Over the last 20 years, breast cancer treatment has undergone a revolution in the UK, with 70-80% of patients now surviving a breast cancer diagnosis. There are many hugely significant developments in breast surgery and in oncology adjuvant treatments that have all contributed, but surgery is still the mainstay and the most beneficial treatment for most women affected. This remarkable transformation is in no small part thanks to leading oncoplastic breast surgeons such as Professor Andrew Baildam, who was responsible for setting up one of the first oncoplastic breast cancer surgery units in the UK and pioneered preventative surgery for those at the highest risk.
We asked Professor Baildam how he became a consultant breast surgeon, how the field has developed over the last 20 years, and what he expects for the future of breast cancer treatment.
How did you become a consultant oncoplastic breast surgeon?
It came out of how surgical training worked in the 1980s and 90s. At that time, everybody had to do ‘general surgery’ first as a training speciality – for myself, this even included orthopaedics for a year and a half, as well as vascular training. In order to become a senior registrar you needed to have an MD degree by thesis, and at the time the only research available to me was into molecular biology in breast cancer.
In the training years, I never had the original intention of specialising in breast surgery. The death rate from breast cancer was high and outcomes were awful. Surgery was being carried out by junior surgeons using crude techniques, while reconstruction was being developed by plastic surgeons with no experience of oncology. It was a very limited field.
After two years of research for my MD, I had learned a lot about the disease and with appropriate further training, I was one of the few surgeons with in-depth knowledge of both breast surgical oncology and plastic/reconstructive surgery. In the mid-90s I was appointed as a consultant surgeon at the Christie Hospital in Manchester to establish best practice in breast cancer surgery. I rapidly developed the department into a pure breast cancer service, travelling to New York, Atlanta, Nashville, Milan and Dusseldorf to get further training that I needed. Once established, I set up the UK’s first cross-speciality ‘oncoplastic’ surgical training fellowship for breast cancer and breast reconstruction. After the first few surgeons underwent training successfully, we received government funding to roll out the programme across the country initially in nine centres. This completely changed the face of breast cancer surgery provision in the UK.
What are some of the most significant advances you’ve seen in your field since becoming a consultant?
The field has changed enormously. If you get breast cancer today, you now have a 70-80% chance of survival. Almost all breast cancer services offer both treatment and reconstruction, and in some cases, this can be carried out in one operation.
On the cancer side, we’re diagnosing a person much earlier, which greatly increases your chance of survival, and we have access to new adjuvant treatments such as monoclonal antibodies.
As for surgery, this is still the primary treatment for breast cancer, with chemotherapy, radiotherapy and monoclonal therapy simply adding benefit. Aesthetic outcomes are much better too – in the past, a poorly done lumpectomy could look far worse than a full mastectomy, but in the last 10-12 years, partial breast reconstruction has really become better. We can now routinely carry out symmetrisation surgery, which involves a reduction or implant on the other side to get breasts to match. The latest advance is the widespread availability of fat grafting, which can actually rejuvenate the treated breast. Finally, nipple reconstruction has become easier, and I expect it will be offered much more in the future.
The best outcome for a woman is a breast – treated and reconstructed – she can forget about. That’s what we aim to achieve.
What is the most rewarding part of your work?
The most rewarding part of my work is the individual relationship with patients – getting them through treatment, giving them support, and then seeing them when they’re through it.
To take an example, I once treated a patient who had developed breast cancer in her late teens. When she first came to the clinic, she thought she wouldn’t live to her mid-20s. We gave her a total mastectomy, breast reconstruction and nipple reconstruction. She survived the cancer.
Two decades later she came into the clinic – now in her mid-30s – with her two children. She was still clear of cancer, and just wanted some surgery to make the breasts match.
What is the most difficult part of your work?
It’s telling people that they have cancer and that they will need major surgery and life-changing treatment. That doesn’t get any easier. As you become older yourself, you appreciate the impact of cancer on life more and more, and the implications it has for family and friends.
Reconstructing the breast after cancer
Who can have breast reconstruction surgery?
Almost any woman who is advised to have a mastectomy can have breast reconstruction surgery. This can be immediate at the same time, or delayed – done later. There are many different types of breast cancer and the decisions have to be decided between the surgeon, the patient and the oncology team – the MDT.
What are the main ways of ‘making’ a new breast?
All breasts are different – size, shape, flow, and direction. So there are many alternative ways of reconstructing the breast, each with its own area of application. In general, creating a large breast is much harder than a medium or smaller sized bust – and the risks of things going wrong are higher too. The main ways involve the use of breast implants, saline and silicone-filled, with or without an internal mesh bra, and the use of living tissue from the patient’s back or abdomen. There are many highly sophisticated ways of doing these, including microsurgery. ‘One size does not fit all’ – for individuals there may not be the full choice of options possible.
