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For the last 100 years, surgery has been a basic procedure for the treatment of women with breast cancer. At the end of the nineteenth century Halsted developed a surgical procedure, mastectomy, which enabled a significant advance in the treatment of breast cancer. In this new context, mastectomy represented the most significant advance in the treatment of women with breast cancer because for the first time in history it enabled locoregional control of the disease, together with an improvement in the patient's quality of life.
However, circumstances have changed considerably in recent years and the role of surgery must be adapted to new challenges. Various circumstances will in the next few years modify the role of the surgeon both as regards the disease and the patient. Firstly, at present the surgeon does not work in isolation when treating women with breast cancer. The collaboration provided by medical oncology and by radiation oncology has meant less need for aggressive surgery in order to guarantee locoregional control of the disease, and at the same time, has improved the life expectancy of patients with breast cancer. Secondly, early diagnosis of the disease by means of screening programmes has enabled a large number of women with small tumours to be diagnosed, which has enabled a less aggressive attitude to be adopted and makes mutilation unnecessary for a significant group of women. Thirdly, women in the 21st century are very different from those whom Halsted treated at the end of the 19th century. In contrast to the resignation and social anonymity of Halsted's patients, today's women have a social role in their own right, as well as the autonomy to take decisions about their disease and body image. In this new social setting, the impact of surgery on a woman's body image and self-esteem is gaining in importance, to the detriment of locoregional control. Fourthly, knowledge of the various types of tumours based on their molecular profile has modified the traditional indications for surgery because in some cases it raises the possibility of initiating neoadjuvant therapies before surgery for those tumours with great sensitivity to chemotherapy.
As a consequence of these clinical and social changes, we may see a modification of the role of surgical oncologists in their treatment of breast cancer.
What will be the most important changes in the breast surgical oncology of the future? Without attempting to play the role of soothsayers, we can anticipate some trends in the surgical management of breast cancer over the next few years.
1. Changes in the philosophy of breast management surgery. From locoregional control to improvements in the quality of life and in self-esteem. In the past, the surgeon's mission was locoregional control of the disease by means of mastectomy, tumorectomy and axillary node dissection. This objective always justified the sequelae and side effects, given that oncological control was the sole objective of surgery. However, this reality has changed over the last few years, since multidisciplinary management of the disease has enabled different treatments to be combined (surgery, chemotherapy, hormone therapy, monoclonal antibodies, radiotherapy) and this has helped to increase women's oncological safety. An example of this has been the slow fall in the number of local relapses in breast conserving surgery due to the combination of local treatments (surgery and radiotherapy) and systemic treatments (chemotherapy, hormone therapy), together with the increase in metachronous tumours during the care of these patients as a result of their higher survival rate. Another example has been the gradual abandonment of axillary node dissection in the treatment of women with node-negative breast cancer, which has ensured locoregional control and diminished the incidence of lymphedema. This new reality is leading to a new focus for breast cancer surgery in which locoregional control is one of the objectives, but not the only one, since new perspectives are opening up for surgeon and patient. We can point to two new objectives to include in the planning and performance of breast cancer surgery:
- Improved quality of life. This today constitutes the main objective of breast cancer surgery and is achieved by diminishing the physical and psychological sequelae of surgery. This decreasing resort to aggressive surgery of the breast and axilla through the use of conservative techniques and biopsy of sentinel lymph node respectively, have made possible a fall in physical sequelae, especially those deriving from axillary node dissection. This decrease in aggressive surgery allows women to recover quickly and return to family and professional life, with a minimal incidence of lymphedemae and neuralgias.
- Improved self-esteem Side effects experienced during the treatment of breast cancer, such as alopecia, temporarily stigmatize the patient. However, mastectomy or deformities secondary to conservative surgery are sequelae which have a chronic impact on a woman's body image and interfere with her personal sphere and self-esteem. For this reason, one objective of breast cancer surgery must be improving self-esteem by lessening the impact of surgical techniques on female body image and this will only be possible if two objectives are achieved: Firstly, an improvement in the quality of conservative surgery by using low-visibility approach routes and remodelling of the defect following tumorectomy. The use of oncoplastic techniques also facilitates this objective. Secondly, the drive towards immediate reconstructive surgery offers the best opportunity of minimizing the impact of a mastectomy on the woman's body image, especially when it is associated with skin and skin/nipple sparing mastectomies. In my view, improving self-esteem is the new horizon for oncological breast surgery.
2. Surgery specific to the breast and tumour. For many years the surgical alternatives for breast cancer turned around a duality of techniques: mastectomy or tumorectomy. This duality was based on the oncological objective of surgery, locoregional control of the disease, and the relationship between tumour size and breast size. However, today breast cancer surgery must include other objectives which are not strictly oncological, and must also focus on the patient's body image. This is why there is increasing interest in diminishing the incidence of deformities and asymmetries in breast-conserving surgery. These deformities and asymmetries depend on the anatomical characteristics of the breast and on the location of the tumour. For this reason, a tumorectomy will present different consequences depending on the area of the breast to be resected. This is the basis for a new concept in breast surgery, breast-specific and tumour-specific surgery. In other words, there is a specific procedure for each tumour location. This new concept makes it necessary for the breast surgeon to be familiar with multiple resection and breast remodelling procedures, which are covered by the term 'oncoplastic techniques'. This new reality will in the future make it necessary to confront the following issues:
- Education and specific training in oncoplastic and reconstructive breast techniques. The breast cancer surgeon will need specific training in most oncoplastic procedures in order to adapt the surgical resection to the breast and the tumour. This specific training must be given by surgeons who are expert in this field and accredited by scientific associations, universities or bodies qualified to do so. This training must be complemented by training in breast units with experience of oncoplastic and reconstructive surgery. The ideal situation would be the creation of an animal model to enable in-vivo training in the main oncoplastic and reconstructive procedures. In our experience, the porcine model can be used to train surgeons in performing a latissimus dorsi muscle flap, a TRAM flap and subpectoral placement of implants.
3. Changes in surgical techniques. The social and conceptual changes described above will have repercussions on surgical techniques to diminish the impact of surgery on women's body image. For this reason, in the next few years we shall see a gradual change in the focus of surgical techniques, both in conservation and radical surgery, intended to better preserve the breast and its anatomy. These trends can be summed up as follows:
- Conservative surgery. The use of low-visibility approach routes to locally extirpate tumours will give added value to the act of surgery, since by using these we can guarantee the preservation of the breast envelope, avoid modifying the volume and shape of the breast and make symmetrisation surgery unnecessary. This scarless surgery will be facilitated by early diagnosis of the diseases in screening programmes and by the use of neoadjuvant treatments before surgery, which will diminish the average size of tumours.
- Radical surgery. Mastectomy will constitute a necessary procedure for a significant group of patients but it will change from being a mutilating technique to a procedure which represents an opportunity to eradicate a multifocal/multicentred disease. At the same time it will make it possible to undertake immediate high-quality breast reconstruction. For this reason, the new concept of mastectomy will be sparing skin, with the aim of guaranteeing the greatest possible amount of breast envelope, and especially preservation of the nipple/areola complex since this anatomical element is the one which will provide the best cosmetic results for the patient after mastectomy.
- Technical advances. Microsurgery will be a highly-specialized field within reconstructive surgery since it will enable free flaps to be manipulated. There will be a place for lipofilling in partial remodelling following breast conserving and reconstructive surgery in order to optimize the aesthetic results.