Early, Advanced Breast Cancer Treatment (Surgery, Chemotherapy)

The mass of abnormal cells with an abnormal growth pattern seen in breast cancer needs to be removed in order to prevent it from invading surrounding tissue. It will also help to prevent these cancer cells from spreading to other sites in the body (metastasis). The form of treatment for breast cancer depends on the clinical stage of the cancer at the time of diagnosis. The approach to treatment can classified as either local or systemic. Local therapy helps to remove or destroy cancer in the breast by means of surgery or radiotherapy. In systemic therapy, cancer cells may be controlled or destroyed by means of chemotherapy, hormone therapy, or targeted therapy.

Treatment of Early Breast Cancer – Stages 1 and 2

Once diagnosed, the aim of treatment is to remove the abnormal mass, prevent spread and limit recurrence. The success in this regard may determine the survival rate of breast cancer patients. However, it is dependent on whether therapeutic measures are undertaken at early stages or in advanced breast cancer. This  in turn is dependent on the stage at which the cancer is diagnosed. Read more on staging of breast cancer.

Surgery

For breast cancer, surgery is the most common form of treatment. The type of surgery is based on factors such as the size and site of tumor, the type of tumor, and the general health of the patient.

Surgery aims at local control of the disease. It may be done as

• Breast conservation surgery may include a lumpectomy, or a segmental (partial) mastectomy. A wide local excision of the tumor is usually done, with at least 1 cm of surrounding normal tissue removed as well. This procedure is not suitable for big tumors more than 4 cm in size, multifocal tumors, or those with extensive intra-ductal spread.
• Mastectomy all or most of the breast tissue is removed surgically. In total or simple mastectomy, the whole breast is removed. Some axillary lymph nodes may also be removed. In modified radical mastectomy, the whole breast and most or all the axillary lymph nodes are removed.

With either of the methods, axillary lymph node sampling or clearance is usually done when the procedure is performed for invasive cancer. Adjuvant therapy is treatment administered after the main therapy. This may include radiation therapy (radiotherapy), chemotherapy, hormone therapy, or targeted therapy after surgery for breast cancer.

Adjuvant Radiotherapy

The main aim of adjuvant radiotherapy is to prevent recurrence.

• Following a breast conservation surgery, postoperative radiotherapy to the affected breast is essential to reduce the risk of recurrence.
• Radiotherapy may be given after a mastectomy when there is a high risk of local recurrence.
• Radiotherapy may be given to the axilla when there is spread of cancer to the axillary lymph nodes. However, radiotherapy is not combined with lymph node clearance.

Adjuvant Systemic Therapy

Adjuvant systemic therapy with a combination chemotherapy, tamoxifen, or ovarian ablation reduces the incidence of recurrence and death in women suffering from breast cancer, both with and without lymph node involvement.

Hormone Therapy

• Tamoxifen, a selective estrogen receptor modulator, is most commonly used for hormone treatment of breast cancer. It blocks the effects of estrogen and it is most effective in women with estrogen receptor positive (ER-positive) tumors. Read more on types of breast cancer. Tumor recurrence and death rate are both significantly reduced with use of tamoxifen. It may be given for 5 years at a dose of 20 mg daily.
• Ovarian ablation (removing the hormonal effects of the ovary) may give good results in premenopausal women with breast cancer. This may be done by medication that blocks the ability of the ovaries to produce estrogen, surgical removal of the ovaries, or by radiation.
• Aromatase inhibitors, such as exemestane, letrozole, and anastrozole, act by blocking estrogen production. It may be effective as tamoxifen and show good results in postmenopausal women.
• Luteinizing hormone releasing hormone (LHRH) agonists, such as leuprolide and goserelin, may be used subcutaneously once a month in premenopausal women. It acts by inducing ovarian suppression similar to radiation-induced ovarian ablation.

Chemotherapy

Adjuvant chemotherapy may be given following curative treatment by surgery and radiotherapy. Cyclophosphamide, methotrexate, and 5-fluorouracil or CMF regimen are most frequently used. Other anthracycline-based regimen is more often used for recurrent and metastatic cancer. Presurgical chemotherapy may be given prior to surgery so as to shrink a large tumor, thus making surgery easier.

Targeted Therapy

In targeted therapy or biologic therapy, special anticancer drugs, such as trastuzumab and lapatinib, are used to effect specific changes in a cell that blocks the growth of breast cancer cells. This therapy is used in women with HER 2-positive breast cancer.

Breast Reconstruction

• May be done at the time of initial surgery or later.
• Aims to restore normal shape and consistency of the breast after surgery.
• An external adhesive prosthesis worn with the bra may be the simplest form.
• Internal prosthesis (silastic implant) may be inserted after temporary skin expansion by a tissue expander.
• Flap reconstructions use natural skin, fat, and muscle to recreate the breast. The most common are the latissimus dorsi muscle flap and the transverse rectus abdominis myocutaneous (TRAM) flap.
• Nipple reconstruction can also be done.

Treatment of Advanced Breast Cancer

Local treatment will not be effective for advanced breast cancer when there is extensive local spread of the disease or the cancer has metastasized to distant sites.

A combination of surgery, radiotherapy, chemotherapy, and hormonal therapy is usually necessary for treatment of advanced breast cancer.

• Hormonal treatment is usually undertaken in such patients.
• Tamoxifen is the drug of choice in postmenopausal women, particularly in those with ER-positive tumors.
• Aromatase inhibitors may be used as second-line of treatment.
• Ovarian suppression is the first line of treatment in premenopausal women.
• Chemotherapy may be advisable, particularly in younger patients, those with ER-negative tumors, those with metastasis in the liver, lungs, and brain, or those with rapid growing tumors
• Chemotherapy and radiotherapy are used for inflammatory cancers. Surgery may be done following chemotherapy and radiotherapy to remove any remaining cancer.
• Toilet mastectomy or radiotherapy may be done in some cases to restrict a fungating tumor.
• Palliative treatment will not cure the disease but will aim at reducing symptoms such as pain and improving the quality of life as far as possible.