Samp­son Nan­ton

Deputy Man­ag­ing Ed­i­tor

For some women di­ag­nosed with breast can­cer, surgery is the first thing they fear. The prospect of los­ing a breast can be so over­whelm­ing that they de­lay seek­ing med­ical at­ten­tion, even as a tu­mour grows.

But breast sur­gi­cal on­col­o­gist Dr Ly­ronne Olivi­er says ad­vances in treat­ment are chang­ing the con­ver­sa­tion, with some pa­tients now re­ceiv­ing med­ica­tion be­fore surgery to shrink tu­mours, im­prove sur­gi­cal op­tions and help doc­tors de­ter­mine how ef­fec­tive­ly the can­cer is re­spond­ing.

The ap­proach, known as neoad­ju­vant ther­a­py, is par­tic­u­lar­ly im­por­tant for cer­tain pa­tients with HER2-pos­i­tive and triple-neg­a­tive breast can­cers, sub­types that can be more ag­gres­sive and car­ry a greater risk of re­cur­rence.

Dr Olivi­er said the ben­e­fits ex­tend be­yond re­duc­ing the size of a tu­mour. Treat­ing the can­cer be­fore surgery al­lows doc­tors to as­sess its re­sponse and use that in­for­ma­tion to guide sub­se­quent treat­ment.

“The first time a pa­tient comes to me, they think the can­cer needs to come out, and they need to have surgery. But there are cer­tain sce­nar­ios where you get treat­ment be­fore, which is called neoad­ju­vant ther­a­py.

“That’s what makes breast surgery dif­fer­ent from all oth­er surgery: some­times we have to treat be­fore and then op­er­ate.”

For pa­tients whose tu­mours re­spond well, the treat­ment can al­so mean less ex­ten­sive surgery.

Dr Olivi­er ex­plained that the re­sponse to treat­ment can help de­ter­mine the most ap­pro­pri­ate sur­gi­cal ap­proach, in­clud­ing whether breast-con­serv­ing surgery is pos­si­ble.

Pre­serv­ing the breast

The be­lief that a breast can­cer di­ag­no­sis au­to­mat­i­cal­ly means a mas­tec­to­my re­mains a source of anx­i­ety for many pa­tients.

Dr Olivi­er said breast-con­serv­ing surgery can of­fer sur­vival out­comes com­pa­ra­ble to mas­tec­to­my for ap­pro­pri­ate­ly se­lect­ed pa­tients, al­though the best op­tion de­pends on the in­di­vid­ual di­ag­no­sis and treat­ment plan.

“Breast con­ser­va­tion surgery is on par with a mas­tec­to­my. There are sev­er­al stud­ies that showed, go­ing back for many years, some fol­low­ing them up to 20 years, that showed that there is no sur­vival dif­fer­ence in peo­ple who ac­tu­al­ly pre­served the breast ver­sus re­moved the breast.

“But breast con­ser­va­tion surgery is some­thing that I love the most, be­cause it’s some­thing I al­low to do breast re­con­struc­tion, what we call par­tial breast re­con­struc­tion, with tis­sues that are around the breast to recre­ate de­fects cre­at­ed by re­mov­ing the tu­mour.”

He said the prospect of pre­serv­ing the breast is one rea­son pa­tients need to un­der­stand their op­tions be­fore as­sum­ing the most ex­ten­sive op­er­a­tion is in­evitable.

How­ev­er, breast con­ser­va­tion is not suit­able for every pa­tient, and treat­ment de­ci­sions must be guid­ed by the char­ac­ter­is­tics and ex­tent of the can­cer.

The cost of new­er treat­ments

While treat­ment ad­vances of­fer new pos­si­bil­i­ties, Dr Olivi­er ac­knowl­edged that ac­cess to some ther­a­pies re­mains a chal­lenge in Trinidad and To­ba­go.

Im­munother­a­py, which is used for se­lect­ed pa­tients with triple-neg­a­tive breast can­cer, has ex­pand­ed treat­ment op­tions in­ter­na­tion­al­ly. Dr Olivi­er said its use has moved be­yond some ad­vanced cas­es to in­clude se­lect­ed pa­tients with ear­ly-stage dis­ease.

