Breast Cancer treatment involves truly multidisciplinary care. That means that a medical oncologist, radiation oncologist, surgical oncologist and reconstructive surgeon work together as a team to achieve the best possible outcome, unique for each patient’s disease and their needs.
You may have gone through a doctor's clinical examination and mammography indicating that you have breast cancer but a confirmed diagnosis requires a small surgical procedure with either a Fine Needle Aspiration Cytology (FNAC) in which a needle is used to suck out a few cells from the tumour or biopsy in which a small piece of the tumour is excised in an OPD procedure. The cells are then stained and examined under a microscope to diagnose which kind of breast cancer you have. The most common form is infiltrative or invasive ductal carcinoma involving the cells lining the ducts that transport milk from the lobules where it is formed to the nipple. Alternate forms are lobular carcinoma. Infiltration means that the disease has spread beyond the ducts into other parts of the breast tissue.
Additionally, the doctor must investigate whether the disease has spread (metastasised) to other locations. The first site of spread is the lymph nodes on the underarms. Other sites where the disease could spread are lung which must be determined by doing a chest X-ray, liver by doing a pelvic ultrasound, brain by conducting a CT scan and bone which is determined by a bone scan. Depending on how large the tumour is the disease is termed Stage 1 (less than 2.5 cm), Stage 2 (2.5-7cm), Stage 3 (larger than 7 cm) and Stage 4 (spread outside the breast). If the disease has spread to lymph nodes, it is called locally advanced, if it has spread to other sites, it is called metastatic. The treatment for each stage is different, but the aim is complete cure. In the case of metastatic breast cancer however, cure is not possible, but long term control may be. Typical treatment involves surgery, followed by radiation and/or chemotherapy. In case of large tumours, the doctor may prescribe chemotherapy to reduce the size of the tumour followed by surgery.
Like all surgeries, breast cancer surgery is most successful when performed by a specialist with a great deal of experience in the particular procedure. When choosing a surgeon, ensure that s/he has performed a large number of surgeries for breast cancer each year. Also check success rates where possible. Ask if you are eligible for reconstructive surgery. If so, our breast cancer surgeons and reconstructive surgeons could work together to plan procedures that minimize incision and scarring and the best possible cosmetic outcome and symmetry.
Some patients will receive chemotherapy or targeted therapy prior to surgery. The goal of these treatments is shrink the tumor and any involved lymph nodes in order to make the procedure and recovery as easy as possible on the patient. This also allows the treating team to assess how the cancer has responded to treatment, which can be important for some breast cancer subtypes.
The surgeries themselves fall into one of two categories: lumpectomies and mastectomies. Your surgeon will recommend the best option for you based on the size and location of tumors in the breast, the size of the breast itself and the need for radiation treatment.
In a typical lumpectomy surgery, the tumor and a small amount of surrounding normal tissue is removed. Lumpectomies are generally outpatient procedures and have shorter recovery times. These procedures are usually followed by radiation therapy.
In a typical mastectomy surgery, the tumor and the entire breast are removed. There are a number of different types of mastectomies, including procedures that spare the breast’s skin and nipple/areola. Often a mastectomy and breast reconstruction can be performed in the same procedure.
In some cases, both breasts are removed. This can help prevent the development of a new breast cancer. It is typically done for patients who are at high risk for developing breast cancer due to family history or their own genetic profile, such as a BRCA mutation.
In both lumpectomies and mastectomies, surgeons may also remove nearby lymph nodes. These are important parts of the lymphatic system, which helps the body fight disease. Breast cancer can spread through nearby lymph nodes. Doctors will study the ones that are removed to determine if there are cancer cells within the nodes. This information can help determine the risk of the disease spreading to distant organs, as well as the need for chemotherapy and radiation therapy.
Radiation therapy uses powerful beams of energy to kill breast cancer cells remaining after surgery that can’t be seen by the naked eye. Radiation may also be used as a palliative treatment to reduce symptoms caused by cancer spreading to other parts of the body for example bones and improve the patient’s quality of life.
Radiation is given to the breast tissue surrounding the area where the tumor was located, as well as to nearby lymph nodes and the chest wall. After a lumpectomy, patients often receive three to four weeks of daily radiation therapy. In some cases one to two weeks may be appropriate. When the lymph nodes are involved or a mastectomy was needed, patients usually need six weeks of daily radiation therapy.
The plan is carefully made keeping in mind the size, location and type of tumour. The area to be radiated is marked with a tattoo so that radiation can be delivered to exactly the same spot at each fraction. The total amount of dose is calculated and a fractional dose is delivered every day.
A newer form of radiation therapy is Proton therapy which delivers high radiation doses directly into the tumor, sparing nearby healthy tissue and vital organs. For many patients, this results in better cancer control with fewer side effects.
Chemotherapy uses powerful drugs to kill cancer cells, control their growth or relieve pain. It can be given either orally or intravenously and can therefore reach any part of the body where cancer cells may be present. It is often given to patients prior to surgery to shrink the tumor and simplify the procedure. Chemotherapy targets fast growing cells and can not distinguish between healthy ones and cancer. As a result, it causes side effects such as sore mouth, darkening of nails, problems of the digestive system, lowered WBC count resulting in infections. But the side effect that breast cancer patients fear the most is loss of hair. You should be reassured that hair will grow back once chemotherapy is completed, just like you had before.
Cancer cells rely on specific molecules (often in the form of proteins) to survive, multiply and spread. Targeted therapies stop or slow the growth of cancer by interfering with, or targeting, these molecules or the genes that produce them. Since only cancer cells produce these proteins, the therapy only affects disease cells and side effects are less.
In recent years, targeted therapy has become a major weapon in the fight against breast cancer. Breast cancer subtypes that once had poor prognoses are now highly treatable.
One type of targeted therapy is endocrine therapy, which is given to patients with hormone receptor-positive breast cancer. This can be given before surgery to shrink the tumor. It is also given after surgery for five to 10 years to prevent recurrence. Patients with the metastatic form of this disease are also given endocrine therapy in order to prevent disease progression.
Patients with HER2-positive breast cancer also receive targeted therapies. These patients may receive a different set of targeted therapy drugs both prior to and after surgery. Since about half of patients with HER2-positive breast cancer also have hormone receptor-positive tumors, they are also given endocrine therapy.
While there are no targeted therapies for triple negative breast cancer, researchers are studying the disease to identify possible drug targets.