In days gone by, having a mastectomy was a pretty standard procedure for many women who were diagnosed with breast cancer. But what are the treatment options today?
When people think of breast cancer treatment, what springs to mind most often is a mastectomy, which entails the removal of the breast. Fortunately, today it is not the only option available.
"The treatment of breast cancer depends on a variety of things, such as the stage of the cancer, the type of cancer, as well as the patient's age and wishes," says Dr Jenny Edge, Cape Town surgeon and breast cancer specialist.
So what stages are there? And which types of cancer? And what does the treatment entail?
Four stages of the diseases
There are four stages of cancer. In stage 1, the tumour in the breast is small and it has not spread. In stage 2, the primary tumour is smaller than 5 cm and it may have spread to the lymph nodes. In stage 3, the primary tumour is larger than 5 cm and it has usually spread to the lymph nodes. In stage 4, there is evidence that the cancer has spread to other organs such as the lungs, liver or bone.
Two types of treatment
There are two basic types of treatment. The one is local, and involves surgery and radiation, both of which are aimed at removing and killing the cancer cells in the breast, lymph nodes or other target organs. The other is called systemic therapy, which describes treatment that involves the whole body. This is usually in the form of hormonal therapy or chemotherapy.
Stage 1 disease is treated locally (usually surgery) and sometimes also hormonally. Stage 2 disease is treated with surgery first, followed by systemic treatment. Treatment for stage 3 disease is mostly treated systemically first and then with surgery. Stage 4 disease is usually treated systemically. Radiation may be used to treat spread to the bones.
What is radiation therapy?
Radiation therapy uses high-energy rays to reduce the size of the tumour or destroy cancer remaining in the breast area after surgery. It may also be used to treat localized areas of spread, such as bone involvement.
What is chemotherapy?
Chemotherapy is a systemic therapy, which is given via the bloodstream, or taken by mouth. This treatment is used to kill off cancer cells that have spread beyond the breast.
Hormone therapy involves drugs that change the way hormones work. Sometimes it also involves removing hormone-producing organs, such as the ovaries. Many women undergo systemic therapy after surgery, as it appears to reduce the chances of the cancer recurring and may decrease the chance of developing breast cancer in the other breast.
What types of surgery are there?
Three issues need to be considered when deciding on breast surgery: the treatment of the breast itself, the treatment of the lymph nodes and the question of reconstruction.
Radical mastectomy means the removal of all breast tissue and entails the removal of the breast, underarm lymph nodes and the chest muscles under the breast.
"But, because of the disfigurement and side effects, and because modified radical mastectomy has proved equally effective, radical mastectomy is now rarely done," says Edge.
Modified radical mastectomy involves the removal of the breast tissue, the fascia on top of the muscle and the lymph nodes. The advantages of this procedure are that it is less disfiguring, and can also be done through a small incision keeping the skin, and this allows for immediate reconstruction.
Breast conservation therapy (BCT) can be performed if the tumour is less than 5 cm in size. When used with the correct patients, modified radical mastectomy and BCT are equally effective as long as radiotherapy is given after the surgery.
The lymph nodes must be dealt with at the same time. All the underarm lymph nodes may be removed or a sentinel node biopsy may be performed. The sentinel lymph node is the first node to which the cancer usually spreads. The bigger the tumour, the greater the likelihood is of this happening. A radioactive substance is injected into the cancerous region and is carried by lymph vessels to a sentinel node, which is the first lymph node receiving lymph from the tumour. If this sentinel node contains cancer, more nodes are removed.
The body's lymphatic system is used for drainage – so what happens when these lymph nodes are removed?
"The fluid drains through alternative routes. But one has to remember that cancerous tumours block these lymph nodes, so if they are involved, it is better to remove them," says Edge.
Can breast cancer be prevented?
Some women who have several family members who have had breast cancer and therefore have a predisposition for breast cancer, consider having a mastectomy done in order to reduce their risk of breast cancer. Or women who have had breast cancer on one side, consider a mastectomy of the other breast as well.
"Cancer that has spread is always worse than a mastectomy," says Edge. "But, for the general populace, this is certainly not the way to go. If you are at risk for breast cancer, regular mammograms are recommended."
She stresses that choosing a mastectomy is merely a risk-reducing procedure and not a sure-fire preventative mechanism. There are a few women who have a very high risk of developing breast cancer, who will benefit from a mastectomy, but for most women annual mammography is better. Breast reconstruction with implants or prostheses can go a long way to reducing the trauma of having a mastectomy.
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