Rethinking Breast Cancer

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For a variety of reasons, radiologists in the U.S. tend to err on the side of caution. That is, they identify lots of "abnormalities," of which only 2% to 11% prove to be cancerous--either DCIS or an invasive tumor. Sometimes a second mammogram or an ultrasound provides the necessary reassurance. Other times, a biopsy--which entails the removal of some breast tissue--is required to resolve any ambiguity. Here the odds of finding cancer rise to about 25%, which means that 75% of biopsies come back negative.

For years many women got an ugly scar along with their answer because most biopsies began with a wide surgical incision. Nowadays, more breast centers offer such minimally invasive biopsies as the Mammotome, which relies on careful positioning of the breast to remove the least amount of tissue. "We're trying to reserve surgery for treatment, not diagnosis," says Dr. Joshua Gross, chief of breast imaging at Beth Israel Medical Center in New York City. "So many women I see have scars all over their breasts. The scars aren't from being treated. They're from doctors finding out if a woman even needs to be treated."

Thirty years ago, surgery meant mastectomy--removal of the entire breast. By the 1980s, studies had shown that for tumors that had not spread, only the portion immediately surrounding the cancerous growth needed to be cut away--provided the operation was followed by radiation therapy to destroy any wayward cancer cells the surgeon may have missed. Today, as more women are being treated for ever smaller tumors, doctors are finding that even these so-called lumpectomies can be further refined.

The new minimalist approach begins with the first cut, which many surgeons now place near the nipple, under the arm or in the lower portion of the breast so that any scars are much less obvious. Because many small tumors are confined to the duct or its immediate vicinity, doctors have learned they don't need to remove so much of the overlying fatty tissue as they used to. "Taking out too much fat was what led to the concavities and deformities we saw in the past," says Dr. Alexander Swistel, director of the Weill Cornell Breast Center in New York City. The remaining tissue can then be rearranged to fill in the void.

Doctors have also developed a new technique for determining whether a cancer has spread to the lymph nodes. Instead of taking 15 to 20 lymph nodes from in and around the armpit for further examination--a procedure that can lead to problems with swelling and disability of the arm--they are focusing on certain key spots called sentinel nodes. The surgical team injects a blue dye into the tissue from which it has just removed a tumor and traces its path through the lymph system. The first node or two that the dye reaches are presumably also the first nodes in which any cancer cells would take up residence. The sentinel nodes are removed and closely examined. If they are free of cancer, chances are all the other nodes are clear. Preliminary evidence suggests that this is indeed the case, though two randomized controlled trials of the technique are under way to make sure.