A 41-year-old woman is diagnosed with stage 2 breast cancer in 33rd week of pregnancy. After extensive evaluation of both the mother and the fetus, a multidisciplinary council drafts a treatment plan and starts a well selected chemotherapy regimen prior to delivery. Three weeks later the patient gives birth to a healthy baby and three months later the tumor is totally removed with breast conserving surgery. Today, she is free from cancer and a happy mother of two.
How is it possible to cure the patient without harming the baby?
Favorable results both for the mother and the child are possible in a set of clinics around the world: those that have extensive experience and apply a multidisciplinary approach to achieve effective treatment while minimizing the risk for the fetus. “Multidisciplinary approach enables joint decision on which diagnostic method and treatment are appropriate for each patient,” says Professor Cihan Uras, a prominent surgeon for breast cancer treatment in Turkey, whose team planned and performed the successful treatment. After more than 30 years of experience among the firsts who apply the novel techniques in surgical treatment, Prof. Cihan Uras headed the Acibadem Research Institute of Senology, which was established to conduct trials and investigations that will make contributions to the senology – the science of breast.
Why science matters for breast cancer patients?
Breast cancer is not just one single disease. It is a group of diseases, impacting the lives of 2.1 million women in the world each year. Just like there are o two people alike, no two tumors are the same. The common point is that they all start with abnormal and uncontrollable growth of cells. However, breast cancers can start from different parts of the breast: the ducts that carry milk to the nipple or the glands that make breast milk, or some other tissues in the breast. Besides, breast tumors differ in their grade, stage and hormone receptor status, and each of these differences affects progression rates and prognoses. That is why the treatment of breast cancer becomes more and more personalized, as doctors learn more about the disease. Scientific researches are aiming to contribute to better understanding of the breast cancer and improve survival rates.
How medical advancements affect breast cancer patients?
The 41-year-old pregnant woman, diagnosed with the disease, for instance, benefited from a new treatment option, using chemotherapy before surgery. “We especially avoid starting treatment with surgery in tumors of stage 2 and higher, which are referred to as locally advanced breast cancer,” says Prof. Cihan Uras. In those cases, samples from the tumor are collected and analyzed, and medical treatment is determined in accordance with the biological structure of the cancer cells. Prof. Uras explains: “One of the advantages of starting with medical treatment, which is chemotherapy, is the possibility that the nature of the surgical procedure to be applied can change for the better. For instance, surgery on a patient with locally advanced breast cancer, which also involves the axilla area, requires us to remove all lymphatic glands. However, chemotherapy can eliminate cancer from the glands and revert them to their condition in the early stages of the disease. This allows us to try the early-stage method of removing a gland sample for analysis. If it turns out that cancerous cells are entirely eliminated from the sample, we choose not to remove all lymphatic glands. It completely eliminates the risk of developing lymphedema in later stages of life for the patient. This is one of the most important innovations of the last 3 or 4 years.”
From radical mastectomy to breast-conserving surgery
Breast cancer is probably the most feminine of all diseases, affecting the very essence of a woman, her body image and emotions. “Our first choice is always breast-conserving surgery,” says Prof. Cihan Uras. In breast protective surgery, tumor tissue is excised with about 1-2 cm normal breast tissue around it. The surgeon explains: “We prefer to spare the breast by removing only the cancerous part and the tumor, and then apply oncoplastic surgery, which is a method that combines the concepts of cancer surgery and plastic surgery, to ensure for the breast to be left in a condition which is cosmetically satisfying for the patient.”
In some cases, removal of the entire breast tissue cannot be avoided. These are not necessarily only advanced cancer cases. For instance, total removal is required when multiple tumors at different locations of the breast are detected, even if the cancer is not in advanced stage. “We apply two methods to remove the entire breast while sparing the nipple, the area surrounding it and the skin,” Prof. Cihan Uras points. The surgery can be done using either conventional or endoscopic techniques. The latest accomplishment in this field is usage of Da Vinci robotic system for mastectomy which does not involve any incisions on the breast. Prof. Uras explains: “We are able to remove the entire breast tissue from a small incision from the armpit. This is followed by placement of prosthetics through the same incision by a plastic surgeon. It allows us to perform an operation which yields much better cosmetic results since there are no incisions on the breast and it is easily possible to conceal the incision under the arm.”
Breast cancer surgery of the 21st century involves medical and aesthetic treatment performed simultaneously: “It is possible for us to reconstruct the breast tissue in cases where we remove the entire breast. This is what we prefer in any case. Rather than delayed breast reconstruction, we prefer to perform the procedure at the same time as the removal of the breast.” Professor Cihan Uras adds that breast prosthetics or patient’s own tissues can be used for the reconstruction.
The evolution of radiation treatment to a Single Dose Radiotherapy
Radiation treatment, which is used to destroy cancer cells, has changed dramatically over the past years, providing new techniques and modalities. One of the latest options is application of a single dose of radiotherapy during surgical treatment of breast cancer (IORT), in the tumor bed itself. It is applied by a special robotic device which involves a lead plate placed over the target region on the chest wall during radiotherapy.
The device focuses and locks on the target, allowing only for the targeted breast tissue to receive radiation, protecting the rest of the body and organs from the effects of radiotherapy. It is usually used on patients over the age of 50, with tumors having a biological structure which does not require chemotherapy.
This method, referred to as intraoperative radiotherapy, is used for another purpose as well, says Professor Cihan Uras: “Standard radiotherapy involves irradiation of the entire breast on patients who undergo breast-sparing surgery, followed by high-dosage irradiation of the tumor area for 8 sessions. Intraoperative radiotherapy reduces 8 sessions of application to a single application during surgery. This allows for a single-dose application which is carried out while protecting the rest of the body to eliminate the need for subjecting the patient to high-dosage radiotherapy 8 times. A short irradiation of the whole breast complements the single-dose procedure and allows us to finish a long treatment in a much shorter time.”
How Acibadem Senology Institute creates better opportunities for the patients?
“Acibadem Research Institute of Senology is not a conventional diagnosis and treatment unit. It is, in fact, a center of science,” says Professor Cihan Uras and adds: “The goal of this center is to discover novelties in both diagnosis and treatment. These studies are conducted on surgery, medical oncology and radiation oncology, and we can place our patients on appropriate treatments based on our investigation results. This approach creates many future opportunities for our patients.”
The increasing variety of medical options requires an integrated approach, with a care team of specialists in different branches, taking into account the specific needs of every patient. At Acibadem Research Institute of Senology, the multidisciplinary approach is adopted for all patients, with experts in general surgery, medical oncology, radiation oncology, cosmetic and plastic surgery, radiology, pathology and genetics, who have specialised especially in breast cancer treatment. All of them are highly experienced in their medical disciplines and have qualifications of an instructor. Only in the last 5 years, Acibadem has provided breast cancer treatments to nearly 3.000 patients from more than 20 countries. “We have all the equipment that is available in a limited number of centres around the world,” Professor Uras adds. Acibadem Research Institute of Senology is the first high education board-certified institute in Turkey and one of the few specialized research institutions in the world that are expected to create better opportunities for breast cancer patients in the years to come.