Breast cancer treatment has greatly improved over the years and consequently so have breast cancer survival rates and we have only research to thank for.
Today, most women with breast cancer are diagnosed early, which makes the cancer better treatable with an improved outcome and cure.
There are several options for breast cancer therapy and the oncologist makes his choice of treatment after evaluating the case based on the following.
- General condition and age of the patient
- Type of breast cancer – whether ductal or lobular, invasive or non-invasive
- Size of the breast tumor
- Stage of breast cancer
- Its grade
- Results of the hormone receptor and HER2/neu tests obtained after investigating the breast cancer
All treatment options have two goals: To get rid of cancer from the body and prevent its recurrence
Breast cancer treatment can be local or systemic.
- Local breast cancer treatment consists of surgery, which can be a lumpectomy in which the cancerous tumor in the breast is removed and later usually targeted with radiation. The second surgical option is mastectomy in which the whole breast is removed and which may also comprise of removal of the draining lymph nodes.
- Systemic breast cancer treatment consists of chemotherapy, hormonal therapy, and targeted therapy in which the medication enters the body via the blood and destroys the cancer cells situated elsewhere in the body.
After having completed a detailed investigation for breast cancer, the oncologist arrives at a confirmed diagnosis and chalks out the treatment plan.
The purpose of breast cancer treatments differs and depends on the stage of cancer. Most breast cancer patients require a combination of treatments.
Surgical treatment of breast cancer consists of either a lumpectomy or mastectomy
In a lumpectomy, the surgeon removes the whole breast cancer tumor and some of the surrounding breast tissue. This surgery is done in cases where the breast tumor is small and not attached to the neighboring breast tissue.
The surgeon may also remove some of the lymph nodes under the armpit to examine them and find out if cancer has spread to the lymph nodes. Lumpectomy is almost always followed by radiation therapy to ensure that any cancer cells left behind after surgery are destroyed.
Read the full note on a lumpectomy.
Mastectomy involves surgical removal of the breast. It can be a simple or a radical mastectomy and may also involve removal of the axillary nodes depending on the stage of the breast cancer as explained below.
- Simple mastectomy. In simple mastectomy, the oncosurgeon removes the entire breast tissue – the lobules, the ducts, the fatty tissue, the skin along with the areola and the nipple.
- Radical mastectomy. In a radical mastectomy, the entire breast tissue is removed along with the muscles of the chest wall and the lymph nodes in the axilla. In some cases where possible, a skin-sparing surgery is performed to allow for breast reconstruction.
- Removal of lymph nodes. During the lumpectomy or simple mastectomy, the surgeon may also consider removal of the lymph nodes in the axilla, because this is where the lymphatic drainage of the breast takes place. The surgeon identifies the lymph node which first drains that part of the breast where the tumor is situated. This is done by injecting a dye or radioactive substance before surgery near the tumor and the first lymph node where the visible dye drains into is identified as the sentinel lymph node. This lymph node is then removed by a procedure called the sentinel node biopsy, It is then sent to pathology to be tested for cancer cells. If the report comes negative, then the other lymph nodes are left intact. If the report is positive, the other lymph nodes in the breast are also removed. Such cases require chemotherapy and radiation after surgery to improve survival. This also reduces the chances of lymphedema (chronic swelling in the armpits), which often occurs after the removal of the lymph nodes.
Read the full note on mastectomy.
Radiation for breast cancer involves the use of high-energy ionizing radiation rays to target and destroy the cancer cells and stop their uncontrolled growth. X-rays, gamma rays, and charged particles are used for radiation in treating breast cancer. Read the full note on radiation therapy.
Radiotherapy for breast cancer can be either external or internal. Each of these types of radiation has its indications and sometimes both types of radiation may be used to cure the patient.
- Internal radiation for breast cancer, also called brachytherapy, involves placing an implant or “seed” containing radioactive isotopes inside the tumor or near it. The patient is hospitalized for this type of radiation treatment.
- External radiation for cancer makes use of a radiation machine to give radiation treatment from the outside to the patient. It is given when the patient has undergone lumpectomy for small tumors and also may be recommended after mastectomy for large tumors. Radiation after a positive sentinel biopsy also reduces the chances of cancer spreading to the other lymph nodes.
A common treatment course includes one radiation session a day, five days a week for five or six weeks. This course is also usually used in people who require radiation to the lymph nodes.
