I used to work with Professor Veronesi in the clinical trials proving that breast conservation therapy was very effective in treating breast cancer. From there to now we did a lot of progress in conservative treatment: we improved our indications, we improved the cosmetic outcome. The breast conservation therapy enriched in the last ten years by oncoplastic surgery, that is a combination between the cancer surgery and the plastic surgery in order to give better cosmetic outcomes to our patients.

Also we gave in the last years a better indication for conservation surgery. We know better now when conservation therapy is safe and we can do it with a very reasonable risk of local recurrences for the patients. We know that conservation surgery is not so indicated in patients carrying the mutation for the BRCA gene and for this reason we prefer to do some mastectomies in this type of patients.

We are more and more committed to do the so-called personalised medicine, personalised surgery, personalised treatment for breast cancer and for this reason we evaluate the patients at the beginning, taking into consideration the possible variants for the risk of local recurrences that we would like to be as less as possible.

What are the characteristics of a breast tumour that would allow for this procedure?

Now we are doing conservation therapy in two modes that are, at the beginning, too large to allow the conservation therapy. We do more neoadjuvant treatments in order to reduce the cancer and able to do conservation therapy.

In the last 5-10 years we are more and more conservative regarding the lymph nodes. For instance, in the past we used to remove the axillary lymph nodes, increasing the risk of lymphedema. Lymphedema can appear after the removal of the lymph node in about 10-15% or so of the patients, especially if they need radiation therapy on their axilla. Now we know that we can spare the lymph nodes; we apply the technique of the sentinel lymph node biopsy and we know now that even if the sentinel biopsy is positive for cancer in some selective patients we can spare the axillary dissection – they don’t require anymore to remove the lymph nodes. This is the result of one big trial, an American trial, showing that when the residual disease is not a lot the other treatments can clean up the possible residual lymph nodes and it’s not necessary anymore to remove the lymph nodes. So in the first phase in which we were able to save the breast, now we are entering a second phase in which we can spare also the lymph nodes.

We are doing more and more of these so-called conservation mastectomies. In patients in which, unfortunately, we need to do mastectomy we are able to improve the quality of life doing mastectomies that are better and better – skin sparing mastectomies, nipple sparing mastectomies – the evolution in the last ten years of the plastic surgery allows us to obtain excellent results. So if the patient needs mastectomy we know that we can give good results and the patient can have a very good quality of life.

How does the surgical strategy change if the patient has a mutation in BRCA?

We are looking more and more for the genetic mutation. We know that about 10% of women with breast cancer would have a mutation and the more we search for the mutation the more we find mutation. In the past the only mutation that we were able to detect was the BRCA – BRCA1 and BRCA2 – but now we know that there are many genes that can increase the risk of breast cancer. Now there is a panel of 28 genes that we are able to evaluate including, for instance, the ATM, the CHEK2; for instance in the Caucasian population we have quite a high risk of the CHEK2 mutation compared to the Ashkenazi population in which the BRCA is the most diffuse. So when we consult in the beginning the patient we look for the family history – we look at the age, we look at the type of cancer, for instance triple negative cancers may have an increased risk of mutation in our women, and we start right away the process of the genetic test. If the patient has a mutation, even if the cancer is very small and the patient may be eligible for conservation therapy we opt for something that is more preventive and we opt for the bilateral mastectomy because we know that we can give a better final outcome regarding the survival in this patient.

How are more conservative therapies taken up by the patients?

The patients are very happy because, of course, the quality of life is important. Sometimes the patient may overact at the beginning with the diagnosis of breast cancer and a patient may say, ‘Well, I don’t care. Do what I need – please remove both breasts.’ Of course we need to speak and evaluate with the patient the risk. We know that medicine is more and more personalised; guidelines are important but a little less important than in the past because medicine is options and each patient can evaluate with the surgeon, the medical oncologist, the better option for her. So the patients can really feel that we tailor the treatment for her.