Dear Dr. Marga:
I have been diagnosed with breast cancer and do not know what to do next. I need a mastectomy. I want breast reconstruction. I have been reading about how implants do not work out so well for everybody. My doctors do not know if I will need radiation. One of my friends told me that she had chemotherapy before her mastectomy and she took that time to organize how she was going to travel to a different city to get her DIEP flaps. Do you ever do this with your patients?
Thanks for having the Ask Dr. Marga section on your website. Not all plastic surgeons do DIEP and I did not know who else to ask.
Thank your for your question about having chemotherapy before having a mastectomy. This is an exciting area for discussion!
Chemotherapy administered before a mastectomy is referred to as neoadjuvant chemotherapy.
Most commonly, patients with tumors larger than 5 cm or those who have clinical evidence of advanced regional disease in the axilla, adjacent to the chest wall or in the dermal lymphatics (inflammatory breast cancer) at the time of diagnosis are advised to consider receiving neoadjuvant chemotherapy before definitive surgical extrication of the tumor i.e. mastectomy with axillary lymphadenectomy. The therapeutic desire is to: i.) start definitive systemic care as soon as possible to affect prolonged survival; ii.) “shrink” a large breast or axillary mass to facilitate surgical removal with wide negative margins; and, less commonly, iii.) to convert a patient felt not to be a candidate for breast conservation to being an adequate candidate (decreasing the tumor to breast volume relationship so they may have a lumpectomy and keep the breast).
The controversial aspect of this care option of starting chemotherapy prior to definitive surgical care lies in whether you should undergo a sentinel lymph node procedure (SLNP) prior to starting chemotherapy.
Some oncologists relate that patients such as these are typically the “high risk” group for regional recurrence and all should undergo regional irradiation. They commonly relate that a pre-chemotherapy SLNP is not necessary as the patient will be advised to have radiation regardless of the result… Hence, the need to start chemotherapy as soon as possible given either: i.) large tumor size, generally > 5 cm; ii.) large tumor size relative to the breast size; iii.) tumor proximity to or involving the chest wall; iv.) large/fixed lymph nodes in the axilla; or v.) evidence of inflammatory breast cancer (cancer in the breast dermal lymphatics or skin), dominates the treatment plan.
In my practice, we agree with this method of administering neoadjuvant chemotherapy prior to mastectomy and before irradiation in selected patients. We commonly recommend the immediate placement of a filled, submuscular tissue expander with an AllodermTM sling at the time of skin sparing mastectomy to preserve upper pole skin for use in the final breast reconstruction, i.e. to improve the final aesthetic appearance of a breast reconstruction in an irradiated field. In the medical world, this is referred to as “Delayed Immediate Breast Reconstruction”. In my office and on the Dr. Marga website, we call this “Burning No Bridges” as the patient is able to choose any form of reconstruction after the completion of their cancer care, whether it be implants or natural tissue flaps. Placement of the filled tissue expander at the time of mastectomy and prior to irradiation does not hinder any choice of the final reconstruction and in fact, may prevent the need for tissue expansion. Further, it allows the patient to evaluate what a prosthetic reconstruction may feel like prior to making a final decision on their reconstruction method of choice (implant or natural tissue flap).
In some centers, the fluid in the tissue expander may be removed immediately prior to radiation and then is returned sometime thereafter with serial saline injections (tissue expansion) to restore the expander to the prior volume. The final implant is then placed 3-6 months thereafter. In others, the tissue expander is removed and replaced with the permanent implant prior to starting irradiation. In my office, I choose to leave the tissue expander in place and fully expanded until six months after irradiation before moving forward with additional surgery. If a patient has a care providing team that requests removal of the saline immediately prior to irradiation, we graciously provide that service in addition to serial expansion thereafter. Every case is unique and we strive to work well with diverse care providers from all over the country and Europe.
