Surgery of Breast Cancer during the Last 5 Years: More Sophisticated and Specialized?

Abstract

189 There are debates among breast cancer surgeons around the world regarding what is still considered “experimental” and what is considered routine in the surgical management of breast cancer. During the last 5 years there have been important changes in the surgical approach to breast cancer. These have been applied to the routine management of breast cancer in a rapid pace never seen before. The conservative treatment of breast cancer took approximately 20 years to become well accepted and applied worldwide. The 25-year findings still needed to be published to convince some reluctant surgeons that the procedures were safe.(1,2) Recently proposed procedures, the sentinel node biopsy, for example, were quite uniformly accepted(3) as routine management only a few years after the first consistent preliminary results were published.(4,5) The sentinel node procedure is only one example of the several proposed procedures during the last 5 years; others include intraoperative radiation therapy(6) and new localization techniques on nonpalpable breast lesions.(7,8) Several factors may explain this fast change in the routine surgical management. The detection of small tumor is the most important explanation of the continuous trend in developing less aggressive surgery and improving the quality of life of breast cancer patients. In the last 10 years surgeons have had to face a new entity of breast cancers: often, ductal carcinoma in situ (DCIS), sometimes with microinvasion and small tumors with low probability of axillary node involvement. The surgical approach and even the surgical techniques in use 10 years ago are often no longer applicable to the “modern breast cancer patients”; the surgery is becoming more and more sophisticated. The patients are more aware of this sophistication and are searching for the “best” treatment. This induces surgeons and hospitals to offer the modern treatments in order to be competitive. This acceleration in putting experimental procedures into practice may sometimes be excessive, especially when the benefit of a new procedure is not well demonstrated and clinical trials are still in progress. On the other hand, patients participate more in the decision of their treatment and better understand the risks and benefits of a specific treatment. They may accept the risk of a new treatment with the benefit, for example, of a less aggressive surgery. Another important element that safeguards patients is the use of a controlled clinical trial. More often, clinical trials are designed to be multicentric and involve several institutions, sometimes small ones that benefit from the experience and quality control of the bigger centers. The most important task for a physician facing new proposals is to honestly consider the evidence of whether or not the method is safe and better than previous techniques. If evidence is not provided, the physician should consider joining a clinical trial and should never apply the procedure only because it is fashionable and may draw patients. Surgery still remains the cornerstone of therapy for almost all women diagnosed with this disease. In fact, one of the key objectives in detecting breast cancer in its earliest stages is the opportunity to cure this disease only with surgery. Efforts should be made to ensure a good local control of the disease and at the same time to approach the ideal line between overand under-treatment. In the following paragraphs I would like to describe the most important changes in the surgical management of breast cancer that have occurred in the last 5 years.