Breast cancer affects one in nine women over a life time. Whilst the initial diagnosis can be very stressful and shocking, the success of treatment now means that over 80% of women will survive more than 20 years and longer. On this page you can read about treatment of breast cancer including: Surgery to the breast and axilla (lymph glands), sentinel node procedure,chemotherapy, radiotherapy and hormone therapy .
If a needle core biopsy shows breast cancer, the results will be reviewed by a team of experts called the "Multidisciplinary team", which consists of surgeons, radiologists, pathologists , medical and clinical oncologists along with the breast care nurses.The results of the tests and treatments recommended will be given to the patient via the surgeon and breast care nurse who will explain the treament options.
For those women who do have breast cancer diagnosed, there are very effective treatments which aim to cure the vast majority of patients.
Help and support is also available free of charge at the new "Breast cancer Haven " Leeds
HRH Prince Charles Opening the Haven in Leeds Feb 09. Rick is a member of the advisory board to the Haven.
http://www.breastcancerhaven.org.uk/Surgery to remove the cancer is usually the first part of the treatment, and is then followed by chemotherapy if needed (only some patients need chemotherapy) and radiotherapy (if having a wide local excision or lumpectomy).Once these treaments are completed, hormone therapy can be given as a single tablet once a day. (see later).
Types of Breast Cancer
Breast cancer is not a disease which affects all people the same.
There are several different types of breast cancer and each can behave slight differently in individuals. However the main stay of treatment is the same;-usually surgery followed by chemotherapy, radiotherapy and hormone therapy.
The common types of breast cancer are:
Invasive ductal Carcinoma of no special type (NST)
This type accounts for the majority of Invasive breast cancer (80%). The cancer cells form in the lining of your milk duct, break free of the ductal wall and invade surrounding breast tissue. The cancer cells may remain localized—staying near the site of origin—or they can metastasize, carried by the lymphatic system
Invasive Lobular cancer (10%)
Although less common than IDC, this type of breast cancer acts in a similar manner. ILC starts in the lobules and invades the surounding breast tisssue. It can also spread to other parts of the body.
Non Invasive Ductal Carcinoma in situ (DCIS)
Ductal carcinoma in situ (DCIS) refers to abnormal cells in the lining of a duct that have not invaded the surrounding breast tissue. This is early-stage breast cancer and is often picked up on screening mammograms as fine microcalcification. Some experts call DCIS a ‘precancerous’ condition but if left untreated it can progress into Invasive carcinoma, and at an unpredictable rate. Almost all women with DCIS can be successfully treated.
Special types:- Tubular, Medullary, spindle cell
Surgical treatment for Breast Cancer
Breast conservation treatment:- also called Wide Local Excision or Lumpectomy
Wide local excision :The remove of the lump(cancer)
Axillary staging: Assessing the glands (lymph nodes) under the arm to see if the cancer spread.
When a wide local excision is performed (lumpectomy which removes only the cancer and a small rim of normal tissue), a skin crease incision is made usually over the lump or around the areolar. If there is skin involvement, a small ellipse of skin is removed as well.If the abnormality is impalpable, a hooked wire is used to localize the cancer.The skin is elevated above and below the incision, and a cylinder of tissue (which incorporates the cancer and a 1 cm margin of palpable normal tissue) is removed to the level of the deep muscle. The edges of the specimen are marked with sutures or clips to aid orientation and pathological assessment of the margins. If the lesion was impalpable, a specimen radiograph is taken. Drains are not usually needed.
Following wide local excision for invasive cancer (which may be ductal (90%), lobular (5-10%), tubular or rarely medullary in type) or non invasive Ductal Carcinoma in situ (DCIS an early form of breast cancer), the margins are assessed to ensure there is no known residual disease. A clear margin of at least 1-2mm is required. Further surgery will be required if margins are not clear. All patients with an invasive carcinoma and ductal carcinoma in situ require radiotherapy to the breast to lessen the risk of local recurrence. .
Some women may be keen to preserve the breast, but wide excision of some cancers will produce a significant cosmetic deformity because of the extent of the malignancy. Also any tumour bigger than 4cm, or where there are more than one tumour within the same breast is usually treated with mastectomy, unless the breast is large (D cup or bigger)If so, a mastectomy with or with out reconstruction may be advised (see later after axillary surgery).
