Commentary: Breast Cancer Awareness Month sheds light on surgical progress

For 100 years, mastectomy was the only choice for women with breast cancer: Removing one or both breasts could potentially save a woman, but it left a deep and permanent scar on her chest and her psyche.

Then, during the1970s and 1980s, studies found that for tumors 5-centimeters or smaller, breast saving surgery (lumpectomy) yielded an equivalent survival rate, while maintaining better cosmetic and sensual results. The cure rate was equal to mastectomy, but the local recurrence rate was slightly higher.

Some women found the trade-off worth it, others didn’t. It took surgeons another 10 years to fully adopt breast conservation and initially, women were often not given a choice.

A lot has changed in the last 30 years. California law now mandates that women be fully informed and given a choice of treatments. All surgeons now routinely perform breast conservation surgery — some of them trained in my operating room as fellows. Breast conservation is now the primary option for most women with breast cancer and the idea that it only works for small tumors is being challenged.

In a study I recently published in the Breast Journal in January with Nirav Savalia, M.D., and breast fellows Sadia Khan, D.O. and Jessica Ryan, M.D., we found that breast-conserving surgery is a viable option for some patients with larger, multifocal tumors who were told by multiple oncologists and surgeons that mastectomy was the only option.

Most patients with larger tumors are routinely denied a chance to pursue breast conservation. The idea that breast-conserving techniques for large tumors would deform the breast also deterred many surgeons from trying.

During the last five years, we had the opportunity to treat a group of patients with large (greater than 5 cm), multifocal breast cancers who had been told that they needed a mastectomy. They specifically came to Hoag Hospital to seek out the option of “extreme oncoplasty.” Extreme oncoplasty is a breast-conserving procedure performed in a patient who has been told that because of large tumor size and/or multifocality, she is not a candidate for breast conservation.

I pioneered oncoplastic surgery in the 1980s at the Van Nuys Breast Center, the first free-standing breast center in the United States. It is a specialized surgical approach that combines the principles of oncologic surgery with the techniques of plastic surgery. This win-win combination allows a woman to save her breast without deforming it, and, in most cases, the breast looks better than before surgery.

Oncoplastic breast conservation was initially used for smaller tumors but the envelope has now been pushed so that larger, multifocal tumors can be included.

Dr. MELVIN J. SILVERSTEIN is medical director of the Hoag Breast Center and the Gross Family Foundation Endowed Chair in Oncoplastic Breast Surgery.