All About Mastectomy..

Breast cancer is the commonest cause of death among women between the ages of 37 and 55. According to statistics, six of every .100 American women will get breast cancer, and to most of them the conventional treatment, radical mastectomy, followed by radia. tion, seems to be almost as bad as the disease itself.

United States surgeons have treated breast cancer with the radical mastectomy for over 100 years, although it is no longer the preferred treatment in England or Scandinavia. Studies done in England and Scandinavia raise the question of whether or not the women who submit to radical mastectomies are doing so with informed consent,

The California Supreme Court, in a landmark decision on the question of informed consent, has attempted to spell out a physician's duty to tell a patient about the choices of treatment available and the dangers involved.

(American Medical News December, 1972)

Treatments

Partial Mastectomy removal of the part of the breast in which the tumor is located including the overlying skin and the underlying membrane which covers the muscle and a zone of surrounding breast tissue. After removal the breast is reconstructed as far as possible to its former shape.

ART

removal of all of

Radical Mastectomy the breast, the muscles of the chest wall, the lymph nodes and fat in the armpit.

Modified Radical Mastectomy

—

same as

the radical mastectomy except that no muscles of the chest wall are removed.

—

Simple Mastectomy removal of the breast. Subcultaneous Mastectomy removal of the breast tissue. The skin and nipple are left intact.

Radiation may be used with any of these forms of treatment.

In the incidence of a partial mastectomy the breast will always be a little smaller than before but the shape of the reconstructed breast is nearly normal depending on the size and location of the tumor. A plastic implant is usually inserted at the time of the operation and cosmetic surgery may be done later. Pain and discomfort are usually minimal, and most women resume their normal activities within a few days.

The chief disadvantage of this procedure is that the cancer may not be confined to lump, but may be scattered elsewhere. If not removed these tumors may grow and necessitate another operation. Tumors located in the lymph nodes can be removed later with just as good prospects of a cure as when removed at the first operation.

Partial mastectomy preserves the nipple and most of the breast, and this is the chief advantage of this form of treatment.

With partial mastectomy there exists the danger that a new breast cancer will occur in the remains. For this reason, simple or modified radical mastectomies are better and are almost as easy for the patient in terms of

page 6/What She Wants/December, 1974°

discomfort. However, if the patient wishes to have a partial mastectomy over the other forms of treatment she should be given that option. If there is a reoccurence of breast cancer, another operation can often be a successful treatment.

The reported rates of survival at both five and ten years of patients treated by local excision and radiation are nearly identical to those of patients treated with radical operations.

The muscles of the chest wall are removed in the case of radical mastectomy and the skin lies on bare ribs. This causes great discomfort to the patient who is left with no cushioning fat tissue. If the nerves to the muscle are damaged, weakness of the shoulder can result and sometimes the scar left binds the upper arm to the side so that the patient cannot reach over her head. Swelling can also result in the removal of the axilliary nodes. Often the woman cannot wear anything but high necked clothing because removal of the chest muscles leaves a sunken area. When radiation is added to this treatment, the complications are usually more se-

vere.

Radical mastectomy does not always cause disability and discomfort, and many women have made physical and emotion adjustments to this treatment. But for those who have not, it can be a bitter alternative to the disease.

The use of modified radical mastectomy as

a treatment for breast cancer causes no more deformity and a little more disability than the removal of the breast. With this operation swelling is rare. This operation is best when the lymph nodes are moderately involved. However, when involvement of the nodes is extensive, they are usually best treated with radiation alone. Radiation, when used with a modified radical operation, usually causes severe swelling.

The simple mastectomy leaves the muscles and lymph nodes intact and never causes swelling of the arm or weakness in the shoulder. If the nodes left intact are not infected by cancer they may help in maintaining the patient's

Feeling in armpit

Stand before a mirror:

first with arms

of sides, then

arms raised -

Watch out for Dimpling Change in shape Change in nipples

Feet for lumps with fingers flat against the breast.

Examining outer,

upper quarter of breast,

Examining upper, inner

Quarter

Think of the breast os being divided into quarters.

Lower, inner quarter

Examining lowRT, outer quarter Self-examination of the breast. (From Dowling. H. F., and Jones, T.: That the Patient May Know. Philadelpha, W. B. Saunders Co., 1959.)

immunity to cancer. Occasionally, even if the nodes appear not to be involved, they may contain tiny deposits of cancer which grow and later necessitate a small secondary operation to remove them.

Studies indicated that the cancer is as well controlled by this secondary operation as it would have been if the nodes had been removed with the breast at the first operation.

Subcutaneous mastectomy leaves the skin and nipple intact, removing only the breast tissue. Later, a plastic implant can be inserted to restore the breast to its former shape and size. The plastic form is not inserted immediately because the presence of foreign material might stimulate the growth of new cancer cells. This operation has been reserved for women with "noninvasive cancer," which means that the disease is localized and has no tendency to spread. Dr George Crile, former head of Surgery at the Cleveland Clinic believes that the subcutaneous mastectomy will gain favor and be used in the future as a treatment for deep seated cancers in which the skin and nipple have not been invaded.

Radiation may be used with any of the operations, but usually causes severe swelling of the arm when used-with radical or modified radical operations. If no tumor seems to be left, its use as a precaution does not increase the survival rates.

Controversies

It seems absurd that after more than 100 years of experience with modern surgical techniques, there is still no agreement among surgeons as to the best way to treat breast cancer. But there are good reasons for this lack of agreement. The most important one is that once the primary cancer in the breast is completely removed whether by partial or simple mastectomy there is almost no difference in the patient's chances of survival regardless of what else is done at the primary operation.

(Dr. George Crile)

If the tumor has spread throughout the system and is incurable, it makes no difference what kind of treatment is given to the primary tumor located in the breast. A radical operation will not increase survival rates any more than a simple one will.

When the nodes are not involved and cancer is limited only to the breast, any operation that removes the primary tumor in the breast is just as effective as an operation that removes the nodes. The radical operation in this case will not increase survival rates.

If there is no apparent spread to distant organs but the axillary nodes are involved, there is one chance in four that the cancer has not spread to the other organs of the body. In the case that it has, it does no good to do a big operation that removes the nodes and causes the patient added discomfort. If the cancer has not spread to organs other than the breast and lymph nodes, an operation that removes the breast and nodes would cure the patient. However, these patients comprise ten jout of 100 women who might live longer after a radical operation than after a simple one. If these women are treated with a simple operation, the nodes, having been found to be

cont.

Page 7