Breast Cancer ChoicesTM  
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Scrutinizing the evidence for breast
cancer procedures and treatments



    I'm scheduled for surgery in two weeks but I'm discovering
    there's a lot more information I should know. I definitely want
    to "look before I leap" after hearing from breast patients who
    say they would do their surgery differently. Can I safely postpone?

    Please let your doctor know you want to get as much information
    as you can to make the choice you must live with the rest of your life.
    Putting off surgery a month or so on a tumor that has most likely been
    there 6-8 years in order to get your thoughts straight is most always
    acceptable to your doctor.

    I am going to have surgery. How can I reduce the spread
    of cancer cells before and during my procedure?

    According to Robert Rosser, MD., writing in The Breast (2000), choosing
    minimally invasive procedures may help to reduce the spread of cancer cells around the
    time of surgery. Most surgeons want to get a wide margin, that is,
    cut as far out from the tumor as they can and still achieve a good cosmetic
    effect. But Rosser and others suggest further steps be taken.

    1. Avoiding trauma to the breast may prevent the spread of cancer:
    No compression of the breasts, no squeezing of the breasts, no massaging
    of the breasts during medical procedures.  The longer an injury-induced
    traumet exists, the longer this occult micrometastasis has time to grow larger, divide, and become a
    full-sustaining malignancy if not removed.  See Dr. Rosser's article.


    2. "Full surgical procedures should be done as soon as possible, taking great care
    in handling the tumor and to excise wide margins around the neoplastic mass." See
    Carroll RG, Lancet Oncology, [2004].

    3. "Tumor cells may be inadvertently spread by several mechanisms during surgical
    procedures. These include the grasping of lymph nodes with forceps, the local
    injections of analgesic agents, and the insertion of the arterial clip into the tumor to
    protect bleeding." See also Coffey, et al., Lancet Oncology, [2003]

    The take home question is:

    Can you plan your surgery with your doctor in order to avoid
    trauma to your  breast in order to forestall possible spread of
    cancer cells?

    Are there other ways to decrease the possibility of surgery induced metastasis?


    I’m scheduled for a lumpectomy with no node procedures. Must I have
    general anesthesia?

    Some patients request a mild sedation with local anesthesia.  Some prefer to be
    awake and alert. Still others want to be out cold. Discuss your preferences with your doctor
    and if you prefer local anesthesia get complete assurance from your surgeon in advance.  
    Otherwise, you may arrive at the hospital and you may be pressured to have a general anesthesia.
    When you sign the surgical consent form, it is necessary to read it carefully. Be sure
    to indicate on the form that you are not consenting to general anesthesia for your lumpectomy
    unless complications ensue and your life is at stake.

    I have heard that timing my surgery with my menstrual cycle may improve my
    outcome. Is this assertion true?

    This subject has been studied several times with conflicting results,
    depending upon how the researchers got their information. However, timing surgery after ovulation
    appears to improve outcomes. Timing Surgery

    In The Lancet article, "Excisional Surgery for Cancer Cure: Therapy at a Cost," (Dec.
    2003), Coffey, et al. suggest that the activity of NK (natural killer) cells are already
    impaired in patients with underlying malignancies. Add to this insight the fact that  NK cell activity
    changes during the menstrual cycle such that the numbers of these
    immune cells are lower in the follicular phase prior to ovulation and higher in the
    luteal phase after ovulation.  This difference in immunity may help explain why there
    is an earlier pattern of recurrence in premenopausal women operated on during their follicular cycle.

    Veronesi, et al. (see below) found that premenopausal women who were operated
    on during the luteal phase had a "signficantly better prognosis" than women
    operated on during the follicular phase due to the reduced NK cells and/or the high
    concentration of unopposed estrogens during the follicular phase.

    Similarly, other researchers agree that the luteal phase is when the protective benefit of
    progesterone helps to balance what had been estrogen dominance.

    Dr. Susan Love has endorsed the notion of timing surgery.  (See her website,www.
    susanlovemd.com, for more specific details.)  Your doctor, however, may feel that
    timing surgery is hogwash. If so, you can only ask if there is any evidence that waiting this
    small amount of time will have a negative impact on your survival.

    The medical journal, The Lancet (1994),  published clinical trial information on breast
    cancer surgery timing that is excerpted below with emphasis for clarity.

    Effect of menstrual phase on surgical treatment of breast cancer.