The status of the axillary (arm pit ) lymph nodes is the most important predictor of outcome from breast cancer and should be assessed in all cases of invasive cancer, but not for ductal carcinoma in situ. Axillary nodes may be assessed in a variety of ways.
Axillary node clearance was the traditional method of assessment. The operation can be performed at the same time as a mastectomy via the same incisions or through a separate axillary incision when combined with breast-conservation treatment (wide local excision). If there are pathological nodes (nodes with breast cancer in them) a clearance should be performed because this is the best method for control of local disease. This operation is, however, associated with significant problems, including: • seromas• lymphoedema (swelling of the arm )• shoulder stiffness • numbness due to sacrifice of small nerves under the arm.
Sentinel node biopsy of the axilla: Most breast cancers present early or are detected by mammogram screening. Up to 70% of arm pit glands are completely clear of breast cancer disease. The sentinel node technique has been developed and evaluated in Europe and USA. The sentinel node is the first node(lymph gland) to which cancer cells will spread. A radioisotope (e.g. technetium-labelled colloid) is injected around the tumour and a lymphoscintiscan (xray) is performed to identify the sentinel nodes. At the time of the operation, a blue dye is also injected around the tumour. A small incision is made in the axilla(arm pit) and the sentinel node is identified by detecting a radioactive node using a gamma counter or by following a blue lymphatic channel to a blue lymph node. The sentinel node is currently assessed by immunohistochemistry and microscopy by the pathologist. If the sentinel node is free of disease, no further axillary surgery is necessary. If the sentinel node is contains breast cancer deposits, axillary node clearance should be performed.Sentinel nodes may be multiple and all should be removed and assessed. Using radioisotope and blue dye, several studies have shown a >95% detection rate. There is, however, a learning curve associated with this technique. Surgeons should be performing it regularly having previously been trained. The blue dye will leaving stainig on the breast for several months and occassionally will cause a allergic reaction, mild in most causes, but serious in around 1 in 1000.
Mr Rick Linforth is fully trained and regularly performs the sentinel node technique. Rick is also a national trainer for other surgeons in this technique.
Mastectomy (To remove the whole breast) is needed to treat 30–40% of breast cancer cases in the UK. It may be combined with immediate reconstruction of the breast (see reconstruction pages).
Indications for mastectomy:
A mastectomy should be advised if there is:
1 Large tumour in a small breast .
2 Widespread ductal carcinoma in situ (DCIS) >4 cm in diameter
3 Patient choice: If a patient wishes to remove the breast to prevent a second operation or avoid radiotherapy.
4 Previous radiotherapy to the breast.
Relative indications include:• if wide excision would remove >10–15% of the breast volume (which significantly affects the cosmetic appearance).
A total mastectomy is performed by making a transverse elliptical incision incorporating the carcinoma and ensuring removal of any involved skin. Thin flaps of skin that preserve the subcutaneous vessels are elevated and the breast is removed from the chest wall, cauterizing the vessels.Two drains are usually placed underneath the flaps and most patients are discharged home after 3-4 days. Recover usually take 3-4 weeks.
A skin-sparing mastectomyis removal of the breast tissue with preservation of the skin envelope. It is usually combined with a reconstructive technique (see reconstruction page).A periareolar incision is usually made, with removal of the nipple–areola complex and the breast tissue from within the skin envelope. A separate incision may be needed to allow access for a full axillary clearance. This technique produces a better cosmetic result if combined with reconstruction because breast shape and skin are maintained. This technique is often used for women requesting prophylactic mastectomy(remove of the breast without any know cancer in it for high risk patients) it is particulary useful for small invasive cancers or extensive ductal carcinoma in situ.
Many women who need a mastectomy can have an Immediate Reconstruction. Make sure you discuss this with your Surgeon.
Complications: the common immediate complications of mastectomy are:
• haematoma: a collection of blood
• infections: Occur in 3% of patients and need antibiotic treatment.
• necrosis of the skin flaps (Part of the skin breaks down and the wound takes longer to heal
.• seromas: Very common and usually settle with simple aspiration of the fluid.
