Innovations in Breast Surgery Improve Precision, Avoid Re-operation

Anna Johnson-ChaseWhen 63-year-old Anna Johnson-Chase had her annual mammogram in September 2011, she was relieved to hear that everything was normal. Despite the normal result, her astute primary care physician suggested a sonogram anyway, because dense breast tissue can mask abnormalities on a mammogram, because Anna was never pregnant (her children are adopted) and years of hormone replacement therapy increased her risk of breast cancer. Sure enough, a small lump was visible. A biopsy found it positive for cancer, and by New Year’s, Anna was calling oncologists in the New York area.

Fortunately for Anna, her cancer was small and caught early. She would undergo a simple lumpectomy, in which the tumor alone is removed and healthy breast tissue is preserved. However, despite lumpectomy’s prominence as the most common breast cancer surgery performed today, “simple” may be a misnomer.

When enough healthy tissue surrounding the tumor is removed, surgeons can be confident that they haven’t left any cancer behind. But this goal conflicts directly with that of preserving cosmetic integrity of the breast, so they may, literally, cut it close. Yet experts widely disagree on how wide a safe surgical margin truly is. A study, Variability in Reexcision Following Breast Conservation Surgery, published by by Laurence E. McCahill, MD in the January 2012 edition on JAMA, highlighted this lack of consensus; it showed huge inconsistencies in the interpretation of pathology reports, which determine whether a woman will require additional surgery to remove any cancer left behind. Nearly half of those in the study who had a second surgery may not have needed it, the study found, and 14% of those with unsafe margins did not have additional surgery.

Anna was lucky to have chosen Sheldon Feldman, MD, Chief of NewYork-Presbyterian/Columbia’s Division of Breast Surgery, as her surgeon. Dr. Feldman and his team are using intraoperative radiofrequency ablation (RFA) during lumpectomy, a technique that uses heat to carefully destroy remaining cancer cells. RFA causes no adverse effects, and it significantly decreases the risk that patients with close margins will need radiation or re-operation.

Determined to avoid additional surgery and the potential side effects of radiation, Anna thought RFA made perfect sense. Just ten days after her procedure in January 2012, Anna returned to work as a Feldenkrais teacher. She has full range of motion and an excellent prognosis. With several friends who have endured more aggressive cancers and one who just underwent a total mastectomy, Anna is enormously grateful that her cancer was resolved the way it was.

NewYork-Presbyterian Hospital/Columbia University Medical Center is one of only two centers in the U.S. and the only hospital on the east coast using this method. Dr. Feldman’s success (more than 25 procedures with only one re-operation) has garnered a great deal of attention, including an invitation to be lead guest editor of an issue of the International Journal of Surgical Oncology, an award by The Breast Journal, and a featured story on an ABC breast cancer special in October 2011. This work was recently published in the Annals of Surgical Oncology with an accompanying video of the procedure: Radiofrequency Ablation After Breast Lumpectomy Added to Extend Intraoperative Margins in the Treatment of Breast Cancer (ABLATE): A Single-institution Experience.

For more information on Dr. Feldman’s work, visit the Clinical Breast Cancer Program at Columbia University.