Beating Breast Cancer Involves Understanding the Treatment Options

As much as a woman tries to brace herself for the news, a diagnosis of breast cancer can be traumatic. And at the very time a woman needs to be clearheaded, there may be only fog. Not surprisingly, it is not uncommon for some women to rush into treatment without carefully considering the best option. But it need not be this way, says Joseph Crowe, M.D., breast surgeon at The Cleveland Clinic Foundation.

Dr. Crowe says a diagnosis of breast cancer should be followed by an intensive education program that ensures that a woman understands the benefits and risks that come with each breast cancer treatment, as well as each phase of treatment. "That education," says Dr. Crowe, "becomes the basis for making the right treatment choice."

One place to receive that kind of education is a large medical center that has an experienced and diverse breast cancer team, says Dr. Crowe, director of breast services at The Cleveland Clinic Taussig Cancer Center. For instance, education about treatment options is the foundation of breast cancer management at The Cleveland Clinic.

"Because of our experience and expertise, we have a pretty good sense about what we can and can’t do for a patient," says Dr. Crowe, who has performed some 6,000 surgeries for breast cancer. "Once the patient information has been reviewed, our job as breast cancer specialists is to spend the majority of our time consulting with the patient and family to ensure that they understand the advantages and disadvantages of the treatment options."

At the Clinic, breast cancer patients may sit down with nearly a half dozen specialists—surgeons, plastic surgeons, medical oncologists, radiation therapists, radiologists and breast pathologists—before they make a decision about treatment. "Our role here is to educate women about the choices, not to steer them into one treatment or another," says Dr. Crowe.

Mastectomy or lumpectomy: Factors, advances that influence choice
The two main surgical treatments for breast cancer are mastectomy and lumpectomy and are part of what is called local therapy. The aim is to remove all cancerous tissue and cells from the breast. Mastectomy involves complete removal of the breast—including the nipple and areola—and underlying breast and other tissue. Lumpectomy, of which there are various types, is a "breast conservation" or "tissue sparing" procedure that preserves as much breast tissue as possible while still removing the cancer. It is followed by radiation therapy. Mastectomy and lumpectomy both are usually followed by systemic therapy, which involves using drugs to kill or prevent the growth of cancer cells that have spread beyond the breasts to other parts of the body.

Whether local therapy will consist of lumpectomy or mastectomy depends in part on how advanced the cancer is at the time of diagnosis, what a woman’s expectations are regarding physical appearance after surgery and whether or not she is willing to undergo radiation therapy following lumpectomy, says Dr. Crowe. "So we are very focused on educating patients about the advantages and disadvantages and risks and benefits of either approach."

Not long ago, the only option for local therapy was removal of the entire affected breast (mastectomy), a procedure that results in significant disfigurement. Increased understanding of breast cancer, however, together with refinements in surgical techniques, expanded the options. Now women can choose various breast conserving surgical procedures (lumpectomies) that still remove the cancer but preserve varying degrees of breast tissue.

One caveat for lumpectomy is that breast conservation surgery must be followed by radiation therapy to ensure eradication of possible remaining cancer cells. For some women, unwarranted fear of radiation eliminates lumpectomy as an option; in others, lumpectomy may not be recommended because of breast size or the advanced state of the cancer. So these women must opt for the more extensive mastectomy.

Surgical refinements also have helped make mastectomy less physically transforming. For instance, breast cancer patients who go to a large center like The Cleveland Clinic can opt for a "one step" procedure that involves mastectomy followed by immediate breast reconstruction. Most Clinic patients who choose mastectomy now also opt for immediate reconstruction, says Dr. Crowe. Both procedures can be covered by insurance.

Although lumpectomy has been part of breast cancer care for almost 20 years, Dr. Crowe says that for a variety of reasons, many women for whom the procedure would be appropriate are never offered it.

Because of resources and staff, smaller centers may be more likely to combine exploratory surgery (used to examine and extract breast tissue for making a diagnosis) with the treatment surgery. In such cases, mastectomy is common. "That scenario doesn’t give the woman the opportunity to examine the options," says Dr. Crowe. Breast cancer centers like the Clinic’s, he says, have a range of diagnostic tools available (e.g., core needle biopsy, stereotactic breast biopsy) that allow for rigorous patient assessment that pinpoints a diagnosis before a major surgical procedure is ever performed. "So there’s no reason for a woman to go into major surgery without knowing her cancer status."

A modified nipple-sparing technique
To achieve some level of tissue conservation in the one-step procedure, Dr. Crowe, along with several Clinic colleagues, recently developed a mastectomy technique that preserves the nipple and areola, which in traditional mastectomy are always removed. Various approaches to preserving the nipple have been evaluated over the years, but the concern has always been the risk of cancer recurrence due to the concentration of milk ducts beneath the nipple, a site where breast cancers often develop.

Dr. Crowe got around the problem by "skeletonizing" the breast, that is, removing all of the breast tissue under the nipple and areola and leaving only a thin envelope of skin underneath. This minimizes the risk of leaving cancer cells in the preserved breast tissue, says Dr. Crowe.

During surgery, tissue samples are tested for the presence of cancer cells. If there is any hint of disease in the area under the nipple, the nipple is removed. If the samples are negative, the nipple and areola are left intact for reconstruction. Not all breast cancer patients will be eligible for the nipple-sparing procedure, but its existence broadens the options for women faced with a major decision about their bodies.

And all of these issues should be ironed out, says Dr. Crowe, before treatment ever begins. For The Cleveland Clinic, providing this kind of service can be labor intensive. But Dr. Crowe says that the Clinic’s breast cancer team has a lot of experience helping lay people understand the fundamental concepts and issues involved in breast cancer treatment. "The goal for the patient should be to learn about and understand all of the possibilities as early in the process as possible."

Tips on choosing a cancer center
According to Joseph Crowe, M.D., breast surgeon and director of breast services at The Cleveland Clinic Foundation’s Taussig Cancer Center, women seeking treatment for breast cancer should try to choose a cancer center that:

• mobilizes a range of specialties—surgery, plastic surgery, oncology, radiation therapy, pathology—to manage and treat the disease
• ensures that all treatment options are clearly explained and examined
• offers the opportunity to meet with—before any treatment is undertaken—all of the specialists who will be involved in the care
• performs a large volume of breast cancer procedures. The Cleveland Clinic, for instance, performs approximately 500 lumpectomies and 250 mastectomies per year.