Radiation has several side effects and they are explained in this post.
Chemotherapy forms part of the systemic treatment for breast cancer. It involves the use of chemotherapeutic drugs, which stop the fast-growing cancer cells from spreading. It is recommended when your chances of recurrence or metastasis are high.
There are three types of chemotherapy:
- Neoadjuvant chemotherapy is given before surgery to reduce the size of a larger breast tumor to easily facilitate its removal.
- Adjuvant chemotherapy is given after surgery to reduce the chances of recurrence.
- Palliative chemotherapy does not serve a curative purpose but is administered to reduce the symptoms of the patient. This is used in cases of metastatic breast cancer.
See side effects of chemotherapy to know problems that can occur due to chemotherapy.
Certain malignant tumors of the breast require hormones to grow. They, therefore, have receptors on the surface of the breast tumor cells. They may have receptors for estrogen (ER-positive), progesterone (PR-positive), or both.
A positive hormone receptor test indicates sensitivity to hormones, in which case hormone therapy becomes an option to treat breast cancer. This therapy is also referred to as hormone-blocking therapy.
It is used in ER or PR-positive breast cancers after breast surgery or after other forms of breast cancer treatments to reduce risks of recurrence. It is also used in metastatic breast cancer to control metastasis.
Hormone therapy to treat breast cancer involves stopping the hormone from being produced or by stopping the hormone from reaching the cancer cells.
This is done by administration of hormone-blocking drugs or stopping the production of hormones by surgical removal of an endocrine organ such as orchiectomy in males (surgical removal of testes) and oophorectomy (surgical removal of ovaries) in females.
- Tamoxifen is the most commonly used drug. It is a selective estrogen receptor modulator (SERM). It acts by blocking estrogen from being taken up by the estrogen receptors that are present on the surface of the cancer cells. This slows down the growth of the tumor by killing the cancer cells. It can be used in pre and post-menopausal women. It is indicated in the early stages of breast cancer and metastatic breast cancer. Side effects of Tamoxifen include fatigue, night sweats, and vaginal dryness. It also has more dangerous side effects such as cataracts, stroke, and endometrial cancer. Women on Tamoxifen should be periodically checked for the development of any symptoms and signs of these side effects.
- Aromatase inhibitors are a group of drugs that stop estrogen from being produced in the body by blocking the action of an enzyme called aromatase which converts androgens into estrogen. They give better results in post-menopausal women. They include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). They may be used in the early stages of breast cancer as adjuvant therapy and also after tamoxifen therapy for 2 years. Side effects include joint and muscle pain and osteoporosis ( thinning of the bones).
- Surgery to stop hormone production can be an effective treatment in premenopausal women where the ovaries are surgically removed so that estrogen production in the body is stopped. Certain drugs can also be used for this purpose. This surgery is referred to as prophylactic oophorectomy or surgical menopause.
HER2/neu is a cancer gene. In 20% to 30% of invasive breast cancers, this gene is amplified and the protein, HER2/neu protein, which it produces, is increased.
HER2 positive test indicates that the tumor has HER2 protein receptors on the surface of its cells. Blocking of these receptors stops the tumor from growing.
Targeted therapy, as the name suggests, is the use of drugs that specifically target cancer cells without harming the normal cells. Monoclonal antibodies and tyrosine kinase inhibitors are two therapies used in this form of breast cancer.
- Trastuzumab (Herceptin) is a monoclonal antibody. This chemotherapeutic drug, Herceptin blocks these protein receptors thereby inhibiting the growth of the tumor. Side effects include heart problems, skin rashes, and headaches.
- Lapatinib is a tyrosine kinase inhibitor that inhibits the action of the proteins like HER2/neu which are present inside the tumor cells. Its use is reserved in women who have HER2/neu positive breast cancer and treatment with Lapatinib has proved ineffective. Tyrosine kinase inhibitors are sometimes used in combination with other drugs as adjuvant therapy.
- Bevacizumab (Avastin) prevents the cancer cells from forming new blood vessels for their growth. Without oxygen and nutrients, the cancer cells die. The use of this drug today is in question.
Treatment for breast cancer is continued for a period of time. Surgical breast cancer procedures may be followed up with reconstructive breast surgery, which at times is done at the same time as the mastectomy.
Blood tests, mammograms, and other tests for breast cancer are done to check for recurrence even after the breast cancer has been treated.