1. Overview: Breast Cancer- Surgical Treatment
Ms S Tormey
Consultant Breast Surgeon
MWRH Dooradoyle Limerick
Slainte an Chlair Meeting, Ennis
June 2011

2. Statistics 1 in 9 women Rising incidence
2010 > 2,500 cancers diagnosed in Ireland
Outcome from breast cancer has improved

3. HISTORICAL PERSPECTIVE
Ancient Eygptians 3,500
Hippocrates 460 BC- humoral disease
Breast Cancer considered systemic- surgery did not cure because this was a disease involving the entire body
(Humoral Theory)

4. Move to Localised Theory
17th Century- Localised disease potentially curable with surgery
19th Century-Halstead-Era of Radical Mastectomy

5. Anatomy Halstedian theory Cancer spread anatomically
Breast- Lymphatics/ direct invasion of surrounding tissues

6. Oncology Development 1895 Beatson- oopherectomy
1896 Emile Grubb- radiotherapy
Chemotherapy- 20th century

7. Influential Clinical Trials
NSABP
Milan
Breast Conservation and radiotherapy
Chemotherapy development and trials

8. Modern Surgical Practice
Less invasive surgery
More attention to cosmetic outcomes
Improved prognosis

9. Oncological Approach Combining treatments:
Surgery/Chemotherapy/Radiotherapy/Biological treatments
Multidisciplinary
“Tailored” approach

10. Breast Cancer Services in Ireland
Specialist Cancer Centres
Population of 250, ,000 per centre
new cancers p.a. per centre
High volume of cancer cases leads to experienced personnel
National Quality Assurance Standards for Symptomatic Breast Disease Services (Ireland 2000)

11. National Cancer Control Programme
Established 2006
Cancer Strategy
8 Cancer Centres
West: GUH and Limerick
South:CUH and Waterford
East:Mater/Vincents, Beaumont and James’

12. Minimally invasive surgery
1970 Breast conservation
1990’s Sentinel node biopsy

13. Breast Conservation/Oncoplastic Surgery
Volume reduction
Scars
Symmetry .

14. Oncoplastic/Reconstructive Surgery
In past decade- evolving speciality
Preservation of the breast with a cosmetic appearance, after oncological resection (oncoplastic resection)
or reconstruction after mastectomy- either immediate or delayed

15. Neoadjuvant Chemotherapy
Pre-op Chemotherapy
NAC may convert a tumour from a unifocal entity to a multifocal entity
Following neoadjuvant therapy, it is possible to have a cPR, a pPR or no response.
Negative Margins
Negative Margins
Positive Margins

16. Reconstruction
Skin sparing immediate
Nipple sparing- immediate

17. Who? Multidiciplinary discussion Factors influencing: Breast size
Tumour size
Pathology
Age
Prerequisite before decisions:
Triple assessment and diagnosis

18. Triple Assessment Triple assessment- gold standard
Clinical, Radiology, Pathology

19. Clinical Assessment History and Examination Clinical diagnosis
Accuracy- clinical breast examination is reported to have sensitivity of 68-80%

20. Radiological Assessment
Mammography
Ultrasound- focal palpable area on clinical assessment/focal area of pain

21. Mammography Standard screening tool for breast
Sensitivity increases with age
Overall sensitivity 75%, but 54-58% < 40years, and 81-94%> 65 yrs
YOUNG WOMAN
POST MENOPAUSAL WOMAN

22. Ultrasound
Used to evaluate focal areas in breast- palpable lumps/painful areas, or an area seen on mammography
Low sensitivity and specificity when used for screening

23. Ultrasound Guided core biopsy
Increases accuracy
Current standard for performing breast biopsy in lesions graded U3 or above

24. Same Day Service TAC visit takes 2-3 hours to complete
Results from imaging available at the end of the visit
Re visit the primary clinician for results
Second visit necessary for biopsy results

25. Multidisciplinary Meeting
Consists of symptomatic breast unit core personnel ie surgeons, radiologist, pathologist, medical oncologist, radiation oncologist, breast care nurses, radiographers
Held weekly
All imaging, and clinical assessment re visited, and biopsy results
Consensual decision re outcome
All surgically excised breast cancer discussed- decisions son treatment

26. Summary Last 25 years- many large trials have led to better outcomes
Current research- focus on understanding cancer genes and cancer cell growth to achieve potentially more targeted “individualised” treatment