May 14, 2013

Women have more options for breast cancer surgery

The Associated Press

CHICAGO — One of the world's most glamorous women had an operation that once was terribly disfiguring — removal of both breasts. But new approaches are dramatically changing breast surgeries, whether to treat cancer or to prevent it as Angelina Jolie just chose to do. As Jolie said, "the results can be beautiful."

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Rose Ragona is photographed in Chicago on May 1, 2013. Ragona was diagnosed with breast cancer and recently had a mastectomy where surgeons saved much of her skin and started reconstruction during the same surgery. Treating breast cancer almost always involves surgery, and for years the choice was just having the lump or the whole breast removed. Now, new approaches are dramatically changing the way these operations are done, giving women more options, faster treatment, smaller scars, fewer long-term side effects and better cosmetic results. (AP Photo/Carrie Antlfinger)

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Actress Angelina Jolie arrives for the British Gala premiere for the film 'Salt', at a central London cinema, in this Aug. 16, 2010 file photo. Jolie authored an op-ed for Tuesday’s May 14, 2013 New York Times where she writes that in April she finished three months of surgical procedures to remove both breasts as a preventive measure. She says she’s kept the process private but is writing about it now with hopes she can help other women. (AP Photo/Joel Ryan, File)

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Jolie revealed on Tuesday that she had a double mastectomy and reconstruction with implants because she carries a gene mutation that puts her at high risk of developing breast cancer.

For women who already have the disease, the choice used to be whether to have the lump or the whole breast removed. Now there are more options that allow faster treatment, smaller scars, fewer long-term side effects and better cosmetic results. It has led to a new specialty — "oncoplastic" surgery — combining oncology, which focuses on cancer treatment, and plastic surgery to restore appearance.

"Cosmetics is very important" and can help a woman recover psychologically as well as physically, said Dr. Deanna Attai, a Burbank, Calif., surgeon who is on the board of directors of the American Society of Breast Surgeons. Its annual meeting in Chicago earlier this month featured many of these new approaches.

More women are getting chemotherapy or hormone therapy before surgery to shrink large tumors enough to let them have a breast-conserving operation instead of a mastectomy. Fewer lymph nodes are being removed to check for cancer's spread, sparing women painful arm swelling for years afterward.

Newer ways to rebuild breasts have made mastectomy a more appealing option for some women. More of them are getting immediate reconstruction with an implant at the same time the cancer is removed rather than several operations that have been standard for many years. Skin and nipples increasingly are being preserved for more natural results. Jolie, for example, was able to keep her nipples and presumably her skin.

Some doctors are experimenting with operating on breast tumors through incisions in the armpit to avoid breast scars. There's even a "Goldilocks" mastectomy for large-breasted women — not too much or too little removed, and using excess skin to create a "just right" natural implant.

Finally, doctors are testing a way to avoid surgery altogether, destroying small tumors by freezing them with a probe through the skin.

"Breast surgery has become more minimalistic," said Dr. Shawna Willey of Georgetown's Lombardi Comprehensive Cancer Center.

"Women have more options. It's much more complex decision-making."

Breast cancer is the most common cancer in women around the world. In the U.S. alone, about 230,000 new cases are diagnosed each year.

Most can be treated by just having the lump removed, but that requires radiation for weeks afterward to kill any stray cancer cells in the breast, plus frequent mammograms to watch for a recurrence.

Many women don't want the worry or the radiation, and choose mastectomy even though they could have less drastic surgery. Mastectomy rates have been rising. Federal law requires insurers to cover reconstruction for mastectomy patients, and many of the improvements in surgery are aimed at making it less disfiguring.

Here are some of the major trends:

IMMEDIATE RECONSTRUCTION

Doctors used to think it wasn't good to start reconstruction until cancer treatment had ended — surgery, chemotherapy, radiation. Women would have a mastectomy, which usually involves taking the skin and the nipple along with all the breast tissue, followed by operations months later to rebuild the breast.

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