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A multi-disciplinary team (MDT) approach is recommended where a surgeon, oncologist, pathologist, radiologist and family practitioner debate the best approach for managing each patient upfront.
Treatment for invasive cancers
Invasive cancers are staged according to the size of the primary breast cancer, the spread to the axillary nodes and evidence of spread elsewhere in the body.
• Stage 1: The tumour in the breast is small and there is no evidence of spread anywhere.
• Stage 2: The primary tumour is smaller than 5cm and there may be evidence of early spread to the lymph nodes.
• Stage 3: The primary tumour is locally advanced or there is evidence of obvious lymphatic spread.
• Stage 4: There is evidence of spread to other organs such as the lung, liver or bone.
The treatment may be thought of as being aimed at the primary tumour, the lymph nodes or the whole body.
Treatment plans are divided into local and systemic therapy.
Local therapy, such as surgery and radiation, aims to remove or kill cancer cells in the breast and adjacent lymph nodes.
Systemic therapy may be in the form of chemotherapy or hormonal therapy. This may mean a tablet once a day or intravenous drugs.
In general:
• Stage 1 disease is treated locally, usually with surgery. There is a growing tendency to give patients hormonal therapy, even when the disease is in such early stages.
• Stage 2 disease is usually treated by surgery first and then systemic treatment afterwards. Systemic treatment given after local treatment, when there is no sign of disease, is known as adjuvant therapy.
• Stage 3 disease is increasingly treated with systemic treatment first to "downstage" the disease, and with surgery afterwards. Systemic treatment given before local treatment is known as neoadjuvant therapy.
• Stage 4 disease is usually treated systemically, although radiotherapy may be used.
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 be used to control the local tumour in stage 4 disease, or may be used to treat local recurrence at a later date. It is generally painless and given on an outpatient basis. Side effects include fatigue, swelling and sunburn-like skin changes in the treated area. These changes usually disappear in six to 12 months. Radiation therapy is nearly always given after a lumpectomy.
Cancer can be cured by local therapy if it has not spread further. Unfortunately, cancer can spread, even though the primary cancer is small and there is no evidence of spread to lymph nodes.
Breast cancer does not always follow predictable growth patterns, and a prognosis cannot be predicted with absolute certainty. Therefore, systemic therapy is incorporated to treat the potential and actual risk of cancer spreading. This is seen as adjuvant treatment.
Chemotherapy and hormonal therapy are systemic therapies, given via the bloodstream to kill cancer cells that have spread beyond the breast. Chemotherapy comprises drugs received intravenously or by mouth. Hormone therapy involves drugs that change the way hormones work, or the removal of hormone-producing organs such as the ovaries.
More patients are being put on systemic treatment after apparently curative surgery, as there is increasing evidence that patients are less likely to develop problems, such as recurrence, second primary in the remaining breast tissue or metastatic disease, if they take systemic treatment. The traditional roles of hormonal treatment and chemotherapy are constantly being challenged and are changing, although hormonal therapy in a tablet form is still the most common form of adjuvant therapy.
The surgical options must be considered from various angles: the treatment of the breast, the treatment of the lymph nodes and the question of reconstruction.
Mastectomy means removal of all the breast tissue. If this is done by a breast surgeon, 3 to 5 percent of the breast tissue will still be left between the muscle bundles or in the skin.
Originally, radical mastectomy was done as a standard procedure. It entails removal of the breast, underarm lymph nodes and chest muscles under the breast. Because of disfigurement and side effects, and because modified radical mastectomy has proved equally effective, radical mastectomy is now rarely done.
Modified radical mastectomy entails removal of the breast tissue, the fascia on top of the muscle and the lymph nodes. It is less disfiguring and may be done to achieve a flat chest wall, or may be done through the nipple to allow immediate reconstruction.
Simple or total mastectomy removes the breast, but not underarm lymph nodes nor muscle tissue beneath the breast.
In certain circumstances, if the tumour is smaller than 5cm, breast conservation therapy (BCT) may be a satisfactory option. This maintains the major part of the breast and often shape is not altered significantly.
Both BCT and modified radical mastectomy are equally effective in the correct patients. BCT has to be followed by radiotherapy, and so is contraindicated in patients who cannot have radiotherapy. Neither guarantees a cure as approximately 25 to 30 percent of all women with breast cancer ultimately die from their disease. (The chance of dying from the disease is related to the stage of the disease at the time it was first diagnosed.)
The axillary nodes can be dissected out through a separate incision at the time of BCT. If nodes are felt on clinical examination, they will nearly always be removed at the time of surgery. This may be as part of the mastectomy (modified radical mastectomy) or may be through a separate incision.
If there are no nodes palpable and there is no evidence of cancer spread to the axilla, a Sentinel Lymph Node Biopsy may be performed. 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 the sentinel node contains cancer, more nodes are removed.
If the sentinel node is cancer-free, additional lymph node surgery is avoided. If there are axillary nodes that are palpable at the time of surgery, then the axillary lymph nodes should be removed surgically (axillary dissection).
If cancer has spread to lymph nodes, risk of recurrence is much higher and chemotherapy and/or hormonal therapy are usually needed.
Risk of metastasis roughly increases with the size of the original tumour, spread to lymph nodes, number of nodes involved and microscopic characteristics of the cancer. No tests can show precisely whether there is microscopic metastasis. Even when the tumour is small and there is no evidence of spread to lymph nodes, there may be reasons to use adjuvant systemic therapy, as about 10 to 15 percent of women in this group will develop metastatic cancer.
Adjuvant therapy is treatment that is given even when there is no evidence of any residual disease. The rationale for giving it is based on the fact that although the breast cancer is early, some women will have another problem from their cancer. Giving extra treatment makes this more unlikely.
