment volume. Image-guided radiotherapy will prove to be necessary for PBI by external beam to keep the irradiated treatment volumes within long-term tolerance. The optimum dose and delivery schedule for PBI is yet to be finalized. Overall, the local control rates for all breast cancer treatment scenarios are generally good, and therefore, the emphasis is now on maintaining local control while reducing toxicities from treatment. The long-term risks of breast cancer radiotherapy on subsequent cancer induction are subject to ongoing studies. Biological enhancement of the effect of radiotherapy could allow dose reduction, with presumed reductions in the toxicity of treatment. In conclusion, breast cancer radiotherapy has much to understand and optimize in the 21st Century.     

Is surgery always indicated in older women with breast cancer?

Although surgery has long been considered the main form of curative treatment for breast cancer, its use in older women may not always be indicated. Whilst surgery has been shown to provide superior local control for breast cancer, there is conflicting evidence on whether surgery offers a significant improvement on overall survival in these patients. The more indolent tumour biology commonly seen in older women with breast cancer, coupled with competing causes of death may alter the goals of treatment. The differing needs of older patients should be thoroughly assessed to consider their comorbidities, functional status and quality of life. A comprehensive geriatric assessment and quality of life assessment could identify pretreatment risk factors and guide clinical decision making, improving morbidity and prognosis. Alternatives to surgery include primary endocrine therapy and primary radiotherapy. Further research is required to identify different patient or tumour factors which can be used to individualize treatment for breast cancer in older women and to develop holistic assessment tools which take into account their individual quality of life, geriatric syndromes and functional needs. A dedicated multidisciplinary-led clinic may provide a suitable platform for the assessment, review and management of this distinctive set of patients.     

Diagnostic and therapeutic concepts in breast neoplasms

Therapeutic decisions in breast cancer are no longer as simple and straightforward as they were. Radical masectomy has long ceased to be a routine application to every patient. A number of patients are now candidates for conservative surgery combined with irradiation. Patients who still require total mastectomy with axillary clearance may wish to undergo immediate or delayed breast reconstruction. In our department most patients with breast tumors are first seen in the outpatient clinic, where diagnostic work-up is completed and the therapeutic concept is discussed. If necessary, consultation with the radiotherapist and the plastic surgeon is available. Our diagnostic and therapeutic concepts are summarized in Fig. 1 and Table 1.     

Beauty and the beast: management of breast cancer after plastic surgery

OBJECTIVES: Cosmetic surgery procedures increase in incidence annually, with 11 million performed in 2006. Because breast cancer is the most frequently occurring malignancy in women, a personal history of cosmetic surgery in those undergoing treatment for breast cancer is becoming more common. METHODS: This review identified key studies from the PubMed database, to consolidate existing data related to treatment of breast cancer after plastic surgery. Data were reviewed for factors affecting breast cancer treatment after breast augmentation, breast reduction, abdominoplasty, and suction lipectomy. RESULTS: There are little comprehensive data on the management of breast cancer after plastic surgical procedures. Plastic surgery may affect diagnostic imaging, surgical options, and radiotherapy management. Breast augmentation and reduction are two of the most common cosmetic procedures performed and knowledge of their influence on the incidence, diagnosis, and treatment of breast cancer is important for proper management. CONCLUSIONS: Plastic surgery does not significantly affect breast cancer outcomes but does present management challenges that must be anticipated when deciding various treatment options. Knowledge of the existing literature may be helpful in discussing those options with patients and planning the multidisciplinary approach to this malignancy.     

Australia's breast surgery workload is changing: comparison of a metropolitan and a rural hospital

BACKGROUND: Breast cancer is a common disease in our community and its incidence is increasing. As a result of the improvements in community awareness and introduction of screening, patients are being diagnosed with earlier breast cancer and with a higher incidence of pre-invasive disease. Improvements in radiology, often coupled with minimally invasive diagnostic modalities, have lessened the requirement for open diagnostic biopsies and also reduced the number of operations for benign breast disease. METHODS: An audit of the surgical workload at Prince of Wales/Prince Henry Hospitals and Tamworth Base Hospital was conducted to document and compare the above changes in the metropolitan and rural settings. This study was conducted between 1987 and 1996 to assess the effect of screening and improved technology over a 10-year period. RESULTS: The study found that a high percentage of malignant lesions are being diagnosed by fine-needle aspiration biopsy (FNAB) with a corresponding reduction in open biopsy rate at the Prince of Wales Hospital. There is a smaller percentage of benign operations in both settings with a reduction of equal proportion. The reporting of the pathology specimens has markedly improved at both institutions. There has been a reduction in the number of patients having modified radical mastectomy and there has been a corresponding increase in breast conservation surgery especially at the Prince of Wales/Prince Henry Hospitals, although there was an unexpectedly high incidence of breast conservation surgery at Tamworth Base Hospital in 1987. In 1996 the rates of breast conservation surgery were the same in both hospitals. CONCLUSIONS: There are minimal differences in the quality of surgical care being offered to patients at the Tamworth Base Hospital compared with the Prince of Wales Hospital and both institutions are within reach of the accepted best management practices available.     

AUSTRALIA’S BREAST SURGERY WORKLOAD IS CHANGING: COMPARISON OF A METROPOLITAN AND A RURAL HOSPITAL

Background : Breast cancer is a common disease in our community and its incidence is increasing. As a result of the improvements in community awareness and introduction of screening, patients are being diagnosed with earlier breast cancer and with a higher incidence of pre-invasive disease. Improvements in radiology, often coupled with minimally invasive diagnostic modalities, have lessened the requirement for open diagnostic biopsies and also reduced the number of operations for benign breast disease. Methods : An audit of the surgical workload at Prince of Wales/Prince Henry Hospitals and Tamworth Base Hospital was conducted to document and compare the above changes in the metropolitan and rural settings. This study was conducted between 1987 and 1996 to assess the effect of screening and improved technology over a 10-year period. Results : The study found that a high percentage of malignant lesions are being diagnosed by fine-needle aspiration biopsy (FNAB) with a corresponding reduction in open biopsy rate at the Prince of Wales Hospital. There is a smaller percentage of benign operations in both settings with a reduction of equal proportion. The reporting of the pathology specimens has markedly improved at both institutions. There has been a reduction in the number of patients having modified radical mastectomy and there has been a corresponding increase in breast conservation surgery especially at the Prince of Wales/Prince Henry Hospitals, although there was an unexpectedly high incidence of breast conservation surgery at Tamworth Base Hospital in 1987. In 1996 the rates of breast conservation surgery were the same in both hospitals. Conclusions : There are minimal differences in the quality of surgical care being offered to patients at the Tamworth Base Hospital compared with the Prince of Wales Hospital and both institutions are within reach of the accepted best management practices available.