Frequently asked questions that need an answer
The truth is that we do not know how cancer is created, in all its details. What we know are some aggravating factors, which increase a woman’s risk for cancer. We are not in position to prevent cancer. What we can do is decrease the risk or find it early. Early breast cancer has an excellent prognosis.
It is necessary for a woman who will be tested for mutations to know the implications that a positive answer will have in her life and have decided how she will cope with. The woman who has strong family history should realize that even if the test is negative the risk for breast cancer is still increased for her. It is the breast surgeon at first and finally the genetist who select the women who should be tested.
Prophylactic bilateral mastectomy decreases by 95% the risk for breast cancer in women carriers of BRCA1 or BRCA2 mutations. Laparoscopic bilateral oophorectomy decreases also the risk for ovarian cancer by 97-98%. These operations change the life of women by changing their image, their hormonal status. Mutation carriers, face also the implications to their job and family environments. It is the role of breast surgeon to inform them for all the above and for their options to cope with them. This discussion should be done before the genetic testing.
The danger is minimal and is outweighed by the benefit of early diagnosis of a cancerous or precancerous lesion. The breast surgeon will define the beneficial frequency of mammography for every individual woman.
Palpation, when is performed by a breast surgeon, may reveal lesions not shown on mammography. This happens when they are out of field, when there is increased breast density or because some breast cancers do not give clear mammography changes
The stress added to the daily lives of most women seems that it is not balanced by early diagnosis, provided of course that she visits regularly a breast surgeon.
Breast ultrasound is necessary when mammography is not diagnostic due to increased breast density and when there is a lump or an abnormality on mammogram.
When the mammogram and the ultrasound are inconclusive, breast MM may help us to decide if a lesion should be biopsied,. It is imperative to women with prostheses and to mutation carriers. The breast surgeon and radiologist should select on strict criteria the cases that need it, because there are still many false negative or positive results and the MM guided biopsy is not easily performed.
The diagnosis of cancer before the final operation, enables the surgeon to plan, in collaboration with the plastic surgeon and the patient, the best oncologic and aesthetic operation. The patient will be able to complete the screening for metastases and have organized the sentinel node biopsy (injection of radioisotope preoperatively).
Axillary’s lymph node clearance frequently causes arm edema and other complaints. Seventy percent of the patients may avoid lymph node clearance and its consequences if the sentinel node is not involved. It is performed by radioisotope injection few hours before the operation combined with blue dye injection just before the operation. This will help the surgeon to choose the right sentinel node for frozen section intraoperatively.
Breast surgery complications e.g. haematoma, infection, fluid collection etc are rare and simple to treat.
In general breast operations, if not complicated, cause easily controlled pain with simple pain killers. There are cases, mainly when the axillary’s lymph nodes have been removed, that the drainage tube drains fluid for few days, and the patients must keep it for a short period at home.
In most cases immediate restoration or the start of restoration, with insertion of tissue expanders, is possible just after mastectomy. In case of a patient with agressive cancer, who should receive chemotherapy and/or radiotherapy, restoration should be postponed for after the end of adjuvant treatment.
In few cases, chemotherapy is necessary before the operation either because there is a very advanced cancer or because we intend to decrease tumor size in order to achieve breast conservation. Chemotherapy is usually administered after the operation to patients with aggressive cancer and before hormonal treatment or when the cancer is not hormone dependent and hormonal treatment has no role to play.
Radiotherapy is administered to prevent local recurrence and this is may happen either when we do not remove the whole breast, either after mastectomy in patients with infiltration of lymph nodes or with an aggressive cancer.
Breast cancer or rather breast cancers, as no cancer is identical to others, have characteristics, which define their aggressiveness. Cancers with similar characteristics have the same prognosis either they appear in young or older women. Young women though, have more often cancers with aggressive behavior and are diagnosed late due to increased breast density.