Chemotherapy in adjuvant treatment used to involve a combination of drugs, in four or six cycles encompassing about six months of therapy. There are many more regimes that are being used and the advent of new drugs has made it difficult to generalise as to what regime is most suitable.
Side effects from chemotherapy depend on the drug type, amount and length of treatment. Temporary side effects may include nausea and vomiting, loss of appetite, hair loss, mouth sores and menstrual cycle changes. Chemotherapy can damage blood-producing bone marrow cells, resulting in low blood cell counts. A shortage of white blood cells, red blood cells and platelets increases the risk of infection, fatigue and bleeding or bruising respectively. Premature menopause and infertility are potential permanent complications.
Hormone therapy
Oestrogen promotes growth of some breast cancers. If hormone receptors are present, anti-oestrogenic agents such as tamoxifen can be used. Tamoxifen is taken daily in pill form for two to five years, as adjuvant therapy or to treat metastatic cancer. In post-menopausal women tamoxifen can decrease risk of recurrence similar to the decrease with chemotherapy, without many of the side effects associated with chemotherapy. It can also be given following completion of chemotherapy as, in certain women, it can decrease risk of recurrence more than with chemotherapy alone.
This drug helps women with breast cancer in its early stages, regardless of age. Tamoxifen may increase risk of early stage cancer of the uterine lining. Other effects may include blood clots in the legs (DVT), weight gain, hot flushes, mood swings and cataracts.
On the positive side, Tamoxifen strengthens the bones.
Tamoxifen is the only anti-hormone treatment that can be given to premenopausal women.
Aromatase Inhibitors are a newer form of anti-oestrogen drugs that are being used more frequently in post-menopausal women. Trials show them to be as effective or more effective than Tamoxifen. They have different side effects from Tamoxifen and may be used when Tamoxifen is contraindicated, or as a later treatment in a patient who has already had Tamoxifen. Aromatase inhibitors are increasingly being used in combination with Tamoxifen in appropriate patients.
Inflammatory breast cancer is initially treated with chemotherapy, followed by radiation therapy and surgery.
Treatment for non-invasive cancers
Treatment of Ductal Carcinoma In Situ (DCIS) is based on the risk of it evolving into invasive cancer and the fact that it is a curable disease. Treatment options include lumpectomy, lumpectomy with radiation therapy, and simple mastectomy. If the abnormal area is small, then removing this alone may suffice. Further therapy is usually indicated for a larger abnormal area, because risk of recurrence is reasonably high. In 50 percent of cases, recurring cancer is invasive. With simple mastectomy, the cure rate is 98 to 99 percent.
Lobular Carcinoma In Situ (LCIS) is not pre-invasive, but represents high-risk potential for development of invasive cancer. No treatment is required, but affected women should be monitored with mammograms and physical exams. Lumpectomy, with or without radiation, does not significantly decrease the risk of developing invasive breast cancer with LCIS. A single mastectomy is not a solution either, since invasive cancer can occur in either breast.
Side effects and post-surgical recovery
Clearly these depend on the surgery. There are complications from the anaesthetic and those from the operation itself.
After a lumpectomy, it is usual to feel a mass there, which takes months to settle. Eventually, the tissue under the scar will feel similar to the remaining breast tissue, but this takes many months. If immediate reconstruction is done at the time using the patient’s breast skin, there may be more complications relating to skin healing.
If the operation has included removal of the axillary lymph nodes (Modified radical mastectomy, axillary dissection or radical mastectomy) then other side effects may occur. Seroma (a build-up of fluid) in the cavity left by surgery is very common. It can usually be simply treated by drainage with a needle and rarely causes a problem. A major but unusual side effect is lymphoedema, which occurs in about 1 percent of women. Lymphoedema is swelling of the arm due to fluid accumulation. It is quite common to get very mild swelling but very uncommon to get marked swelling. It is more common if there has been both surgery and radiotherapy.
The potential for developing lymphoedema remains for life. Injury or infection involving the affected arm can aggravate existing lymphoedema or trigger its development, so the arm and hand should be protected. Avoid having blood drawn from the affected arm, and report swelling, tightness, pain or injury to the arm or hand to your doctor promptly.
There may be temporary or permanent limitations to arm and shoulder movement after surgery. Numbness or pinching/pulling sensations of upper inner arm skin is another common side effect, because the nerve controlling this travels through the lymph node area.
After surgery, you may need drains from the breast or underarm to remove fluid that collects during healing. Fluid must be emptied and measured for about two weeks, while drains remain in place. Some doctors put the arm in a sling, but most encourage moving the arm to avoid stiffness. Most women who have lumpectomy or mastectomy have little pain in the breast area. Written instructions on post-operative care are usually provided for the patient and the caregiver.
Most patients see their doctor within seven to 14 days after surgery. Your doctor should discuss the results of your pathology report as well as further treatment.
Long-term follow up (outcome)
The management of a patient who has been treated for breast cancer includes life-long surveillance. This is to detect any disease progression early and to check if there is a chance of the patient developing a second cancer. After finishing the first course of treatment, it is important to continue with scheduled follow-up appointments. During these appointments, your doctors will ask about any symptoms, do physical examinations and order laboratory or imaging tests, as needed, to look for recurrences or side effects.
At first, follow-up physical exams are done every three to four months. The longer you are free of cancer, the less often exams are needed. After five years, they are done once a year. Annual mammograms of the remaining breast and the breast treated by lumpectomy are needed. Women taking tamoxifen should have annual pelvic examinations.
A chest X-ray, CT scan, bone scan and a biopsy may be done if initial exams and tests suggest a recurrence or if there are worrying symptoms. Depending on the location of a recurrent cancer, treatment may involve surgery, radiation therapy, hormonal therapy or chemotherapy.
