Form and Function

Breast cancer, and the prospect of surgery to fight it, is always an anxious experience in a woman’s life, and the decision between a mastectomy and a lumpectomy often a difficult one. Now, however, patients have yet another choice.

It’s called oncoplastic surgery, and it offers some women the opportunity to have cancerous tissue removed and their breast repaired cosmetically — all in one surgery.

“We borrowed a few techniques from plastic surgeons, from augmentation to lifts, to use in breast-cancer patients,” said Dr. Susan Cash, a breast surgeon at Baystate Medical Center. “We have the ability to remove cancer with good margins, and we’ve observed decreased recurrence rates with a much more cosmetically acceptable breast.”

Traditionally, women with breast cancer would have the cancerous tissue removed by one surgeon — through either a lumpectomy or mastectomy — and later undergo a separate procedure with a plastic surgeon for either repair or reconstruction.

But oncoplastic surgery essentially merges the two fields. Cash and Dr. Holly Mason, Baystate’s director of Breast Surgical Services, are among a slowly growing number of cancer surgeons becoming trained in these cosmetic techniques that better preserve the breast’s shape with fewer procedures and less trauma.

In this issue, BusinessWest examines how this breakthrough injects more flexibility into the decision-making process — and offers greater peace of mind to women in Western Mass.

Fewer Complications

Breast cancer afflicts one out of eight American women at some point in their lives. That’s a lot of tough decisions to be made between women and their families, said Dr. Thomas Frazier, a Philadelphia-based surgeon who serves on the advisory board of Breastcancer.org, a nonprofit informational resource.

“When I explain to a patient that they have more than one option, many ask, ‘what would you do if it was your wife?’ and I say that I’d explain the options to my wife in the same way and let her make the decision,” Frazier wrote. “But for myself, in this group of patients who have the choice, I’d feel comfortable going either way based on the scientific information. It’s basically a matter of where your comfort level is.”

That comfort level touches on what risks and side effects are acceptable to each patient. Although, statistically, most women who have a choice prefer the less-invasive lumpectomy over mastectomy, the choice between the two procedures incorporates factors ranging from whether it’s important to keep the breast — in which case lumpectomy with radiation might be the call — to how anxious the patient is about reoccurrence; some patients worry less about this possibility after a mastectomy.

Both procedures have disadvantages, however. Because lumpectomy is usually followed by several weeks of radiation, the timing of reconstruction can be thrown off, and the risk of reoccurrence is higher. Additionally, the tissue will not safely tolerate additional radiation if there is a recurrence in the same breast after lumpectomy, meaning a second cancer in the same breast will usually necessitate a mastectomy.

As for choosing mastectomy, it takes longer and is more expensive than lumpectomy, with more post-surgery side effects and a longer recuperation time — in addition to the permanent loss of the breast and the likelihood of additional reconstructive surgeries.

Oncoplastic surgery lessens some of these impacts. Making plans for breast reconstruction at the same time as cancer surgery, some doctors say, can speed the pace of recovery, both physical and psychological. Combining procedures may also reduce the risk of complications from successive surgeries.

In a typical lumpectomy, the surgeon makes an incision, removes the cancerous tissue, and then closes the opening, which often leaves the breast with a disfiguring dent. In oncoplastic surgery, however, a wedge is removed, and then tissue under the skin is pulled together to close the defect.

Doctors who pioneered the procedure say it not only maintains the shape of the breast, but usually its sensation and lactation capability as well. An oncoplastic approach may be taken by two surgeons teaming up to do cancer removal and reconstruction in the same operation.

“You need a dedicated breast surgeon willing to do these techniques and to have good relationship with a plastic surgeon in order to take care of these patients with oncoplastic techniques,” Mason said.

Many women will want to follow up the surgery with a cosmetic reduction of the other breast to even out the size and shape. Mason added, however, that some women’s breasts are asymmetrical to begin with, and occasionally oncoplastic surgery will bring them more into proportion than before.

Mason said that most cancer surgeons are accustomed to doing lumpectomies for small cancers and mastectomies for larger ones, but oncoplasty has provided an option of removing a larger cancer without the trauma of mastectomy.

It’s important, Mason said, for surgeons to be able to take out the cancer but also manipulate tissue so that the breast, while smaller than before, still retains a natural shape.

“It’s an enhanced lumpectomy,” Cash said. “What we do depends on where the cancer lies in the patient. There are several options for how we can approach it, based on the size of the patient, how big the cancer is, and where it’s located.”

In some cases, she added, chemotherapy is recommended first, in order to shrink the tumor down to a size that will allow an oncoplastic lumpectomy.

Pioneer in the Valley

Baystate is among the few hospitals in the Northeast with cancer surgeons trained in oncoplasty, but Cash said the procedure is gaining traction across the country. She and Mason traveled to Baylor University in Dallas to receive specialized training.

“For these women, the alternative is either mastectomy or lumpectomy, both which may result in a significant breast deformity,” said Dr. Mia Talmor, assistant attending surgeon at the Breast Center of the Iris Cantor Women’s Health Center at New York-Presbyterian, interviewed for the hospital’s Web site. “After surgery, both breasts will look the same, and look no different from breasts that have been reduced for strictly cosmetic reasons.”

Of course, doctors must consider more than aesthetics when guiding patients in their decision-making process. “We’re very much committed to keeping things cosmetically nice,” Mason said, “but at the end of the day, cancer surgeons must adhere to the principles of minimizing risk and reoccurrence.”

Still, many cancer patients do have choices, and Mason is happy to add another one to the list.

“We’re trying to reduce our rate of mastectomies, but some patients actually choose mastectomy over lumpectomy for their own comfort level,” she added. “We certainly respect the patient’s wishes. The nice thing is that we also have newer technologies for doing mastectomies to minimize scarring.”

“We’re giving patients more options,” Cash said.

And more confidence when it comes to deciding on one.

Joseph Bednar can be reached at

[email protected]