Welcome to our 4th Surgery with Soul Newsletter! My hope with this little monthly note to patients and practitioners is to not only provide valuable information but also a spark of inspiration! If you find this newsletter useful, make sure you subscribe on our website – just to be sure in lands in your inbox!

This month’s note is short and sweet – a really brief summary to give more clarity around the concept of breast conserving surgery. 
A breast cancer diagnosis is overwhelming and terrifying for many reasons – and the myriad of treatment decisions a patient is faced with is often a contributing factor to much anxiety.
One of the first and often most challenging decisions that needs to be made is around surgery. Except for palliative cases and now recently in very select patients with low grade DCIS, surgery is always an integral part of the treatment of breast cancer. A lot has changed over the last decade and we, thankfully, have come a long way from the radical surgery deemed necessary previously for breast cancer. The days of a breast cancer operation being disfiguring and traumatic are something of the past and patients have the option to choose between a variety of procedures – all backed by strong scientific evidence. I have found that the psychology of the patient and fear often rules the day – and despite the availability and safety of less radical procedures, patients would still opt for a bilateral mastectomy with or without reconstruction. The media exposure of celebrities opting for radical surgery often informs these fears – we have come to call it the Angelina Jolie effect, especially when taken out of context. (Jolie made her decision for radical surgery based on a her BRCA gene mutation carrier status – an appropriate indication.) As health care practitioners it is our duty to educate and to counter these fears with empathy and in a language that makes the scientific evidence accessible to our patients.

What is breast conserving surgery?

In the simplest terms breast conserving surgery (BCS) – also previously known as a lumpectomy or wide local excision – implies that only the diseased part of the breast with a margin of normal tissue around it are removed instead of removing the whole breast as with a mastectomy. There is ample evidence that BCS combined with adjuvent radiotherapy is equivalent to a mastectomy and the risk for the recurrence is almost exactly the same. It is therefor imperative for patients to understand that it absolutely is a safe choice – with many potential advantages.

Over the last 5 years the criteria for breast conserving surgery has drastically altered and most international guidelines now states that breast conserving surgery should be the procedure of choice offered to most patients. Where we previously considered many factors contra-indications to breast conserving surgery the only remaining absolute contra-indications currently are:

1. Any contra-indication to radio-therapy
2. Multi-centric disease (more than one quadrant of the breast is diseased)
3. A large tumour in a small breast that does not respond (shrink) to neo-adjuvent treatment (chemotherapy or more recently endocrine therapy)

Onco-plastic principles

It very important to understand that breast conserving surgery asks for an individualized approach – every tumour and patient should be individualized.

The aim of breast conserving surgery is first and foremost to treat the cancer in a safe and effective manner. But this by no means implies that the patient should be left with an awkward looking breast or be “lop-sided”.It is often useful for the breast cancer surgeon to work with a plastic surgeon when planning these procedures to achieve the best oncological and cosmetic results for the patient.

Careful consideration should be given to:

1. The type and placement of the incision: can you position the incision around the nipple or in the axillary fold? If you are going to do a reduction on the opposite side can you do the tumour removal through a similar reduction pattern incision? The possibilities are endless – as long as it is oncologically safe.
2. Attention to the defect and the shape of the breast by applying plastic surgery techniques and principles: consider the use of ipsilateral breast tissue, distant autologous flaps, fat grafting or a small prosthesis to fill large defects
3. A contra-lateral procedure like a reduction of mammaplasty (lift) to achieve better symmetry
4. The position of the tumour in breast: sometimes the position of the tumour makes a good cosmetic outcome more challenging – very medial tumours or tumours behind the nipple may be difficult to manage.I have seen excellent results even with central retro-areolar (behind the nipple) tumours where the nipple areola complex was removed as part of the wide-local excision, a DIEP flap was used to fill the defect and a delayed nipple tattoo was done. The key is to never compromise the safe removal of the cancer.
5. Accurate localization of the tumour: this may be challenging especially in very small lesions or if neo-adjuvent (meaning prior to surgery) chemotherapy was given. An important principle when neo-adjuvent chemotherapy is used is to place a marker in the tumour before treatment starts – in this way localization afterwards is much more accurate. A guide-wire or a radio-active/magnetic seed can then be used during surgery to make sure the right area is removed.
6. Attention to margins:in the past up to a 2.5 cm tumour-free margin was aimed for – we now have enough evidence to accept much smaller margins as safe. As precautionary measure many surgeons would do additional shavings of the tumour bed after removing the lump – I do this as standard practice. This lessens the chances of having to go back for a second procedure (average risk of approximately 10% in the literature). Another important principle is to mark the site where the tumour was removed with a radio-lucent clip – this way it can easily be identified for radiotherapy, on subsequent imaging or if a second procedure is necessary.

Dealing with the fear factor

For many patients the fear of recurrence takes hold of the steering wheel. Where at all possible, this fear should not determine the choice of surgery. The are more than enough evidence to support the safety and efficiency of breast conserving surgery combined with radiotherapy – even in younger women.

Dealing with and actively managing fear after a breast cancer diagnosis is crucial. I strongly advice that patients seek professional counseling – for themselves and their loved ones. Alternative modalities like Body Talk, EFT and Tapping or  TRE may also offer huge benefits to some patients – for those that are open-minded I always suggest exploring these options.

I sincerely hope you found this newsletter helpful and that you have been inspired to explore more! To keep away the winter chill, try Michelle’s lovely soup recipe below – it is bursting with goodness and taste!
We would love to hear your comments – sign up and let us know what you think!

Until next month.
Liana

MICHELLE’S WINTER DETOX SOUP RECIPE

INGREDIENTS

· 1/4 cup water or vegetable broth

· 3 leeks, diced

· 2 cloves garlic, minced

· 3 celery stalks with leaves, diced

· 3 medium carrots, diced

· 1 small head of broccoli, broken into florets

· 1 cup chopped courgettes

· 1 tablespoon fresh ginger, peeled and minced

· 1 teaspoon turmeric

· 1/4 teaspoon cinnamon

· 1/8 teaspoon cayenne pepper, or to taste (optional)

· himalayan salt and black pepper, to taste

· 6 cups water or 4 cups vegetable broth, plus 2 cups water

· 2 cups kale, de-stemmed and torn in pieces

· 1 cup purple cabbage, finely shredded

· Juice from 1/2 of a small lemon

PREPARATION

1.     In a large pot, add the water or vegetable broth and turn on the heat to medium-high. After it’s hot, add the leeks and garlic. Sauté for 2 minutes, stirring occasionally. Add the celery, carrots, broccoli, courgettes, and fresh ginger.

2.     Stir and cook for 3 minutes, adding in extra water or broth as needed. Stir in the turmeric, cinnamon, and cayenne pepper, plus salt and pepper to taste.

3.     Add in the water or vegetable broth and bring to a boil. Reduce heat and simmer for 10-15 minutes, or until vegetables are soft.

4.     Add in the kale, cabbage, and lemon juice near the last 2-3 minutes of simmering, then remove from heat and serve.