JAMES ET ALll
POST-MASTECTOMY BREAST RECONSTRUCTION
nature of her condition. This used to be the role of the doctor, and if he did not do it or did it badly, then he alone had the responsibility for it. But in recent years the nursing profession has developed its own self-image and its own level of expertise in interpersonal relationships, and one could suppose that all professional groups who work with doctors would want to communicate directly with their patients. Consequently it may well be that in the surgical ward the nursing sisters and the physiotherapists and the occupational therapists will all feel that it is their right to discuss the patient’s clinical condition with the patient and to offer advice and prognosis, as well asgiving reassurance.
In some cases this may not be helpful to the patient, who is likely to get quite conflicting views about her condition from various members of the helping professions. Consequently I would suggest that it should be the responsibility of the surgeon to have a clear communication with the nursing staff of the ward, so that it can be determined who is going to communicate with the patient. I think that in most cases the surgeon should carry this responsibility himself. REFERENCE MAGUIRE.G: P. (1978), Brit. med. J. 1: 963.
SURGICAL PATHOLOGY OF BREAST CANCER IN RELATION TO RECONSTRUCTION AFTER MASTECTOMY c. M. FURNIVAL Brisbane IF, before considering reconstruction, an assessment is sought of the prognosis for any individual breast cancer, there are five factors which can be derived from a study of the tumour itself. These are as follows. ’ The histological type.Although only 20% of breast cancers are intraduct carcinoma, lobular carcinoma, well-differentiated adenocarcinoma, colloid carcinoma or medullary carcinoma, with l y m p h o c y t i c i n f i ’ t r a t i o n , this g r o u p has a substantially greater life expectancy than the 80% of patients with breast cancers comprising infiltrating forms of adenocarcinoma or ductile carcinoma, anaplastic tumours, and those invading blood vessels. A bilaterality approaching 30% in lobular carcinoma is stressed. Tumour size.- Survival is inversely proportional to tumour size, but there is no critical diameter where the life expectancy suddenly drops. Local spread.- The absence of metastases, even histologically, in axillary nodes does not exclude the possibility of internal mammary node metastases in medial quadrant tumours. The incidence of axillary node involvement is proportional to tumour size, but
520
averages at 50% in patients with operable breast cancer. Recurrent disease.- Whether in chest wall or axillary nodes, local recurrence is proportional to the initial axillary node involvement and reaches 38% when eight or more lymph nodes are initially involved. Postoperative radiotherapy diminishes the incidence ef local recurrence. Nearly all patients with abnormal bone scans fail to survive five years, but if clear at two years after operation, 90% will survive five years. lrnrnune response.- Until a reliableassociation of carcinoembryonic antigen can be developed, the only crude index of host response is the lymphocytic infiltrate in medullary carcinoma. Age.- Even in Stage 1 disease the survival rate in young women is more than 10% worse than in older women. If prognosis is regarded as important in the selection of patients for post-mastectomy reconstruction, these factors can provide a guide (Furnival, 1979). REFERENCE FURNIVAL,C. M. (1979). AUST.N.Z. J. SURG..49: 561
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POST-MASTECTOMY BREAST RECONSTRUCTION
nature of her condition. This used to be the role of the doctor, and if he did not do it or did it badly, then he alone had the responsibility for it. But in recent years the nursing profession has developed its own self-image and its own level of expertise in interpersonal relationships, and one could suppose that all professional groups who work with doctors would want to communicate directly with their patients. Consequently it may well be that in the surgical ward the nursing sisters and the physiotherapists and the occupational therapists will all feel that it is their right to discuss the patient’s clinical condition with the patient and to offer advice and prognosis, as well asgiving reassurance.
In some cases this may not be helpful to the patient, who is likely to get quite conflicting views about her condition from various members of the helping professions. Consequently I would suggest that it should be the responsibility of the surgeon to have a clear communication with the nursing staff of the ward, so that it can be determined who is going to communicate with the patient. I think that in most cases the surgeon should carry this responsibility himself. REFERENCE MAGUIRE.G: P. (1978), Brit. med. J. 1: 963.
SURGICAL PATHOLOGY OF BREAST CANCER IN RELATION TO RECONSTRUCTION AFTER MASTECTOMY c. M. FURNIVAL Brisbane IF, before considering reconstruction, an assessment is sought of the prognosis for any individual breast cancer, there are five factors which can be derived from a study of the tumour itself. These are as follows. ’ The histological type.Although only 20% of breast cancers are intraduct carcinoma, lobular carcinoma, well-differentiated adenocarcinoma, colloid carcinoma or medullary carcinoma, with l y m p h o c y t i c i n f i ’ t r a t i o n , this g r o u p has a substantially greater life expectancy than the 80% of patients with breast cancers comprising infiltrating forms of adenocarcinoma or ductile carcinoma, anaplastic tumours, and those invading blood vessels. A bilaterality approaching 30% in lobular carcinoma is stressed. Tumour size.- Survival is inversely proportional to tumour size, but there is no critical diameter where the life expectancy suddenly drops. Local spread.- The absence of metastases, even histologically, in axillary nodes does not exclude the possibility of internal mammary node metastases in medial quadrant tumours. The incidence of axillary node involvement is proportional to tumour size, but
520
averages at 50% in patients with operable breast cancer. Recurrent disease.- Whether in chest wall or axillary nodes, local recurrence is proportional to the initial axillary node involvement and reaches 38% when eight or more lymph nodes are initially involved. Postoperative radiotherapy diminishes the incidence ef local recurrence. Nearly all patients with abnormal bone scans fail to survive five years, but if clear at two years after operation, 90% will survive five years. lrnrnune response.- Until a reliableassociation of carcinoembryonic antigen can be developed, the only crude index of host response is the lymphocytic infiltrate in medullary carcinoma. Age.- Even in Stage 1 disease the survival rate in young women is more than 10% worse than in older women. If prognosis is regarded as important in the selection of patients for post-mastectomy reconstruction, these factors can provide a guide (Furnival, 1979). REFERENCE FURNIVAL,C. M. (1979). AUST.N.Z. J. SURG..49: 561
AUST.N.Z. J. SURG.VOL. 49-No.
5 , OCTOBER, 1979