    Veronesi U, Luini A, Mariani L, Del Vecchio M, Alvez D, Andreoli C, Giacobone
    A, Merson M, Pacetti G, Raselli R.
    Istituto Nazionale per lo Studio e la Cura del Tumori, Milano, Italy.

    1175 premenopausal women whose date of last menstrual period was
    known were followed up for up to 20 years (average 8 years) after surgery for
    breast cancer. 525 patients were in the follicular phase and 650 in the luteal
    phase. We observed 192 unfavourable events among patients operated on
    during the follicular phase (36.6%) and 192 among patients operated on
    during the luteal phase (29.6%). The effect of phase was restricted to patients
    with positive axillary nodes. The 5-year relapse-free survival was 75.5% in
    246 node-positive patients operated on during the luteal phase and 63.3% in
    190 node-positive patients who had surgery during the follicular phase. The
    hazard ratio at Cox multivariate analysis was 1.329 for all patients (p = 0.006)
    and 1.431 for node-positive patients (p = 0.03). In our study, premenopausal
    patients with breast cancer and positive axillary nodes operated on during the
    luteal phase had a significantly better prognosis than patients operated on
    during the follicular phase. It may be that the processes of cell metastases,
    such as loss of adhesiveness, may be enhanced by high concentrations of
    unopposed oestrogens or by reduced activity of natural killer cells during the
    first half of the menstrual cycle.

    Are there reasons to avoid general anesthesia when possible?

    The consent form for general anesthesia speaks for itself. Be sure to get a copy of
    your hospital's consent form as far in advance of your surgery as possible. In reading
    it you will see reasons to avoid general anesthesia unless absolutely necessary.
    Some women report more side effects (some lasting months) from the anesthesia
    than the surgery.

    Bear in mind that general anesthesia can affect the immune system: "Depression of
    lymphocyte (a type of white blood cell) transformation is detectable two hours after
    induction of anesthesia and is generally restored to normal after one week." (See
    Coffey, et al. above.)

    How much pain will I feel after a lumpectomy if I do not have a node procedure?

    Most patients report they have not had very much pain following a lumpectomy.
    Some may require mild pain medications for a day or two. Still others may require pain
    medication for a longer period of time

    I have chosen to have a mastectomy without a nodal procedure.  Immediately after
    surgery I expect to be given morphine for pain. I've heard that morphine may promote tumor
    growth. Is there any evidence for this assertion?

    We are currently reviewing evidence that morphine may not be the wisest pain
    reliever choice for cancer patients. See Gupta, et al., Morphine Promotes
    Angiogenesis and Breast Tumor Growth In Vivo," Cancer Research (2002).

    What about breast reconstruction?

    Reconstruction carries a complication rate of up to 24% (Nahabedian [2003]). There
    are Internet groups dedicated to women contemplating these procedures. These
    groups will be able to give you a comprehensive look at the risks.

    Still, a recent article in Breast Cancer Research, by Gem (2005) showed longer
    survival rates among those who had reconstruction than among those who did not.
    The researchers looked at analyzed data from the Surveillance, Epidemiology and
    End Results (SEER) Breast Implant Surveillance Study conducted in San Francisco-
    Oakland, in Seattle-Puget Sound, and in Iowa. Given the infections that often
    accompany reconstruction procedures, this result seems paradoxical and is not fully understood.

    How long will I be hospitalized after a simple mastectomy?

    As long as you have not had nodes removed you will probably only need to stay one
    or two nights. Discuss this question with your doctor.

    Do I have to have general anesthesia during a mastectomy?

    No. Mastectomies can be done under local anesthesia if your doctor is experienced
    with this approach. Local anesthesia has been used on elderly patients, for whom
    general anesthesia would present a higher risk. There  is no reason that younger
    patients would not also benefit. See Grant Carlson, MD., Total Mastectomy
    Local Anesthesia: The Tumescent Technique," The Breast Journal, [2005]

    I'm thinking about what to do after I get out of the hospital. Is there anything I need to do
    immediately, or can I wait a few weeks to think about a protocol?

    Research studies, such as the work by Coffey mentioned above, suggest that the
    immune system is most vulnerable in the days immediately following surgery.  A
    lowered immune system may provide an environment favorable to growth of a new
    tumor. Before your surgery, it is a good idea to begin researching therapeutic
    procedures to bolster your immune system, so that you will be prepared in the event you
    experience postoperative immunosuppression.
Surgery FAQ


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Take home question
to ask yourself:

Can you plan your
surgery with your
avoid
trauma to your  
breast in order to
forestall possible
spread of
cancer cells?
.

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links or suggestions
about this page.

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