What is the Surgeon’s Role in the Treatment of Breast Cancer?

Mark Cooper, M.D., F.A.C.S.

Women enter a "breast-focused" surgeon's office for a multitude of reasons, such as breast pain, discharge, or a mass that is either palpable (felt) or a mammographic abnormality.  An abnormality on the mammogram can be a mass, microcalcifications, or an 'asymmetric density.' Most commonly (80%), these abnormalities are benign (not a cancer). First, the surgeon must decide if a biopsy is indicated and what type of biopsy is best.  This decision is made in conjunction with the radiologist if the lesion is non-palpable (not felt) because radiologic guidance to the area will be needed.  A biopsy takes a small amount of tissue for diagnosis.  If the mass is palpable, the choices are fine needle aspiration, incisional biopsy, excisional biopsy, and core biopsy.  A core biopsy will commonly be performed under local anesthetic through a small puncture in the skin requiring only a Band-Aid.  This method results in the least trauma to the breast, an accurate diagnosis, and additional diagnostic information for breast cancer.  Next, the surgeon will order a breast MRI to evaluate for multifocal (multiple tumors in one area of the breast) and multicentric (multiple tumors scattered throughout the breast) disease.  The MRI will determine the size of the cancer in relationship to the size of the breast.  The information from the MRI will be used to determine the surgical options in treating breast cancer.  Breast conservation therapy (BCT), also known as a lumpectomy, is indicated for a small lesion isolated to one area of the breast.  BCT is followed by radiation, and the surgeon will consult a radiation oncologist for the best method.  If the lesion is too large in reference to the breast or the MRI shows multicentric disease, mastectomy is indicated.  This can be done with or without reconstruction, and the surgeon will have the patient see a plastic surgeon to discuss reconstruction options.  Chemotherapy can be given before surgery to perform a lumpectomy for large lesions, and the surgeon will discuss this with a medical oncologist.  Next, the surgery is performed and gives the necessary information to stage (I-IV) the patient which translates into survival rates.

Although long-term survival for breast cancer depends upon the stage, recent data link survival to performance measures.  Survival is better in hospitals performing greater than 125-150 breast cancer surgeries per year and survival is greater if the surgeon performs more than 15 breast cancer operations per year.  Studies show that the multidisciplinary treatment planning results in increased survival.  The role of the "breast-focused" surgeon in the treatment of breast cancer is to evaluate the patient for the best surgical option, perform surgery using experience and expertise in breast cancer, but most importantly, be a contributing member of the multidisciplinary team focused on long term survival of the patient.