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Treatment of breast cancer

Operative treatments
Operative treatments

Pre Invasive Breast Cancer

If the result of a diagnostic assessment suggests a pre invasive cancer DCIS or LCIS, then surgery is the curative therapy of choice. A mastectomy (removal of the whole breast) may need to be considered if the mammogram suggests widespread pre invasive cancer changes. Following a mastectomy there is usually no further need for other therapy apart from standard surveillance. Where breast conserving surgery has been involved, post operative radiotherapy to the breast reduces the recurrence rate of DCIS and invasive breast cancer.

 

The use of hormonal therapies is under further evaluation as there is some evidence to suggest it may further reduce the incidence of recurrent DCIS and invasive cancer in the involved and contra lateral breast.

    

Treatment of invasive breast cancer

Treatment should be ideally discussed between the surgeon and oncologist as it may involve a multi modal approach including surgery, radiotherapy, chemotherapy, hormone therapy and biological treatments. For all patients where the staging has demonstrated localised disease or disease confined to the breast and lymph nodes in the axilla, the commonest approach would be to consider surgery followed by a combination of chemotherapy, radiotherapy, hormone therapy and biological treatments. In certain patients, prior treatment with chemotherapy or hormone therapy may allow a reduction in the size of the tumour so that the surgeon can perform breast conserving surgery. The decision for radiotherapy, chemotherapy, hormone therapy and biological treatments would be based on certain characteristics of the tumour. The oncologist would discuss when a treatment would not be needed if there was no substantial benefit.

 

The initial assessment at the time of a diagnosis of the breast cancer may, in a small proportion of patients, demonstrate spread of the breast cancer beyond the breast and the lymph nodes in the axilla. Treatment for these patients may not be curative and the oncologist and his team looking after the patient would determine which options of therapy summarised above may be best utilised to prevent progression of the cancer.

 

Surgery

Surgery plays a key role in the management of most patients with breast cancer. For all patients treated with curative intent, surgery would involve removing of the breast tumour with breast conservation or removal of the breast (mastectomy). Surgery also plays an important role in the assessment of the lymph nodes in the axilla and removal of lymph nodes as a diagnostic and therapeutic procedure. Surgery would also need to be considered for biopsies of abnormal areas detected on staging and surgery can play a role in palliation e.g. orthopaedic surgery for fixation of a broken limb involved with cancer. The role of surgery in the management of primary breast cancer and axilla is further addressed here.

  

Breast Conserving Surgery

Small primary invasive cancers of the breast may be treated with breast conservation. The operation being called a lumpectomy (a radical mastectomy), quadrantectomy, (wide local excision). This should allow preservation of the breast in a reasonable cosmetic form but excision of the tumour such that there is no evidence of residual cancer under the microscope at the edges of the specimen (microscopic clearance). The surgeon would also need to consider that pre invasive cancer, which can often account for the invasive cancer, is also cleared. In the majority of patients undergoing breast conserving therapy would need consideration of post operative radiotherapy; this is discussed later in the radiotherapy section.

 

Mastectomy

A mastectomy should be considered when the cancer is advanced with involvement of the skin or underlying muscle, where a cosmetic result of residual breast may be unacceptable, and where the tumour may involve the nipple and duct complex, and for specific patients where there may be concerns of compliance with radiotherapy follow up. The surgeons should in be in a position to discuss the possibility of reconstruction either immediately following the mastectomy or at a later date depending on the patient’s wishes and suitability.

 

The surgeon will discuss the type of mastectomy undertaken which may be a simple mastectomy, modified radical mastectomy or radical mastectomy. These procedures involve excising different areas of tissue with the intent of also removing a number of lymph glands from the axilla. A subcutaneous mastectomy may also be an option as it allows maintenace of normal breast tissue and nipple. However, there is some breast tissue which may not be completely removed.

 

 

Lady presenting with locally advanced breast cancer (left panel) and after successful treatment (right panel)
Lady presenting with locally advanced breast cancer (left panel) and after successful treatment (right panel)

Surgical Treatment for the Axilla

Assessment of the lymph nodes by surgery can help guide further treatment. This may be further surgery, radiotherapy or chemotherapy. The surgeon would discuss investigation of the axilla which may involve injecting tracer dyes and removal of a sentinel lymph node. Further surgery would be considered where there is evidence of cancer of the axillary lymph nodes.