The ob­jec­tive is to achieve a strong re­sponse be­fore surgery, re­duc­ing the like­li­hood of the can­cer re­turn­ing and im­prov­ing dis­ease-free out­comes.

How­ev­er, he said these treat­ments are cost­ly and are not cur­rent­ly avail­able in the pub­lic health sys­tem lo­cal­ly, al­though ef­forts are be­ing made to se­cure the nec­es­sary re­sources.

The is­sue high­lights the im­por­tance of ac­cess to spe­cialised can­cer care, par­tic­u­lar­ly when treat­ment choic­es can in­flu­ence the ex­tent of surgery and a pa­tient’s longer-term out­look.

Care be­yond the op­er­a­tion

Dr Olivi­er said the con­ver­sa­tion about breast can­cer must al­so ex­tend be­yond re­mov­ing a tu­mour and com­plet­ing treat­ment.

Pa­tients can ex­pe­ri­ence phys­i­cal and emo­tion­al con­se­quences, in­clud­ing lym­phoede­ma, or swelling as­so­ci­at­ed with dam­age to the lym­phat­ic sys­tem, as well as side ef­fects from chemother­a­py and hor­mon­al treat­ment.

He ac­knowl­edged that sur­vivor­ship re­quires a co­or­di­nat­ed ap­proach in­volv­ing sur­gi­cal, med­ical and ra­di­a­tion on­col­o­gy teams, along­side oth­er health­care pro­fes­sion­als who can help pa­tients man­age the ef­fects of treat­ment.

His own ex­pe­ri­ence of un­der­go­ing surgery for a tu­mour about two years ago al­so changed his un­der­stand­ing of what pa­tients face.

“I thought I was al­ways em­pa­thet­ic. But it made me un­der­stand what sup­port is, what your physi­cian who’s tak­ing care of you means to you, you know? And that lev­el of where you have that wor­ry, that anx­i­ety, you know, un­cer­tain­ty of what’s the next step.

“It made me now un­der­stand how to ap­proach my pa­tients bet­ter.”

He said pa­tients need an en­vi­ron­ment in which they feel com­fort­able ex­press­ing their fears and un­der­stand­ing their di­ag­no­sis, while fam­i­lies should recog­nise that sup­port­ing some­one through can­cer re­quires pa­tience and em­pa­thy.

Dr Olivi­er is al­so prepar­ing to open a breast clin­ic in Port-of-Spain in mid-No­vem­ber, sub­ject to the ar­rival of equip­ment.

He said the clin­ic is in­tend­ed to pro­vide breast health ser­vices, in­clud­ing mam­mog­ra­phy and ul­tra­sound, while al­so plac­ing em­pha­sis on re­cov­ery sup­port such as lym­phat­ic mas­sage and scar man­age­ment.

Aware­ness be­yond Oc­to­ber

De­spite ad­vances in treat­ment, Dr Olivi­er said late pre­sen­ta­tion re­mains a con­cern. He re­cent­ly en­coun­tered a woman in her mid-50s with an ad­vanced tu­mour that had bro­ken through the skin. The pa­tient had de­layed seek­ing care be­cause she was fright­ened of the di­ag­no­sis and the pos­si­bil­i­ty of los­ing her breast.

He said fear, stig­ma and mis­con­cep­tions con­tin­ue to in­flu­ence how some peo­ple re­spond to changes in their breasts.

The be­lief that can­cer must cause pain be­fore it be­comes se­ri­ous is an­oth­er dan­ger­ous mis­con­cep­tion, as breast can­cer can de­vel­op with­out pain.

For Dr Olivi­er, the chal­lenge is to en­sure that aware­ness trans­lates in­to ac­tion and that pa­tients un­der­stand they may have more treat­ment op­tions than they re­alise.

“It’s just about aware­ness, and seek­ing a con­sult, and if there’s a change, don’t ig­nore it.”

As Breast Can­cer Aware­ness Month draws to a close, his mes­sage is that ad­vances in treat­ment mat­ter most when pa­tients seek help ear­ly enough to ben­e­fit from them.