Breast cancer incidence is rapidly increasing in India and has overtaken cervical cancer in Indian women in metropolitan cities. One in 22 women in India are likely to develop breast cancer during their lifetime. Breast cancer is a disease of old age with peak incidence in the fifth and sixth decades - but in India the disease is seen a decade earlier, probably due to shorter longevity of women living in India (about 62 years according to census of India), compared with peers those in the United States.
Statistically, breast cancer is more common among unmarried women, nulliparous women and those who do not breastfeed their babies. Smoking, drinking alcohol and intake of high fat diet is associated with the causes of breast cancer and a high incidence among women residing in metropolitan cities of India, where Western lifestyle seems to be taking hold.
In India, nearly 50 percent of breast cancer patients present with locally advanced disease. The main reason for this is the final presentation of illiteracy, poverty, lack of awareness, a sense of shame, ignorance coupled with lack of health education. The absence of pain at an early stage adds to the cause of delay in seeking medical advice.
Breast cancer surgery has changed significantly in recent years from radical to conservative approach. Surgical treatment of breast cancer should be determined for each woman individually. Breast cancer patients were twice as likely to be offered breast-conserving surgery (BCS) when treated by surgeons at a dedicated cancer center rather than by a surgeon in private practice, according to a national survey of breast specialists conducted by the American Society of Breast Disease. In this study only 19% of surgeons used BCS in their practice while 81% were performed mastectomy regardless of stage of disease.
Patients may have an initial gut preference for mastectomy as a way to "take it as soon as possible". Women tend to prefer mastectomy more often than their surgeons do because of this feeling. But, study after thousands of women for over 20 years of follow-up showed that there was no difference in overall survival in mastectomy over breast conservation therapy. Therefore, proper counseling is very important. Only a surgeon, who believes him / herself, can spread the idea and convince the patient for breast conservation.
Women whose breasts are preserved have fewer episodes of depression, anxiety and insomnia. A recent multicenter study of patients with early stage breast cancer found that women undergoing breast conservation therapy have improved body image, higher satisfaction with treatment and no additional risk of recurrence compared with women treated with mastectomy. Careful selection of patients for breast conservation is very important for a successful outcome.
Indications for breast-conserving surgery (BCS):
A. Patient's desire for breast conservation.
2. Tumors less than 4 cm (T1 or T2).
3. Both breast vs tumor volume ratio.
4. Availability of radiotherapy and mammographic facilities.
5. Patients with axillary lymph N0 or N1.
6. Non-pendulous breasts to allow uniform distribution of radiation dose.
Contraindications for BCS:
A. Multicentric breast cancer.
2. Diffuse malignant micro-calcifications visible on the mammogram
3. Matted axillary lymph nodes (N2).
4. Recurrence in the conserved breast before.
5. Collagen vascular disease.
6. Early pregnancy.
7. H / o prior irradiation to the chest wall.
8. Positive surgical margin
Relative contraindications for BCS:
A. Tumor size> 5 cm. (T3)
2. High risk of residual tumor or positive surgical resection margin.
3. Large tumors in small breasts.
4. Poor histological differentiation.
5. Extensive intraductal component (> 25% of DCIS tumors)
Breast Reconstruction
Reconstruction should be offered to all women who underwent total mastectomy or breast conservation surgery (BCS) to leave a cosmetic deformity which can not be accepted. Immediate reconstruction is more convenient for patients, less expensive, and limiting exposure to risk of anesthesia. Aesthetic results tend to be better and the patient does not have to live with a disability, even temporarily.
Reconstructive surgery can be delayed or carried out immediately by either breast or autologous tissue. Autologous flaps are most commonly used is the TRAM (transverse rectus abdominis myocutaneous) flap, the latissimus dorsi flap or free flap.
Breast conserving surgery is a treatment modality for early-stage breast cancer that causes less physical disability and psychological trauma to patients. Many prospective randomized trials have shown that the rate of overall survival and disease-free for early stage breast cancer after mastectomy or BCS with equivalent postoperative radiotherapy.
Patients with (retro) sub central areolar cancer or Paget's disease of the nipple that require resection of Nipple-areolar complex (NAC), also can be treated with breast conservation with acceptable cosmesis.
In conclusion, breast-conserving surgery combined with radiation is now well established as a local-regional treatment is preferred for the majority of patients with early stage (stage 0, stage I and stage II) breast cancer. Properly selected patients can expect equivalent long-term survival of this disease, yet avoid mastectomy with all the physical and psychological aspects of the negatives of the procedure, more radical ablative. Not all patients, however, considered appropriate candidates for breast conservation approach.
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