Frequently Asked Questions

Breast cancer refers to the malignant growth of cells within the breast gland. The gland consists of various structures, like lobes (and smaller lobes called lobules) that are meant to produce milk, and ducts, which bring milk to the nipple. Malignant breast tumors are generally either invasive (the majority of breast cancers) or in-situ (confined to the duct or lobule). In-situ lesions have the potential transform into its more aggressive invasive alter ego or recur as an in-situ or invasive tumor after treatment.

Tumorgenesis, along with breast development and function, is controlled by hormones, but is also affected by genetic and environmental factors.Genetic and hormonal risk factors include a family history of cancer, early menarche, late menopause, late onset of first pregnancy, and hormone replacement therapy. Environmental risk factors including obesity, excess alcohol consumption, high-dose radiation, age, and possibly nutritional factors.

Breast cancer is the world’s leading cancer in women, right behind skin malignancies. (Only 1% of all breast cancers occur in men.) After lung cancer, breast cancer is the second most deadly form of cancer in women. It affects one in eight women over a lifetime, and there are roughly 230,000 new cases of invasive breast cancer and over 50,000 cases of non-invasive breast cancer per year in the United States alone. About 40,000 Americans die of breast cancer annually. It continues to be a major cause of mortality world-wide, particularly in developing countries, where access to prevention, screening, and even appropriate management might be scarce.

Most breast cancer patients undergo surgery to remove cancer from the breast. The majority of women are candidates for breast conserving surgery, commonly referred to as lumpectomy, which involves removing the portion of breast containing the tumor along with an adequate amount of normal breast tissue.

A quadrantectomy is a type of breast-conserving surgery more commonly performed in Europe than in the U.S. This surgery involves removal of a fourth of the breast tissue in an effort to reduce the need for re-excision and potentially the risk of recurrence. The downside of this method is that a patient is often left with a large defect without a significant benefit over lumpectomy.

While most patients are candidates for breast conserving therapy, and the majority of women elect this method, some patients are appropriate candidates for mastectomy, or the removal of the entire breast. Some additional tissue, such as lymph nodes from the underarm, may need to be removed as well.

A patient should consider a mastectomy in the following cases:

Cancer that extends to another quadrant of her breast
Malignant cells present in multiple quadrants of her breast
Very large tumors
A tumor that does either does not shrink while on pre-operative chemotherapy
A history of radiation treatment
The inability to undergo radiation treatment (for example, because of pregnancy)
Not all mastectomies are created equal: there are many different kinds of mastectomies available to patients. And often times, it is both safe and preferable to perform breast reconstruction in the same setting, i.e. immediately following the mastectomy operation, while a patient is still under anesthesia. Reconstructive options can either be implant-based or take advantage of a patient’s own tissue (See http://www.diepflap.com)

Simple (total) Mastectomy:
This operation involves the removal of all breast tissue. Often, the lymph nodes from under the arm will be sampled (sentinel node biopsy) but not removed. This operation can be undertaken via a skin-sparing approach (see below) or in a more traditional fashion, removing the skin overlying the breast.

Modified Radical Mastectomy:
The modified radical mastectomy removes all tissue of the breast, including the fascia, or casing, of the pectoralis muscle, as well as removal of some (not all) of the axillary (underarm) lymph nodes. The pectoralis muscles are not removed in this operation.

Radical Mastectomy:
This procedure, first introduced over a century ago, involves radical removal of underarm lymph nodes, removal of the pectoralis muscles, in addition to the breast gland. Because of increased understanding and research on the nature of tumors, radical mastrctomy is rarely undertaken today. It is reserved for patients with locally advanced tumor invading the chest wall.

Is nipple- (or skin-) sparing mastectomy right for you?

Skin and nipple-sparing mastectomies are becoming a popular alternative to traditional mastectomy for both treatment and prevention of breast cancer. First developed in the 1980’s, the skin-sparing mastectomy involves removal of the breast gland with preservation of the native skin overlying the breast. This generally results in smaller, less obvious scars, and preservation of a patient’s native skin envelope, which can then be used to reconstruct the breast, maintaining and sometimes improving the natural shape and contour of the breast.

The nipple-sparing variant of a skin-sparing mastectomy leave the patient’s own nipple and areola behind in order to maximize the natural look of a patient’s breast. Not everyone is a candidate for the nipple-sparing mastectomy, but your specialist will work with you to decide what’s right for you.

