By Dr Ananya Mandal, MD
Breast cancer treatment has advanced to a stage that, if detected early, most women may survive much longer than they did a few decades ago.
Who provides breast cancer treatment?
Care for breast cancer involves a multidisciplinary team or a team of specialists who work together to provide the best care and therapy. The team usually includes specialist cancer surgeon or an oncosurgeon, an oncologist (who specializes in cancer chemotherapy), a radiation therapist, a radiologist, pathologist, a reconstructive surgeon or a plastic surgeon, a specialist nurse, occupational therapist, diet advisor or nutritionist, a psychologist or psychiatrist and a social worker.
Deciding on treatment options
Once diagnosed, the first step is discussion with the oncologist on the available treatment options and possible outcome or prognosis with and without treatment.
Treatment depends on the stage and grade of the cancer, general health, whether the woman has undergone menopause and personal preferences.
Use of hormonal and biological therapy also necessitates certain tests. If these tests (for example Estrogen receptor positivity or positivity for HER2/neu proteins) are positive, hormonal or biological therapies may be initiated.
Main treatment options
The main treatment options include :
These may be used alone or in combination.
Surgery is usually the first step in treatment of breast cancer. The type of surgery depends on the type and extent of breast cancer. Surgery is usually followed by chemotherapy or radiotherapy or, in some cases, hormone or biological treatments.
There are two types of surgery for breast cancer. One of these is to remove the cancerous lump or tumor alone. This is called breast-conserving surgery.
Breast conserving surgery may be a lumpectomy or wide local excision. For this, just the tumour and a little surrounding breast tissue is removed. It may also be a partial mastectomy or quadrantectomy, in which up to a quarter of the breast is removed. The type of breast conserving surgery depends on the type of cancer, size of the tumour, amount of surrounding tissue that is affected and size of the breasts.
The other type is surgery to remove the whole breast, which is called a mastectomy. After a mastectomy the breast may be reconstructed surgery to recreate the breast that was removed. Here the nipple is also removed.
If the cancer has not obviously spread, a lymph node from the armpit is also removed along with the breast. It is called sentinel lymph node biopsy (SLNB). However if the cancer has spread to lymph nodes a more extensive removal (clearance) of lymph nodes from the armpits is needed.
This mode of treatment involves use of controlled doses of radiation to kill cancer cells. It is generally given after surgery and chemotherapy to kill any remaining cancer cells. Radiotherapy is usually begun around a month after surgery or chemotherapy.
Radiotherapy sessions are usually three to five days a week, for three to six weeks. Each session lasts only a few minutes. The duration and intensity of radiotherapy depends on the type of cancer. Some women may not need to have radiotherapy at all. Radiotherapy may be directed to the affected breast after a breast conserving surgery, or may be directed to the chest wall and lymph nodes.
The side effects of radiotherapy include irritation, soreness, burns and darkening of the skin, fatigue and lymphoedema or fluid accumulation in the arm due to blockage of lymph channels.
This modality of therapy involves using anti-cancer drugs to kill the cancer cells. Chemotherapy is usually used after surgery to destroy any cancer cells that have not been removed. This type of chemotherapy is called adjuvant chemotherapy. Sometimes chemotherapy may also be given before surgery to shrink the tumor before surgery. This is called neo-adjuvant chemotherapy.
Chemotherapy is usually administered as an outpatient or day care basis. The drugs are usually given through an intravenous line or as tablets. Chemotherapy sessions may be once every two to three weeks, over a period of four to eight months. Often three drugs are used together in a chemotherapy regimen.
Side effects of chemotherapy include anemia, bone marrow depression, propensity for infections, bleeding tendencies, loss of appetite, nausea and vomiting, hair loss, mouth ulcers etc.
Some breast cancers are stimulated to grow by the hormones oestrogen or progesterone that are the natural female hormones in the body. These cancers contain estrogen and progesterone receptors (ER or PR). These are called hormone-receptor-positive cancers. Hormone therapy works by lowering the levels of hormones in the body thereby stopping the growth of these cancers.
Hormone therapy is usually given after surgery and chemotherapy, but it is sometimes given before surgery to shrink a tumour. In women who have poor health and cannot withstand surgery, chemotherapy or radiotherapy, hormone therapy may be the only option. Usually hormone therapy lasts for up to five years after surgery.
Drugs used include Tamoxifen. Tamoxifen stops estrogen from binding to estrogen-receptor-positive cancer cells. It may be taken as pills. Another group of drugs are called aromatase inhibitors like Ansatrozole, Exemastane and Letrozole. These are offered to women who have has their menopause. These drugs block the enzyme aromatase that helps in the formation of estrogen.
In addition to drugs, the ovaries that produce estrogen may also be supressed using drugs like goserelin, which is a luteinising hormone-releasing hormone agonist (LHRHa) or by surgery and radiation to kills the cells of the ovary.
Sometimes some individuals have breast cancers that are stimulated to grow by a protein called human epidermal growth factor receptor 2 (HER2). These cancers are called HER2-positive. There are targeted therapies that works by stopping the effects of HER2 and by activating the immune system to fight off the cancer.
Notable among these drugs includes trastuzumab. Trastuzumab, also known by the brand name Herceptin, is usually used after chemotherapy. It is a monoclonal antibody. The trastuzumab antibody targets and destroys cancer cells that are HER2-positive. It is given as an intravenous drip.
Treatment of breast cancer also involves familial and psychological support to the women. After therapy follow up focuses not only on possible relapse of the cancer but also to restore self-esteem and relationships.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)