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James Dickinson, M.D., Northern Colorado Surgical Associates, P.C. - Photography by Warren Diggles

“I have never had a breast cancer patient who regretted removing her breast.” says Lisa Burton, M.D. at Surgical Associates of Greeley, P.C. “There is beautiful plastic surgery available and my patients are not usually reluctant to have the tissue gone. A mastectomy doesn’t have to be looked at as the worse thing in the world.”

Many women face that possibility on a regular basis. According to the American Cancer Society, over 190,000 American women will be diagnosed with breast cancer in 2009, accounting for more than one in four cancers diagnosed. But times have changed for treatment.

Those patients who had mastectomies years ago faced a long, hard recovery. “Historically a radical mastectomy involved the removal of all breast tissue and muscle tissue,” says James Dickinson, M.D., PC, at Northern Colorado Surgical Associates in Fort Collins. “The real pain and resulting disabilities came from removing the muscle tissue and doctors moved away from that and began performing modified radical mastectomies in the 70s.”

He explains, “In the 80s, we determined that a portion of the breast could be removed in certain circumstances and the survival rates were the same as a mastectomy, provided a woman completed radiation therapy as well. Recurrence of cancer in the breast occurs at a higher 15 percent rate in patients who have just a portion of the breast removed versus four percent in mastectomy patients. But now patients have some choice in which procedure they want performed.”

With efforts to reduce patients’ pain and allow for easier restoration, the newest techniques allow skin sparing and, in some cases, nipple sparing. The goal is to minimize any chance of recurrence while avoiding any loss of function and also maximizing options for reconstruction.

“The decision we have to make with removal is whether we take a portion of the breast or the entire breast. With a modified radical mastectomy, all fatty breast issue is removed but not the muscle,” Dickinson says.

Incisions are typically located so they are not visible in a low neckline or bathing suit. Through an incision in the shape of an ellipse, the surgeon removes a minimum amount of skin and tissue so that remaining healthy tissue can be used for possible reconstruction. Thin skin flaps are created carefully allowing maximum removal of diseased breast tissue. The skin over a neighboring pectoral muscle is then removed before the surgeon moves to the armpit area.

Lisa Burton, M.D., Surgical Associates of Greeley, P.C. - Photography by Warren Diggles

“I think people still associate mastectomies with muscle removal,” Burton says. “I have patients ask, ‘do you have to take that muscle like they did with my mother?’ We rarely have to take muscle and that is the thing that was particularly debilitating. We also take fewer lymph nodes. We know that taking a huge amount of lymph nodes doesn’t help and can lead to permanent lymphedema.” Lymphedema is a condition where localized fluid is retained, causing tissue swelling. Tissues with lymphedema have a greater risk of infection.

Managing the lymph nodes also caters to less unnecessary removal of tissue in the armpit area. “If cancer is going to spread from your breast to your lymph nodes, it moves in an orderly fashion,” Burton says. “It goes to the sentinel node first. These days, we try to remove only a few sentinel lymph nodes.”

She adds, “In the old days, we took a large number of lymph nodes out of every patient, but we now know most of these will not have cancer. Only about 40 percent of our patients have cancer in their lymph nodes. So women do not need to have a lot of lymph node tissue removed.”

Reconstruction can also be accomplished at the same time as the mastectomy. “Previously, women had a mastectomy in one surgery and plastic surgery in another,” she says. “We now think it’s safe to do both at once. Around 90 to 95 percent of my patients do their reconstruction at the same time as the mastectomy.”

That is, of course, personal option, Dickinson says. “With a mastectomy, a woman can choose to have or not have reconstruction. Frequently women are surprised at how little pain there is from a mastectomy. Much of the pain that occurs is part of the reconstruction process. That comes from stretching the muscle tissue or putting in expanders.”

Most patients, Burton says, opt for reconstruction. “Most women don’t choose to live flat-chested. Most of my patients meet with the plastic surgeon immediately so they can hear their options.”

Recent changes help prepare the area for reconstruction, Dickinson says. “We can leave more skin to allow for better reconstruction. Smaller incisions can be filled in with an implant or the patient’s own tissue. With the skin sparing techniques, implants are easier to do and usually less debilitating.”

Dickinson says that nipple sparing is also possible. “That is controversial, however. There’s an ongoing discussion as to how beneficial that is both from a cosmetic standpoint and an oncologic standpoint.”

“Leaving the nipple is controversial because most breast cancer starts in the ducts,” Burton adds. “Theoretically from a cancer standpoint, all the ducts converge under the nipple so we might be leaving some duct tissue under the nipple. We try to get all the duct tissue off the backside of the nipple and then we follow the patient very closely. It’s also a harder surgery to do and we don’t offer that to many patients.”

Implants are part of the reconstruction option, Burton says, adding that silicone implants are back in use. “Silicone implants are far superior to saline. Saline implants have a more artificial feel to them and silicone looks and feels better.”

While much of the surgical approaches remain the same as in the past decade, there are advances in diagnostics. “One is the digital mammography and another is the breast MRI. Digital mammograms are especially good for women under 50 who have dense breast tissue,” Burton says.

In the past, mastectomy procedures were likely to remove breast and muscle tissue. Today’s mastectomy procedures leave muscle tissue largely untouched, and spare as much breast tissue, lymph nodes, and skin as possible, decreasing disfigurement and pain associated with the procedure.

“The breast MRIs provide a deeper look at the breast tissue. They are especially nice for women who have a diagnosis of breast cancer because they help us determine the right approach for the operation. We can decide if we can save the breast or not,” she explains. “When we do MRIs before surgery, we can see other cancers that wouldn’t show in a mammogram. Fifteen percent of the time, I find more cancer.”

Dickinson says that new tests also determine genetic markers. “We can test for specific genes known to cause breast cancer. Genetic studies allow us to predict the future because we know some of the genes that predispose an individual to breast cancer.” He cautions, however, that “we know some of the tumors that cause breast cancer but we don’t know all of them.”

Dickinson’s prediction for the future is that more genetic markers will become known. “That will not only allow us to know who might get cancer but it can help us with targeted therapy. We’ll be able to identify a target for chemo to go after much like a smart bomb. We’ll be able to direct it at a particular protein.”

In the meantime, Dickinson urges regular screening and self-exams on a regular basis.