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Avoidance and management of complications of breast surgery

Documentation and audit Clear and contemporaneous documentation of patient details, clinical findings, disease characteristics and discussions regarding options for management (both with the patient and with the multidisciplinary team) is crucial for safe patient management and for demonstrating this in the case of queries. Consent for procedures is not an event performed on the morning of surgery but an evolving process usually involving at least a…

Psychosocial issues in breast cancer

Introduction This chapter deals with some of the psychosocial issues associated with treating women with breast cancer; it is not exhaustive as the emphasis is on matters especially relevant to surgeons. We reflect on some of the most topical questions of the day. We discuss the issues when communicating genetic and genomic test results to patients to aid shared decision-making and quality of life (QoL) assessments…

Top surgery for gender affirmation

Introduction Gender affirmation surgery is an important step in the life journey of some gender diverse individuals (the term ‘re-assignment’ is no longer used and is considered harmful). Top (chest/breast) surgery is the most commonly pursued type of gender affirming surgery due to its visibility and the relative perception of this anatomical area as a gender marker. On the other hand, only a portion of these…

Metastatic breast cancer and palliative care

Introduction In all but a few rare instances, once breast cancer has metastasised, the disease is incurable. Treatment is aimed at control of the disease, potentially prolonging life, relieving symptoms or putting off the time that symptoms may occur, aiming to improve or maintain quality of life. Management may involve active anticancer treatment, but as important is an active approach to symptom management and appropriate support…

Adjuvant radiotherapy for breast cancer

Background and history Radiotherapy involves the delivery of ionising radiation to kill malignant cells. Radiotherapy is frequently used in the management of early breast cancer. The radiotherapeutic management of early breast cancer accounts for 20–40% of available resources in most UK radiotherapy departments. Postmastectomy radiotherapy (PMRT) was one of the first medical interventions to be tested in prospective trials. These began around 50 years ago and…

Neoadjuvant therapy for breast cancer, including surgical considerations

Introduction Over the past half century, breast cancer management has evolved from primarily surgical therapy to a multidisciplinary approach including surgery, radiation therapy and systemic therapy. This shift is based on an increased understanding of invasive breast malignancy as a systemic disease and is based on improved outcomes with the addition of systemic therapy to local regional therapy. Observations of micrometastatic disease in early stage breast…

The role of adjuvant systemic therapy in patients with operable breast cancer

Introduction The mortality from breast cancer has fallen by over 15% in the UK over the last 15 years, despite a rising incidence. Historically over half of women with operable breast cancer who received loco-regional treatment alone died from metastatic disease, indicating the presence of micrometastatic disease at presentation. Traditionally, the main risk factors for recurrence have been the involvement of axillary nodes, higher histological grade,…

Treatment of ductal carcinoma in situ

Background Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer in which the proliferation of malignant epithelial cells remains confined by an intact basement membrane, without invasion into the surrounding stroma. The introduction of screening mammography has led to a marked increase in the detection of DCIS, from 2% of newly diagnosed breast cancers before national screening to over 20% of all…

Breast reconstruction

Introduction Rates of breast reconstruction following mastectomy continue to rise, despite significant geographic variation, and for complex psychosocial reasons there is a continual growth in the number of patients undergoing contralateral prophylactic (risk-reducing) mastectomy (CPM). Mastectomy for breast cancer can lead to negative psychological effects in some but not all women, and breast reconstruction, whether immediate or delayed, can provide significant psychosocial benefits. Surgery for breast…

Uncommon presentations of cancer affecting the breast and recurrent breast cancer

This chapter discusses uncommon diseases of the breast, including (i) pregnancy-associated breast cancer (PABC); (ii) male breast cancer (MBC); (iii) Paget’s disease of the breast; and (iv) other breast malignancies, including melanoma, lymphoma, angiosarcoma and metastases, as well as management of local recurrence (LR). Uncommon presentations of cancer affecting the breast Pregnancy-associated breast cancer PABC includes breast cancer diagnosed during pregnancy, up to 1 year after…

