Surgical solutions for breast cancer?

Dr. Ndwambi talks about surgical improvements and unlearning the breast cancer narrative you might have unwittingly subscribed to.

Twenty years ago, the thought of having breast surgery as a treatment response meant that the breast was inevitably coming off. Dr. Phumudzo Ndwambi is a specialist breast surgeon at Busamed Modderfontein Private Hospital.

“These days, we are looking more towards breast conserving surgery, so that the removal of a woman’s breast and in turn the removal of what she might use to identify her femininity is minimised.”

Dr. Ndwambi says breast surgery has completely revolutionised in 2022, especially with a more medically inclusive approach in terms of oncology, psychology and physiological impact for the patient.

“Even with a breast conservation approach, we still discuss mastectomies (full breast removal) and lumpectomies (partial removal of breast) with our patients, What is different now, however, is that we are moving towards procedures such as oncoplastic breast surgery where we consider the oncological impact (which is the cancer) and the reconstruction of the breast no matter the size of the tumour we are removing.”

She says this approach ensures that a patient can have an aesthetically pleasing result which is still medically and oncologically appropriate. “In the past, you’d have to have a less-than 5cm tumour to be able to qualify for breast conserving surgery. Now, we’ve worked around that protocol by sending a patient for systemic therapy (such as chemo), and we downstage the patient or shrink their tumour, and then six months later our patient comes back to us for breast conservation surgery.”

Dr. Ndwambi says even 10 years ago, patients would’ve been told at the outset that they didn’t qualify for breast conservation which only traumatised patients further. “That being said, we are even embarking further on revolutionising surgical options with what we’re calling ‘extreme oncoplastic surgery’.” She says this procedure ensures all the cancerous cells are eliminated by surgically removing more breast tissue than normal, but then going in to reconstruct the breast with a result that gives the patient a breast made up of their own breast tissue.

“Years ago, the reconstruction portion of the surgery would have been completed by creating a flap with tissue either from your abdomen or from your back, or it would have to then be put in a tissue expander and put in an implant for you. But now the woman can still have what resembles her own breasts because it is her own breast and still have had the knowledge of knowing that her cancer is fully and safely out.”

In terms of surgical advancement within breast surgery, Dr. Ndwambi says historically, the first mastectomies completely removed the entire chest wall, which included a patient’s pectoral muscles, and their breast, all the tissues and all the lymph nodes. “It was known to have a high morbidity, which means the woman would then be in chronic pain in her chest, she could have her arms swelling that sometimes rendered her disabled because she wasn’t able to even move it. We’ve now moved towards doing much less for the same and arguably a better result than what they were having historically in terms of the oncology, the systemic therapy.”

Dr. Ndwambi says within the next 5 to 10 years, more and more women will be deemed disease free once they’ve had their surgery and would be deemed unlikely to ever have a recurrence of breast cancer. “In fact, we may see that more women with breast cancer will start dying of other causes, before the cancer comes back or metastasizes to other parts. And that’s because as a global community of cancer researchers, physicians and surgeons, we have put in the time and effort to constantly ask the question of what is so unique or special about a cancer when it is aggressive or does not respond to treatment.”

Her optimism is well placed. Dr. Ndwambi is a recipient of Mail&Guardian’s top 200 young South Africans. She has dedicated her mind to cancer through a deep connection that started with her mother’s diagnosis.

“We don’t write our patients off. I think the breast society has known that our cancers have shown that if you give it the time and the effort, the prognosis can be quite good. But you, as a healthcare professional, have to keep uptodate. You have to keep researching. You have to keep curious.”

She says that anyone experiencing breast pain, discharge from a nipple (especially if it’s just one nipple), lumps, drastically abnormal sizes and skin discolouration needs to be investigated.