Nipple-sparing mastectomy has not been compared to traditional mastectomy or standard skin-sparing mastectomy in head-to-head trials. However, our current retrospective data reflects the relative oncologic safety of the procedure. In recent years, many technical refinements have been made resulting in the improved safety of the procedure.

When considering skin- or nipple-sparing mastectomies, remember that these procedures take a great deal of skill. When researching your options, make sure to ask plenty of questions and to find a practitioner, such as a breast surgeon or surgical oncologist, who is experienced at performing this operation.

Often in breast cancer surgery, it is both safe and preferable to perform breast reconstruction at the same time the cancerous tissue is being removed. A type of breast conservation surgery (BCS), this combination of cosmetic surgery techniques and oncological procedures is called oncoplastic surgery.

Oncoplastic surgery includes excision of cancer with adequately wide free margins, then immediately remodeling any defect created by removing tissue while the patient is still under anesthesia. The surgeon will endeavor to recreate a natural, symmetrical look as close as possible to the patient’s original breasts. Skin- and nipple-sparing mastectomies with immediate reconstruction represent types of oncoplastic surgery.

In order to see if the breast cancer has spread to the lymph nodes, a biopsy of the nearest lymph nodes is performed. First described by Dr. Giuliano in the 1990s, the sentinel lymph node biopsy is an improvement on traditional axillary lymph node dissection, requiring far fewer lymph nodes to be removed than in the past. Lymph nodes in the armpit are sequentially aligned, if breast cancer cells are not discovered in the first (or sentinel) lymph nodes, then there is no need to dissect the subsequent ones. This helps avoid the removal of several lymph nodes under the armpit, a procedure known to cause unpleasant problems such as lymphedema (arm swelling).

Either on the day prior or day of breast cancer surgery (whether a lumpectomy or a mastectomy), a physician or technician will inject a radioactive substance into the breast to help locate the sentinel node. In the operating room the surgeon may also inject a blue dye as a second method of finding the sentinel node. Usually, 1-3 nodes contain either blue dye, radioactivity, or both. All such nodes must be removed and evaluated by the pathologist. This is generally done through a small incision hidden in a crease in the armpit, but during a mastectomy, it may be unnecessary to create a second incision. If no cancer cells are present, it can be assumed with over 90% certainty that there are no cancer cells present in any of the underarm nodes. Pregnant patients may not be suitable to undergo sentinel lymph nodes sampling, due to the potential for fetal harm from the injectables. In general, patients with noninvasive cancer (DCIS) do not require sentinel lymph node sampling if breast conservation is performed

An axillary lymph node dissection, performed through a similar incision as described for the sentinel lymph node biopsy, removes between 10 to 40 lymph nodes under the armpit. When these lymph nodes contain a tumor, this means there is a higher chance of spread to the body. In general, most cancers spread preferentially to the nodes under the armpit, although some can follow a different spread, such as to the nodes of the chest. An axillary lymph node dissection is performed when a patient has clinically evident disease under the armpit, or when a sentinel lymph node yields malignant cells. Rarely, it is necessary to remove lymph nodes that extend up into the neck; this occurs only when there is gross involvement of tumor in those nodes. After an axillary lymph node dissection, a drain is placed temporarily to prevent a fluid collection from forming under the armpit.

Although the incidence of lymphedema has declined with the advent of the sentinel node biopsy and careful skill when performing the axillary lymph node dissection, it remains a problem. Several techniques involving compression and physical therapy are employed to prevent and manage lymphedema. In refractory cases of lymphedema, emerging microsurgical techniques involving transfer of lymph nodes can be considered. At NYEE, we are offering this highly specialized treatment.

Did you know that… obesity and a sedentary lifestyle may increase your risk for breast cancer?

Several studies have demonstrated that postmenopausal women who are obese have over a 50% higher risk of developing breast cancer as compared to similar-aged women who are not obese. Although the reasons for this finding are unclear, it appears that being dangerously overweight can cause elevation of certain hormones, such as estrogen, that are implicated in cancer. Leading a healthy, active lifestyle, and maintaining ideal body weight can optimize health and actually help prevent breast cancer. Furthermore, once diagnosed, weight reduction may prevent breast cancer from recurring. A healthy, nutrient-rich diet, free of excess alcohol (research show that as little as 2.5 glasses of alcohol per week can increase the risk of breast cancer!) is sure to promote a healthy, balanced life and may reduce the risk of breast cancer.

Dr. Rachel Wellner on Dense Breast Tissue

Dr. Wellner Educates Teens at World Academy of Excellence