Will the ‘new’ breast be the same as the original?
A reconstructed breast visually may be highly natural but is never as good as the original breast. The surgeon needs to be a sculptor and artist as well as a surgeon, and bring creativity into the frame. They must be able to offer adjustment to the other natural breast to achieve symmetry – reduction, lifting or enhancement. No woman has perfect breast symmetry naturally, and cannot expect to achieve this with surgery either. But the best results are excellent and convincing, and the woman who can get on with life without giving her bust a second thought and can wear what she wishes is a great outcome.
Whilst a breast mound may be a close match, only nipple-areolar reconstruction finally makes it look like a real breast. Nipple reconstruction is fiddly and precise but is easy to have done and adds that final convincing touch of reality.
You are an advocate of risk-reducing mastectomy for patients at a high risk of breast cancer. Do you see the “preventative surgery” debate extending to other fields in the future?
In the late 1990s, preventative surgery for breast cancer was radical and controversial. It was the patients who were the pioneers. These are the kind of patients with a high lifetime risk, whose mother and grandmother died of cancer in their 30s and 40s, whose families harboured breast cancer–related gene codes such as BRCA1/2. 20 years later, the evidence for preventative surgery has borne out: preventative surgery reduces the subsequent incidence of breast cancer diagnosis by 90-95%.
So we have come a long way in showing that preventative surgery can work and actually save lives. It can also save the NHS huge amounts of money since the cost of preventative breast surgery is far lower than the cost of cancer treatment.
Whether this can extend to other fields is a complex question. I suppose the two aspects to this are: can you accurately predict someone’s cancer risk? And what are the risks of operating?
With breast surgery, we have identified genes which predisposed people to breast cancer. Some people can have a 70-80% lifetime risk of breast cancer. Some types of breast cancer are particularly aggressive. Based on family history and genomic analysis, we can identify those who are most at risk.
When it comes to other types of cancer, there is a gene that predisposes to both breast and stomach cancer, and some patients have had partial gastrectomy to reduce the risk of the latter. Ovarian cancer is another potential candidate. Risk-reducing removal of the fallopian tubes and ovaries is routinely offered to women. Outside these areas, however, we don’t yet have the evidence to assess lifetime cancer risk based on the genes someone has.
As for the risks of operating, breast surgery is a relatively safe operation. If necessary, the breast can be removed entirely and reconstructed. In contrast, we are much more cautious about even operating on essential organs, let alone removing and replacing them, which of course depends on an adequate organ donor pool. So it’s unlikely that we will see preventative surgery extended to other organs anytime soon.
What are your predictions for the future of breast cancer treatment?
In the immediate to short-term, we would hope that breast cancer surgery becomes a standalone speciality. This would ramp up the quality of care available to everybody since all surgeons treating breast cancer will be fully trained in the plastics and aesthetics as well as the oncology side.
In the mid- to long-term, I see several developments ahead. Firstly, breast cancers will be diagnosed at a very early stage and treatment will become less and less invasive. At the moment, out of 100 women, 87-88 will not develop breast cancer, 12 will, and 4 will develop aggressive cancer. The problem is that we are currently screening them all the same way. For high-risk patients, three-year intervals are too long and screening starts too late. It would be better if these patients were offered screening earlier and more often, using magnetic resonance imaging (MRI), contrast mammography and 3D mammography. This is carried out in some NHS trusts but is not standard practice yet.
I also expect that we will be able to identify high-risk patients more easily through cheaper genetic testing. Within the next few years, people will be able to get a readout of their own genome at home, providing a much more accurate assessment of risk than a secondary measure such as family history. As people become more interested in their own health, they are likely to be happy to pay for their own analysis, and hopefully, we will see high-risk patients coming into the clinic early enough to screen them properly.
Finally, I see lifestyle factors playing a role in the incidence of breast cancer. We know that maintaining a healthy weight, not smoking, exercise, diet and eating less red meat will reduce personal risk.
While many people are becoming more conscious of their own health, we are still seeing a rise in obesity levels. The concern is that over the next 20 years the population will fall into two groups: those who have modified their lifestyle and those who haven’t. It remains to be seen how lifestyles change in the long-term, and whether we can reduce the number of preventable cases of cancer.
Professor Andrew Baildam has clinics in Manchester and London. He specialises in all areas of breast health including breast surgery, breast reconstruction and breast cancer, and breast aesthetics. If you would like to book a consultation with Professor Baildam you can do so here.
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