 

Radiotherapy

Radiotherapy plays a key role in the management of patients who have undergone breast conserving surgery.

Radiotherapy would also be considered as treatment to lymph nodes where there is a higher risk of recurrence, palliation of breast cancer recurrence, palliation of bone pain and brain metastases. The commonest form of radiotherapy is external beam radiotherapy using mega voltage photons on linear accelerators. There are studies underway to assess radiotherapy directly targeted to the tumour bed (intra operative radiotherapy, mammosite). In selected centres, radiotherapy may be delivered by a technique called brachytherapy.

 

The treating oncologist would advise on the mode of radiotherapy.

 

Adjuvant therapy.  

Chemotherapy

Chemotherapy can provide substantial benefits to patients treated with curative intent. Adjuvant chemotherapy refers to the usage of medical treatment given after surgery with the intention of reducing the chance of subsequnet relapse. The quantitaion of the benefit can be calculated and certain online methods are available for breast cancer (e.g. www.predict.nhs.uk) Certain prognostic factors such as a large tumour, a high histological grade, the presence of involved malignant nodes and the results of the receptors would suggest a benefit to different chemotherapy agents, but there is also an established benefit for younger patients with smaller cancers. The treating oncologist would advise the patient as to which regime is best suited for their cancer with the resulting benefit of chemotherapy.

 

Chemotherapy can also help in the treatment of patients with metastatic disease and this may be combined with palliative radiotherapy.

 

Hormone therapy. For patients with tumour profiles that suggest sensitivity to oestrogen and/or progestrogen (hormone receptor positive cases of breast cancer), there is a benefit to considering hormonal therapy. Just as we refereed to the term: 'adjuvant therapy' for chemotherapy used in this situation, so the term: adjuvant hormone therapy is used when this type of therpay is given after a potentially curative operation - once again used to reduce the risk of any subsequent relapse. The aim of hormonal therapy is to minimise exposure of a potential cancer cell to oestrogen or antagonise the oestrogen receptor (whic many breast cancers still harbour). The available drugs can achieve this by different mechanisms. These drugs include Tamoxifen, aromatase inhibitors (Anastrazole, Letrozole, Exemestane). In general, a single drug or a combination would be recommended for a minimum period of five years. Sometimes, the treating oncologist will recommend a younger lady to have ovarian suppression with a durg like: Zoladex or Leuprelin and then go on an aromatase inhibitor. The quantitation of the survival benefit from such adjuvant hormone therapy will be discussed by the doctor; there are online methods available for the calculation of this % benefit (e.g. www.predict.nhs.uk).

 

The use of the hormonal therapies is also determined by the menopausal status of the patient. For pre menopausal patients Tamoxifen is the standard drug of choice as the aromatase inhibitors are not suitable for patients who are still menstruating. In the post menopausal setting, the aromatase inhibitors can offer a small survival advantage for those patients with higher risk tumours. The treating oncologist would discuss the ideal hormonal therapy with due consideration to both acute and late side effects.

 

Biological Therapies

Breast cancer cells can express a surplus protein called HER2. This protein expression suggests the cancer cells may be more aggressive. The drug Trastuzumab/Herceptin is an antibody aimed at the HER2 receptor in the cancer cells and when added to chemotherapy has improved survival in the earlier stages of disease. Herceptin therapy should be considered in patients who are positive for HER2 expression if chemotherapy is recommended as part of their treatment programme.

 

Herceptin therapy has also demonstrated increased response rate in advanced metastatic disease.

 

Another drug which also targets HER-2 is lapatinib and this may be also used in combination with other drugs in the therapy of HER-2 positive breast cancer, at present always after the usage of herceptin.

 

Preliminary studies of a drug targeting a vascular growth factor, Bevacizumab (Avastin) have demonstrated increased response rates with a combination of chemotherapy for patients with metastatic disease. This drug has been used most in patients with HER-2 negative breast cancer, who have relapsed.

 

Bisphosphonates are a class of drugs that are aimed at stablisation of the bone architecture. Early studies have suggested a reduction of bone metastases for patients with poor prognostic characteristics at the time or their original diagnosis. This class of drugs is the subject of further continued studies for early adjuvant multimodal therapy. Bisphosphonates are regularly used in patients with metastatic bone cancer to reduce symptoms and prevent the progression of bony disease.


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