Which Surgical Method Should Be Used for Which Patients With Breast Cancer?

Over the past 20 years, breast cancer incidence has increased substantially, and breast cancer now affects one in every 8 women. Contrary to this gloomy picture, however, breast cancer mortality rates have decreased significantly. Although wider use of mammography and increased early diagnosis are considered the main factors, advances in treatment methods certainly play a major role. Substantial progress has been made particularly in surgical treatments, which form the basis of early-stage breast cancer treatment. However, developing techniques and increasing options have brought an important question: which surgical method should be used for which patients with breast cancer?

Previously, breast cancer surgery used radical mastectomy . This method completely removed breast tissue, underarm lymph nodes, and the chest wall muscles beneath the breast. However, as methods developed over time, breast surgery became progressively less extensive. First, modified radical mastectomy was developed, preserving the chest wall muscles and removing fewer lymph nodes. Once studies found this method as effective as radical mastectomy, it quickly replaced radical mastectomy, which became a method used only for tumors involving the chest wall muscles. Subsequently, breast-conserving surgery (lumpectomy) was developed. Instead of removing the entire breast, this method removes only the tumor with some surrounding healthy tissue and is followed after surgery by radiotherapy . Later came a method that empties the inside of the breast while preserving its skin, called skin-sparing mastectomy and finally, nipple- and areola-sparing mastectomy techniques were developed.

The greatest advantage of breast-conserving surgery is preserving a large part of the patient's breast and achieving a better appearance. The greatest concern has been that the remaining breast tissue could provide a potential haven for cancer cells, with recurrence rates reaching %30. However, postoperative radiotherapy (adjuvant radiotherapy) has resolved this problem. Thousands of studies conducted over more than 20 years have shown that patients choosing mastectomy do not live longer than those receiving breast-conserving surgery followed by radiotherapy. In other words, breast-conserving surgery is as effective as mastectomy while providing a much better cosmetic result. Therefore, breast-conserving surgery should be the preferred method for these patients if there is no contraindication.

Unfortunately, However, This Method Cannot Be Used for Every Patient:

• For tumors located at multiple sites in the breast that cannot be removed through a single incision without distorting breast appearance,
• For tumors so large that their removal would fail to meet the cosmetic aim of breast-conserving surgery,
• In patients with inflammatory breast cancer,
• In patients who cannot receive radiotherapy after the procedure (pregnant patients, those with limited access to a radiotherapy center, those previously irradiated in the same breast, and those with severe connective tissue disease),
• Or in patients who are oncologically suitable but do not choose the method because they have little confidence in it or believe that removing all breast tissue would make them more certain of being completely free of the tumor, breast-conserving surgery cannot be performed.

At this point, methods that both completely remove the breast tissue and achieve a better appearance than conventional mastectomy, namely skin-sparing and nipple-sparing mastectomy come to the forefront. In general, these methods can be considered good options for women who are unsuitable for breast-conserving surgery or do not choose it but still want a relatively good breast appearance. However, the tumor must not involve the breast skin and/or nipple for these methods to be used. Which of these two methods should be preferred, and under what circumstances?

Nipple- and/or Areola-Sparing Mastectomy

This method removes breast tissue but leaves the nipple and/or the area around it in place along with the breast skin. It achieves a better appearance than skin-sparing mastectomy. It can also be performed preventively in people at high risk of developing breast cancer (such as those with a family history of breast cancer or mutations in BRCA genes) (prophylactic mastectomy).

In Skin-Sparing Mastectomy,

The nipple and surrounding areola are usually removed, while most of the remaining breast skin is preserved. This method is preferred when the nipple and/or areola are involved, meaning nipple-sparing mastectomy cannot be performed. Both methods require a plan for immediate breast reconstruction (cosmetic surgery). Studies have shown that skin-sparing and nipple-sparing mastectomy are as safe as mastectomy techniques that remove the entire breast. However, some oncologists still approach these methods cautiously.

In conclusion; breast-conserving surgery followed by radiotherapy is as effective as mastectomy for early-stage breast cancer while providing a much better appearance. Therefore, if the patient is suitable and wishes it, breast-conserving treatment should be the first method considered. Mastectomy methods should be used for patients unable to undergo this method for various reasons. At this point, it is extremely important for breast cancer patients scheduled for surgery to take an active role in choosing the appropriate treatment. Patients should openly share their concerns and expectations with their physicians and decide together on the method best suited to them.