Breast Cancer Treatment
Breast cancer treatment method and process depends upon the category of breast cancer, the phase (stage) and grade (extent), medical history, age and overall health of the patient. In recent times, new approach and developments have come up in the field of cancer treatment; however the most appropriate technique is decided by the treating doctors’ team assessing patient’s medical condition. Chemotherapy, radiation therapy and surgery are among the most used types for breast cancer treatment which is same for both genders. Treatment process has 2 main objectives:
- to kill (destroy) existing malignant cell in the patient’s body
- to provide treatment to stop further development of cancer
As removal of malignant tumour becomes the very first goal of breast cancer treatment, surgery is first line of process for most of the patients. But occasionally chemotherapy, hormone or targeted therapy is given prior to surgery. It is a typical cancer surgery procedure in which tumour area is taken away by an operation. Before it is decided by the treating doctor to have breast cancer surgery, several tests are conducted to confirm the exact location of the tumour, the extent till cancerous cells have spread etc. Broadly breast cancer surgery can be classified in two major categories (1) Lumpectomy and (2) Mastectomy.
Lumpectomy is used to remove small size tumour. It is most effective in the early stages of breast cancer. This surgery is also known as breast-conserving surgery. As the name suggests, the aim of this surgery is to eliminate only the cancerous tumour and preserve rest of the breast. To ensure, complete destruction of malignant cells, the surgeon removes not only the tumor but also marginal surrounding area of normal tissues. As a result most of the breast is retained. Mostly other cancer treatment methods are combined with surgery which can be given prior or after as per the suitability decided by the doctor. The different types of breast conserving surgery are named as per the cancer affected area removal such as quadrantectomy, partial (segmental) mastectomy and wide local excision (WLE).
When cancer surgery is performed to remove complete breast, it is called mastectomy. It is meant for total removal of the breast tissues including nipple and skin. In some cases lymph nodes removal and /or breast reconstruction is also done along with mastectomy. Removal of full breast becomes inevitable when cancerous tumour is big or malignant cells are scattered all around in the different areas of the breast. A skin-sparing mastectomy is removal of the breast and nipple area without eliminating much of the overlying skin of the breast. A nipple-sparing mastectomy refers to taking away all the breast tissue, without removing much of the overlying skin and the nipple area of the breast.
Lymph Node Removal Surgery
If a patient has metastatic cancer, malignant cells invade and reach to other parts of the body through either the bloodstream or the lymphatic system. Breast cancer cells that break away from tumour and develop in the lymph nodes such as non-Hodgkin lymphoma and Hodgkin lymphoma does not spread far away and is around the tumour hence by removing lymph nodes spreading of cells can be controlled. Once relevant test (core biopsy or FNA) is done and it is confirmed that cancer has spread to the lymphatic system or lymph nodes; doctor further decides the type of the lymph node removal surgery.
- Sentinel Lymph Node Biopsy (SLNB) : Primary lymph node(s) also known as sentinel nodes are located and removed
- Axillary Lymph Node Dissection (ALND) : Removing all the lymph nodes in the armpit.
This surgery is precautionary operation which is done to extract an organ or gland that has no sign of cancer but is performed to prevent development of breast cancer in future. Prophylactic mastectomy is carried out for removing one or both breasts when a person is at high risk or already suffering from breast cancer.
Breast Reconstruction Surgery
When mastectomy is the only surgical option left to treat a patient, it is inevitable to discuss about breast reconstruction also. However reshaping of breast/s may be required after lumpectomy, altering another breast and nipple correction. It is a specialized surgery done by oncoplastic surgeon. The Surgeon briefs every detail of mastectomy and breast reconstruction options are discussed with the patient before removing one or both breasts. Combining breast reconstruction surgery with mastectomy or deciding for delayed reconstruction operation is suggested by the team of specialist doctors. If line of complete treatment includes other options such as chemotherapy or radiation therapy, then breast reconstruction operation is postponed. But if treating doctor approves combining both surgeries at the same time, the choice is left on the patient to go for immediate breast reconstruction surgery or not.
Broadly there are two types:
- Autologous or ‘Flap’ Reconstruction: In this procedure body tissues are taken from other part/s example stomach, thigh or back and used for reconstruction. Flap reconstruction may or may not need use of implant.
- Implant Reconstruction: This surgery is done with an implant that's filled with salt water (saline), silicone gel or a combination of both.
When medicines are given to kill cancerous cells in the body, the treatment is called ‘Chemotherapy’. This procedure helps to stop the process of invading malignant cells. Oncologists plan the treatment method and schedule after evaluating patient’s overall medical condition and history of the disease, age etc. These anti-cancer medicines are given in two ways, one orally (in the form of tablets or capsules) and second through vein or drip. Chemotherapy is used as combined option for breast cancer patients. Use and process of chemotherapy is different for each patient and decided by team of specialist doctors. When these anti-cancer medicines are given to the breast cancer patient after the surgery to minimize chances of reoccurrence, it is called adjuvant chemotherapy.
Destroying tumor (unhealthy cancerous cells) by using targeted energy is called Radiation therapy. These radioactive waves, usually x-rays and similar rays (such as electrons) are carefully measured and controlled while treating breast cancer patient. Radiation therapy is beneficial in case of breast cancer as it aims to destroy malignant cells present in a patient’s breast area after the surgery although it also affects healthy cells. However healthy body tissues are recovered soon. Radiation therapy is prohibited in case pregnancy and certain other medical conditions.
Two main types are:
a) External Beam Radiation Therapy: Radiation (energy rays) used from a machine outside the body.
- Hypofractionated Radiation Therapy
- 3D-Conformal Radiotherapy
- Intraoperative Radiation Therapy
b) Internal Radiation Therapy (brachytherapy): For this treatment, a radioactive source is put inside the body for a short time.
- Interstitial Brachytherapy
- Intracavitary brachytherapy
Oestrogen, a hormone present in the body may be the underlying reason for certain type of breast cancer which is known as oestrogen receptor positive (ER+).
Endocrine (Hormone) Therapy
This therapy is used when a breast cancer patient is tested to have ER+ (Oestrogen Receptor Positive). Breast cancer oncologist has expertise to design a treatment plan for each individual differently depending upon various factors. Treating doctor provides different combination of medicines that is helpful to stop (or minimize) oestrogen adverse effect to stimulate malignant cancer cells. Hormone therapy can be started as single treatment at one time or can be combined with other treatment procedures too.
Main Objectives of Hormone Therapy:
- to reduce the risk of breast cancer coming back after surgery
- to reduce the size of your cancer before surgery to remove it
- to treat breast cancer that has already come back or spread
Hormone Therapy and Surgery (Preferred Time-line)
The therapy process has its own significance which is not same in each patient’s case. Most often endocrine therapy is used along with breast cancer surgery that is given prior or after the operation. However there are few exclusive medical conditions where hormone therapy is stand alone choice because breast cancer surgery cannot be performed if the patient is also suffering from lung or heart diseases.
- Neo-adjuvant treatment is the name of hormone therapy started before the breast cancer surgery.
- Adjuvant treatment is given to wave off chances of cancer relapse. Therefore hormone therapy is given after breast cancer surgery is performed. For most types of breast cancer for example Ductal Carcinoma in Situ (DCIS); adjuvant treatment is considered best.