Treatments for Breast Cancer

Surgery

Almost all women with breast cancer will have some type of surgery in the course of their treatment. The purpose of surgery is to remove as much of the cancer as possible, and there are many different ways that the surgery can be carried out. Some women will be candidates for what is called breast conservation therapy (BCT). In BCT, surgeons perform a lumpectomy which means they remove the tumor with a little bit of breast tissue around it, but do not remove the entire breast. BCT always needs to be combined with radiation therapy to make it an option for treating breast cancer. At the time of the surgery, the surgeon may also dissect the lymph nodes under the arm so the pathologist can review them for signs of cancer. Some patients will have a sentinel lymph node biopsy procedure first to determine if a formal lymph node dissection is required. Sometimes, the surgeon will remove a larger part (but not the whole breast), and this is called a segmental or partial mastectomy. This needs to be combined with radiation therapy as well. In early stage cancers (like stage I and II), BCT (limited surgery with radiation) is as effective as removal of the entire breast via mastectomy. The advantage of BCT is that the patient will not need a reconstruction or prosthesis, but will be able to keep her breast. Some patients with early-stage cancer prefer to have mastectomy, and this is an appropriate option as well..
More advanced breast cancers are usually treated with a modified radical mastectomy. Modified radical mastectomy refers to removal of the entire breast, as well as and dissection of the lymph nodes under the arm. Sometimes, patients who have modified radical mastectomy will require radiation treatment afterwards to decrease the risk of the cancer coming back.
Some patients with DCIS will be candidates for BCT, while others will require modified radical mastectomy because of the size or distribution of DCIS cells. Most patients with DCIS who have a lumpectomy are treated with radiation therapy to prevent the local recurrence of DCIS (although some of these DCIS patients may be candidates for close observation after surgery). Patients with DCIS that have a mastectomy do not need to have the lymph nodes removed from under the arm.
Your surgeon can discuss your options and the pros and cons of your needed surgical procedures. Many women who have modified radical mastectomies choose to undergo a reconstruction. A patient who desires reconstruction should try to meet with a plastic surgeon before her mastectomy to discuss reconstruction options. For more information on breast reconstruction, see Breast Reconstructive Surgery Options.

Chemotherapy

Even when tumors are removed by surgery, microscopic cancer cells can spread to distant sites in the body. In order to decrease a patient's risk of recurrence, many breast cancer patients are offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body to eliminate cancer cells that have broken off from the breast tumor and spread. Many factors go into determining whether an individual patient should have chemotherapy. Generally, patients with higher stage disease need chemotherapy; however, chemotherapy can be beneficial even for patients with early-stage disease. Individual factors such as age, overall health, and biologic properties of a woman’s breast tumor may go into decisions regarding whether or not she should have chemotherapy. There are many different chemotherapy drugs, and they are usually given in combinations for 3 to 6 months after you receive your surgery. Depending on the type of chemotherapy regimen you receive, you may get medication every 2 to 4 weeks. Most chemotherapies used for breast cancer are given through a vein, so need to be given in an oncology clinic. Drugs that are commonly used in breast cancer treatment include adriamycin (doxorubicin), cyclophosphamide, and taxanes. There are advantages and disadvantages to each of the different regimens that your medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your lifestyle.
Generally, chemotherapy is given after surgery for early-stage breast cancer. Sometimes, chemotherapy may be given before surgery to shrink large tumors and allow surgery to be more effective. For patients with stage IV disease, chemotherapy may be given without surgery, and a variety of different agents may be tried until a response is achieved.

Radiotherapy

Breast cancer is often treated with radiation therapy. Radiation therapy refers to use of high energy x-rays to kill cancer cells. Patients having radiation usually need to come to a radiation therapy treatment center 5 days a week for up to 6 weeks to receive treatment. The treatment takes just a few minutes, and it is painless. Radiation therapy is used in all patients who receive breast conservation therapy (BCT). It is also recommended for patients after a mastectomy who have had large tumors, lymph node involvement, or close/positive margins after the surgery. Radiation is important in reducing the risk of local recurrence and is often offered in more advanced cases to kill tumor cells that may be living in lymph nodes. Your radiation oncologist can answer questions about the utility, process, and side effects of radiation therapy in your particular case.
Some newer techniques for radiation therapy are being used in certain centers. These are ways to reduce the treatment time needed for radiotherapy, and usually take 1 – 3 weeks instead of 6 weeks, and are called accelerated partial breast irradiation (APBI). These techniques may require a patient to have a radioactive implant placed inside the breast. These techniques are experimental, and are only indicated for early-stage breast cancer patients.

Hormonal Therapy

When the pathologist examines a tumor specimen, he or she may determine that the tumor is expressing estrogen and/ or progesterone receptors. Patients whose tumors express estrogen receptors are candidates for therapy with estrogen blocking drugs. Estrogen-blocking drugs include Tamoxifen and a family of drugs called aromatase inhibitors. These drugs are delivered in pill form for 5 - 10 years after breast cancer surgery. These drugs have been shown to drastically reduce your risk of recurrence if your tumor expresses estrogen receptors. They may be accompanied by side effects, however. When taking Tamoxifen, patients may experience weight gain, hot flashes and vaginal discharge.. Taking Tamoxifen may also increase risk of serious medical issues, such as blood clots, stroke, and uterine cancer. Patients taking aromatase inhibitors may experience bone or joint pain, and are at increased risk for thinning of the bones (osteopenia or osteoporosis). Patients taking aromatase inhibitors should have yearly bone density testing, and may require treatment for bone thinning.

Biologic Therapy

The pathologist also examines your tumor for the presence of HER-2/neu overexpression. HER-2/neu is a receptor that some breast cancers express. A compound called Herceptin (or Trastuzumab) is a substance that blocks this receptor and helps stop the breast cancer from growing. Patients with tumors that express HER-2/neu may benefit from Herceptin, and this should be discussed with a medical oncologist when the treatment plan is decided upon.

Follow-up testing

Once a patient has been treated for breast cancer, she needs to be closely followed for a recurrence. At first, you will have follow-up visits every 3-4 months. The longer you are free of disease, the less often you will have to go for checkups. After 5 years, you could see your doctor once a year. You should have a mammogram of the treated and untreated breasts every year. Because having had breast cancer is a risk factor for getting it again, having your mammograms done every year is extremely important. If you are taking Tamoxifen, it is important that you get a pelvic exam each year and report any abnormal vaginal bleeding to your doctor.
Clinical trials are extremely important in furthering our knowledge of this disease. It is though clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your doctor about participating in clinical trials in your area.
This article is meant to give you a better understanding of breast cancer. Use this knowledge when meeting with your physician, making treatment decisions, and continuing your search for information. You can learn more about breast cancer on OncoLink through the related links mentioned in this article.