Management of the axilla

Introduction Management of the axilla has been a key aspect of care of breast cancer patients for decades. It is well established from randomised controlled trials, such as the NSABP B-04, that axillary dissection does not improve survival, but the status of the axillary lymph nodes is a prognostic factor and a component of the American Joint Committee on Cancer (AJCC) staging system. Despite the lack…

Mastectomy

Introduction Performing a mastectomy can be accomplished using a wide variety of techniques, depending on the clinical setting. Any mastectomy should be sensitive to the aims and principles of oncoplastic breast surgery, namely that optimal treatment of the malignancy should be achieved with minimal impact on quality of life. Training in oncoplastic surgery often starts with the ‘simple’ procedure of mastectomy (and of course, an understanding…

Oncoplastic breast-conserving surgery

Introduction The evidence supporting breast conserving surgery is a better option than mastectomy (with or without reconstruction) for those who are suitable is compelling. As such, every effort should be made to offer it. Whilst simple wide local excision for small breast cancers is a routine operation with few technical challenges, for anything slightly larger, many surgeons find it difficult to achieve good cosmetic outcomes, often…

Breast-conserving surgery: the balance between good cosmesis and local control

Introduction The aim of local treatment of breast cancer is to achieve long-term local disease control with the minimum of local morbidity. The majority of women presenting symptomatically to breast clinics and those who are diagnosed through screening programmes have small breast cancers, which are suitable for breast-conserving therapy (BCT), defined as breast-conserving surgery (BCS) and whole-breast radiotherapy. The major advantages of breast-conserving treatment are: equivalence…

Breast screening

Introduction Population-based cancer screening is a complex public health undertaking that is most effective when performed in the context of a programme with defined standards that targets a specific population at risk in a given geographical area with a significant cancer burden, with all those attending being offered the same level of screening, diagnosis and treatment services. There are 26 countries that offer breast screening programmes,…

Epidemiology, risk factors and prevention strategies

Breast cancer is by far the most common cancer in women worldwide, with an estimated 2.3 million new invasive cancers diagnosed in 2020 ( Fig. 5.1 ). In the United Kingdom, where the age-standardised incidence is one of the highest in the world, the annual invasive breast cancer incidence among women aged 50–54 years is 2.8 per 1000, rising to 4.2/1000 in women aged 65–69 years.…

Breast pathology

Introduction The features of a breast cancer on routinely fixed, processed and stained histopathological sections provide, not only the basis for diagnosis of the disease, but also invaluable prognostic information. Predictive biomarkers are subsequently assessed on the tissue facilitating selection of the most appropriate therapies for the individual patient. Accurate provision of all these pieces of information requires good multidisciplinary communication between radiologists, surgeons and pathologists,…

Benign breast conditions

Introduction Over 90% of patients presenting to a breast clinic have normal breasts or benign breast disease. Knowledge of and an understanding of the benign conditions that can affect the breast, the symptoms they cause and their management will ensure correct treatment and patient satisfaction. Benign breast disease can cause considerable morbidity and anxiety, and with increasing patient awareness and expectations, the number of patients attending…

Assessment of patient, breast and common clinical presentations including image-guided intervention

Patients with breast concerns that cannot be adequately managed in primary care should be referred to a specialist breast clinic. This has traditionally been run by surgeons but is now a multidisciplinary enterprise. These clinics can perform a combination of clinical, radiological and pathological examinations. Assessment of a breast lump usually requires triple assessment. Triple assessment Triple assessment is the combination of clinical, radiological and pathological…

Anatomy and physiology of the breast

The breast is a defining characteristic of mammals. Its fundamental purpose is to produce milk, but the appearance and sensation provided by breasts give them a huge role in female personal and sexual identity. Surgical and other therapeutic interventions on the breast may have a significant impact on this. Normal breast development Embryology The breast is a modified sweat gland made up of glandular tissue, supporting…