Breast Cancer Surgery: Conservation vs Mastectomy and Axillary Management

There are three common causes. Duct papilloma is the most common, a benign lesion that can sometimes transform into papillary carcinoma; ultrasound will show the ducts, and if a papilloma is found, a microdochectomy (removal of the duct under image guidance) is done and sent for histopathology. Invasive ductal carcinoma itself is the second cause; around 10% of breast cancer patients present with nipple discharge, sometimes without any lump. The third is duct ectasia, seen in perimenopausal women around 45-57 years old, usually with brownish discharge, treated the same way with a microdochectomy.

The same operation done as open surgery might mean about ten days of recovery, while a robotic approach can have a patient back to work in three or four days, with less pain and lower rates of bleeding and infection, even when the cure rate is comparable. Where next-generation gene sequencing is available, a lung adenocarcinoma patient can sometimes be managed with a single daily tablet instead of radiation, chemotherapy or surgery. For complex cases with no standard guideline, such as a pregnant patient with ovarian cancer, a full multidisciplinary tumour board, pathologist, radiologist, surgical oncologist, medical oncologist, radiation oncologist and social worker, arrives at a genuinely joint decision rather than each specialist pushing their own preferred treatment.

BLK-Max runs fellowships in surgical oncology across sub-specialties, including head and neck, breast, GI and gynaecological oncology. A fellowship candidate must be a postgraduate in that particular discipline, but not necessarily a surgeon. An MBBS doctor without a postgraduate qualification cannot come as a fellow, but can come as an observer for one or two months and rotate through the various departments of oncology to get a basic understanding of case management.

Personalised cancer treatment is already underway, though there is a long way to go. It is similar to culture and sensitivity testing for a urinary infection: molecular sequencing identifies which drug the tumour is sensitive to. Lung cancer has already seen a sea change this way, and a single daily tablet is now available for metastatic pancreatic cancer. If EGFR is mutated, for example, EGFR-targeted tablets can be given depending on what the patient can afford. The next ten years in oncology will be the decade of personalised cancer treatment.

Molecular investigation has a definite role in systemic treatment: where chemotherapy is used, molecular analysis can replace it with targeted therapy or immunotherapy in some cases. For localised cancer, surgery remains the mainstay and the most curative treatment, and cannot be replaced, though in advanced disease chemotherapy can be replaced by immunotherapy or targeted therapy. For radiation, adding radiosensitising drugs identified through molecular analysis can sometimes allow the radiation dose to be decreased. The larger goal should be prevention: a cervical cancer vaccine already exists, and a breast cancer vaccine within two to three years, with vaccines against most cancers within ten to fifteen years, would be the golden day of mankind.

When the patient is pregnant, presents with locally advanced disease, or cannot undergo the radiotherapy that breast conservation surgery requires.

With a sentinel lymph node biopsy and frozen section for N0 disease; full axillary clearance is generally avoided when that comes back negative.