There’s option of saving the breast in cancer surgery

For many women with early breast cancer, treatment has become considerably less radical compared to the 1990s. There was a time in Kenya when mastectomy which involves the removal of the whole breast or both breasts was the only known treatment. But as medicine advances and Kenyan doctors adopt global trends, the medics are slowly turning to breast conservation. 

Prof Ronald Wasike, a consultant breast surgeon at Aga Khan University Hospital, Nairobi, says since 1976, mastectomy has been the standard treatment for breast cancer. Other treatments were not common. But nowadays losing your breast is not the only option.

With the innovation of more cancer treatment methods, Prof Wasike says there is every likelihood of conserving the breast after treatment without compromising survival.

“We had a meeting in May this year in Florida and as researchers we came to a common ground that both methods (mastectomy and breast conservation therapy) of treatment are effective in preventing recurrence of breast cancer. Whatever choice the patient makes, they are likely to have equal chances of survival,” he said.

But he adds that conservation is only possible if the cancer is in its early stages.

He says since he started breast conservation at the Aga Khan University Hospital, he has done 1,200 such surgeries and that the women are now leading normal lives after treatment.

“I am the grandfather of breast conservation therapy (BCT) as a form of breast cancer treatment in this country, having introduced it in 2008 after returning from Canada. Before this, the common option was mastectomy,” said Prof Wasike.

Apart from conserving the breast, BCT is cheaper than the conventional mastectomy. Mastectomy can cost up to Sh380,000 in private hospitals while BCT is Sh280,000. But it can currently only be done in Nairobi.

The outcome of patients with breast and other cancers is better if they are treated by a clinician who has access to a full range of treatment options in a multi disciplinary setting.

BCT allows patients shorter stay in hospital for those who dislike the white walls.

“Mastectomy requires a patient to stay for two days in hospital for pathology tests and radiotherapy (to determine the cancer margins) to be conducted then another day of surgery, while it takes only 45 minutes to conduct BCT (in the presence of pathologists),” said Prof Wasike.

BCT involves the removal of the cancer tumours with clear margins on the affected breast. This is then accompanied with a simple radiation therapy to remove any cancer tissues that may have remained.

It can be done in two ways, namely, lumpectomy or quadrantectomy. Lumpectomy focuses on the removal of the tumour and a small amount of surrounding breast tissue to prevent recurrence followed by a radiation therapy on the breast.

“Quadrantectomy, on the other hand, is done when the tumour is big and the patient has big breasts. It involves cutting out the whole quadrant of the breast where the cancer lies with clear margins,” he said.

He says that as a prevention measure, thorough examination of the resection borders of the specimen during lumpectomy or quadrantectomy must be conducted to ensure that they are free of tumour cells to avoid recurrence. Armpit lymph nodes are also removed to prevent the spread of cancer cells to other parts of the body.

Prof Wasike said one-size-fits-all treatment is not ideal as every patient is different.

“Individualised treatment is the best because it offers treatment that will work well for each person. We have a tumour board where we look at factors such as age, involved lymph nodes, functional status, the molecular sub type of the breast cancer we are dealing with – and they are all brought together to determine the likelihood of recurrence,” said Prof Wasike.

Although there is no difference in overall survival of patients between the two treatments, Prof Wasike notes that women who had BCT felt better about themselves as compared to those who have undergone mastectomy.

“What I have come to establish however is that conservation does not give some patients peace of mind. They always worry that they will go back to square one but a majority feel good about themselves as they still have their breasts intact,” he said.

Another challenge facing this treatment is that most patients go for check-up too late when conservation cannot be done. He says two weeks ago, 12 patients went for screening when it was too late. They were all sent for immediate new advanced chemotherapy before surgery.

“I have seen patients who come late even up to the fourth stage. When they come late you cannot save the breast,” he said.

On what point treatment is determined, the doctor says he decides together with the patient when she is diagnosed with the disease. A patient is then sent for ultra sound, mammogram, CT scan, and treatment is done depending mainly on the size and site of tumour and also the ratio of tumour to the breasts (depending on the size of breasts).

The breast that is conserved must at the end of the surgery look closely like the one that has not been operated on, he said. If the breast is small and the tumour is big, it cannot be conserved. The opposite is the case for a big breast and small tumour.

“Also if it is close to the nipple and the tumour is big, the tumour cannot be removed because for most women the nipples equals breasts. We look at all these factors and determine type of treatment,” said Prof Wasike.

“But doctors need to be more educated because most of them say cancer equals mastectomy,” he noted.

For BCT to be successful. teamwork is important. 

“You cannot do BCT without a pathologist on the side to do the margins, it is team work to determine if a surgeon has removed all clear margins. Radiologists are also important to determine the tumour from skin, muscle, surrounding tissues. It is crucial,” he said.

Prof Wasike has since embarked on a mission to educate doctors countrywide on other forms of breast cancer treatment like BCT.

“I was in Mombasa and Eldoret recently and I am going to Meru tomorrow. At the end of it once I get a particular group of champions to do that, it will be all good. It is my mission and it is working and a few people (doctors) have been converted,” he said.

The doctor says that the alarming rate of cancer deaths currently in the country can only be managed if people go for yearly screening. Last week, the American Cancer Society revised its guidelines for when and how often women should receive screenings for breast cancer.

The group suggests women start yearly breast scans at age 45 instead of 40 and for healthy women to have scans every other year at ages 55-74.

Historically there has been much disagreement over the right time and frequency for mammograms. But, do Kenyans care to go for early screening?

Indicative statistics show about 40,000 people are diagnosed with different cancers every year in Kenya, at least 80 of them die of the disease daily. Of the same total, 30,000 die yearly.

Professor Wasike said that cervical cancer is the most commonly diagnosed in women, with 5,000 diagnosed annually and about 3,750 dying, followed by breast cancer.