Breast Cancer Surgery

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Breast cancer is the most common cancer of women in the United States. As of 2018, 1 in 8 women in the U.S. will have had a diagnosis of invasive breast cancer in their lifetime. The management of breast cancer is in constant evolution. Fortunately, survival rates continue to improve, likely due to improved individualized treatment as well as earlier detection. Surgery has been a mainstay of breast cancer treatment for several decades. It is often the sole treatment in the management of early-stage breast cancer. Understanding the current recommendations for surgical treatment is vital in the accurate diagnosis, staging, and treatment of patients with breast cancer. Multiple landmark studies published in the last several decades have led to the transition from more radical options, such as radical mastectomy, towards breast-conserving surgery (BCS). The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 was instrumental in this transition. The study examined radical mastectomy to total mastectomy with or without radiation therapy. In patients who underwent a total mastectomy, axillary dissection was only necessary for the setting of positive lymph nodes. The NSABP B-04 trial confirmed there was no difference in disease-free survival, relapse-free survival, distant-disease-free survival, or overall survival between those who received total mastectomy or radical mastectomy. This development led to an overall shift away from radical surgical intervention. To further direct treatment away from radical approaches, the NSABP B-06 trial was a randomized prospective study that included women with tumors less than 4-cm and compared mastectomy, lumpectomy, or lumpectomy with radiation. All women in the study also underwent axillary lymph node dissection as part of their surgical treatment. The study found no difference in disease-free, distant-disease-free, or overall survival between groups. Additionally, there was a significant decrease in local recurrence rates when lumpectomy was supplemented with radiation therapy, rather than lumpectomy alone. This study was monumental in the evolution away from mastectomy towards breast-conserving surgery in women with early-stage invasive breast cancer. Despite these advances indicating similar overall survival between mastectomy and BCS when combined with radiation therapy, in recent years, mastectomy rates have continuously been increasing in number. There are a variety of theories regarding this, but most attribute the rate of increase to younger patient age, genetic testing, patient education, and the increasing availability of reconstruction options. Also, the use of magnetic resonance imaging (MRI) of the breast has shown recent interest, particularly in patients with dense breasts, positive family history, or difficulty in characterizing a breast tumor following diagnosis. It is important to note, however, that studies have demonstrated that the use of MRI has a positive correlation in mastectomy rates, despite no increase in survival.

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