Most patients treated with neoadjuvant chemotherapy undergo a full axillary lymph node dissection (ALND) at the time of mastectomy. As a Certified Lymphedema Therapist and a microsurgeon with expertise in lymphatic reconstruction, I advise patients to have a SLNP prior to starting chemotherapy rather than blindly accepting a full ALND after chemotherapy. If the pre-chemotherapy SLNP is negative, I recommend that patients be treated with mastectomy with no additional surgery to the axillary lymphatic system. If the pre-treatment SLNP is positive, I recommend that the patient proceed with irradiaiton and ALND as is customary. Again, this aspect of patient care is controversial but I believe our approach may reduce one’s risk of developing lymphedema later in life should you be that patient with a negative SLNP prior to chemotherapy. The lifetime risk of lymphedema in patients having completed an ALND and regional irradiation has been reported to be in the range of 50% compared to that of SLNP and irradiation reportedly in the range of 25%.
It may be difficult for you to appreciate why patients commonly undergo a full ALND after neoadjuvant chemotherapy even if a concomitant SLNP is negative. The reasoning rests on the theory that the fact that such lymph node surgery commonly is done AFTER neoadjuvant chemotherapy that may have “sterilized” the axilla i.e. destroyed all of the pre-existing cancer cells. So, no one really knows if the patient had regional involvement or not if they have had an excellent response to chemotherapy. Doing a SLNP prior to neoadjuvant chemotherapy addresses this issue with an objective and definitive answer with little delay in starting systemic treatment.
Interestingly, the “Burning No Bridges” approach to our practice has gone on to evolve into an additional treatment approach for newly diagnosed patients that we call “Taking Time for a Surgery Sabbatical”.
I commonly evaluate women who have just received a cancer diagnosis. They are frightened, overwhelmed and feeling lost in the decision making process. Even if they have the opportunity to attend our daylong “The Doctor Is In…” educational series, most newly diagnosed patients feel uncertain about their reconstructive options. As such, I recommend that patients consider proceeding with a definitive surgical staging of their tumors (lumpectomy + SLNP +/- ALND) followed by “neoadjuvant chemotherapy” – not truly neoadjuvant as the tumor has been removed. This smaller surgical procedure provides definite staging of a newly diagnosed tumor and defines the need for chemotherapy and irradiation – the treatment plan is fully defined early. Patients not needing either chemotherapy or high dose regional irradiation for locally advanced disease proceed with either breast conservation (chest wall and regional irradiation in a lower dose) or completion mastectomy within 3 months. Patients requiring chemotherapy proceed with chemotherapy while keeping the breast i.e. they take a Surgery Sabbatical. While receiving definitive systemic chemotherapy, patients have time to research their reconstructive options in addition to learning more about their unique risk profile for the development of lymphedema, proactive lymphedema care and treatment options for lymphedema should it occur. After chemotherapy is complete, patients are more prepared to make decisions regarding breast conservation vs. mastectomy and implant vs. natural breast reconstructive options. Further, they have had time to plan to travel for more sophisticated medical care that may not be available to them locally. Taking a surgical sabbatical has the additional benefit of preserving nearly the entire volume of the breast prior to mastectomy such that they are still a candidate for nipple sparing mastectomy – a unique aspect of care that improves the final aesthetic result.
Your Question: Do we recommend chemotherapy prior to mastectomy?
Short Answer: Yes!
Long Answer: Many patients are candidates for “Taking a Surgical Sabbatical” i.e. doing neoadjuvant chemotherapy prior to mastectomy! We strongly encourage appropriate candidates to keep their breast while receiving chemotherapy. This time off from surgery provides the essential time needed to research reconstructive options AND to learn more about proactive lymphedema care without delay of systemic care. Further, most medical oncologists support this option as surgical complications related to all forms of breast reconstruction can delay the start of chemotherapy if an immediate breast reconstruction attempt is complicated by a wound healing issue.
Thank you for highlighting this very important question.