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For decades, women have relied on two types of surgery for removing breast cancer – mastectomy, which removes the entire breast, and lumpectomy, which removes only the part that contains the cancer.

“It used to be that mastectomies were routine for treating breast cancer,” says Stefanie Kolpak, MD, a board-certified general surgeon with Kaiser Permanente Colorado. “Today, lumpectomies are often a good option. Compared to mastectomies, these breast-conserving procedures offer women a quicker recovery – physically and emotionally.”

Still, even mastectomies have greatly improved in the past few decades. “Decades ago, some of the chest wall muscles and all the underarm lymph nodes were routinely removed during mastectomies. Today, these procedures are usually much less invasive,” Dr. Kolpak explains. “And, sometimes, it’s possible to have the breast reconstructed immediately after the mastectomy, while the patient is still under anesthesia.”

Promoting preservation
Years ago, fewer women qualified for lumpectomies, usually because their tumors were too large, or they were located in a part of the breast that was difficult to reach. Thanks to better and more frequent screenings, more tumors are now discovered when they are small.

Today, even some women who have larger tumors can qualify for lumpectomies. This is due to the introduction of neoadjuvant therapy, which uses chemotherapy to shrink a tumor before performing the lumpectomy. “Neoadjuvant therapy works on a small percentage of patients, who in the past would have required mastectomies,” Dr. Koplak says.

Supplementary treatments
Women who have lumpectomies generally receive radiation afterward to prevent cancer cells from coming back. Studies show survival rates are the same for women who have lumpectomies with radiation as they are for those who undergo mastectomies.

Doctors may also tailor chemotherapy and hormone therapy, depending on the actual characteristics of the cancer. “Today, we can perform tests, such as the Oncotype DX, which enable us to match our treatment to the tumor’s behavior, or ‘personality,’” Dr. Kolpak explains. “If the tumor is likely to return, we can aggressively treat patients with chemotherapy. If it’s not, we can spare them this treatment – and its side effects.”

Preserving lymph nodes
During a mastectomy or lumpectomy, it is important to evaluate the lymph nodes to determine if the cancer has spread beyond the breast. This lymph node evaluation has also become less invasive.

“In the past, women undergoing mastectomies and lumpectomies would have most of the underarm lymph nodes removed as part of breast cancer staging,” Dr. Kolpak says. “Thanks to recent studies, we have learned this is not always necessary. When tumors are five centimeters or less, we know there is only a 15 percent chance of cancer being in the lymph nodes.”

As a result, today’s doctors typically remove only one to three lymph nodes and check them for cancer. This procedure, known as a sentinel node biopsy, has become standard in the past 10 years. If no cancer is detected, women can keep their remaining lymph nodes. This decreases the risk of arm numbness and lymphedema, a condition that occurs when fluid builds up in the arm. Lymphedema has a 20 percent chance of occurring when all the lymph nodes are removed, but only a 2 percent chance when the sentinel node biopsy is performed.

“If we do find cancer during the sentinel node biopsy, the remaining lymph nodes must be removed – and the patient will usually require postoperative chemotherapy,” Dr. Kolpak adds.

Early detection remains goal
“At Kaiser Permanente Colorado, we are dedicated to caring for patients with breast cancer and their families at every step – from detection, through treatment, and lifetime follow-up,” Dr. Kolpak says. “However, our ultimate goal is to empower more people to catch breast cancer tumors early – even before patients or doctors can feel them.”

Along these lines, Kaiser Permanents Colorado is also working to identify people who have a genetic risk for breast cancer, such as the BRCA1 and BRCA2 genes, and develop screening programs just for them. “As always, the best way for any patient to detect cancer early is with routine screening mammograms,” Dr. Kolpak says.

To learn more about surgical advances for treating breast cancer, visit KaiserPermanente.org.
 
Dr. Kolpak received her medical degree from the University of Florida College of Medicine, Gainesville. She completed her general surgery residency at The University of Colorado Health Sciences Center.