Following surgery you may need chemotherapy and or radiotherapy.
Immediately after surgery your results of the removed breast tissue and lymph nodes will be assessed by a pathologist and the results discussed in the multidisciplinary team meeting. Here the Consultants will decide if further treatments are recommended. These recommendations are based on the size of the cancer, the lymph glands removed (if they have any cancer within them (local metastases)) and the sensitivity of the cancer to hormones measured by the oestrogen receptor and progesterone receptor (ER and PR)
You will be referred to a medical oncologist for the chemotherapy, and a clinical oncologist for the radiotherapy.
The surgeon usually prescribes the hormone therapy.
Chemotherapy after Surgery
Dr Chris Bradley and Dr Shazza Rehman are the Consultant Medical Oncologists in Bradford, and treatment takes place on ward 15 at the Bradford Royal Infirmary as day case visits.
Chemotherapy involves giving medication directly into the blood stream to kill off cancer cells that can't be removed by surgery. In the Adjuvant setting it is given after surgery to reduce the risk of breast cancer recurrence or the development of spreading (metastatic) disease.
The indications for chemotherapy include:
Young age, Large tumours, grade 3 cancers, lymph node involvement, hormone receptor negative cancers (ER negative), and HER 2 (Herceptin positive ) cancers. You have to be relatively well to receive chemotherapy, and generally under 70 years of age, but fit over 70's may also be suitable.
Chemotherapy is given in cycles. One cycle is a course of drugs given with a three or four week period of no treatment.This cycle is then repeated usually 6 or 8 times.Often two sets of 4 cycles are given, meaning 8 in total.
Once chemotherapy is completed, hormone therapy will be started if the cancer is hormone sensitive, decided by testing the cancer for the hormone receptors of Eostrogen and Progesterone.
Radiotherapy is most commonly given after breast preserving or wide local excision of the breast tumour. Occasionally radiotherapy is given after mastecomy,
this is when there is a large tumour, lymph glands involved or close margins.
A large proportion of women with breast cancer are identified as being hormone- receptor positive, suggesting that the female hormones oestrogen and/or progesterone stimulate the tumour to grow. For these women, hormone therapy represents an important part of treatment.
Tamoxifen For pre-menopausal women, tamoxifen remains a gold-standard treatment, greatly reducing the risk of recurrence and increasing overall survival rates.
Tamoxifen works by having a similar structure to oestrogen, blocking oestrogen receptors on the breast cancer cell surface and therefore preventing growth.
Tamoxifen also affects other tissues within the body causing side effects such as hot flushes and vaginal dryness. While tamoxifen prevents oestrogen from having an effect on breast cancer cells, it has been found in some women to have an oestrogenic effect on endometrial tissue (womb), increasing slightly the risk of uterine cancer. There is also an increased risk of thromboembolic events (blood clots in the leg, heart attack or stoke) when taking tamoxifen, but the benefits of taking this drug on the whole outweigh the risks.
To put this risk into perspective ,for every 1,000 women using tamoxifen for five years, there will be approximately 80 fewer deaths from breast cancer set against one more death from endometrial cancer.
Tamoxifen in pre-menopausal women is generally taken for a period of five years. This is more effective than shorter periods of treatment. Post-menopausal women may also be prescribed tamoxifen.
Ovarian ablation Ovarian ablation may be offered to pre-menopausal women in addition to tamoxifen as a method of oestrogen reduction.
Ablation is achieved either by the toxic action of chemotherapy on the ovaries, or more
deliberately, by oophorectomy, ovarian radiotherapy or medically with the use of
luteinising-hormone-releasing hormone agonists such as goserelin. Goserelin is the only method that can be reversed, making it an attractive option for women wishing to preserve their fertility after treatment. It is usually given as a monthly injection for a period of two to five years. Meta-analysis confirmed goserelin to be a beneficial treatment for younger women with breast cancer, with equivalent
efficacy to some chemotherapy regimens.). Side effects of ovarian ablation include menopausal symptoms and an increased potential for osteoporosis and cardiac events.
Aromatase inhibitors have changed the hormonal management of post-menopausal women with hormone-receptive breast cancer. Before their development, tamoxifen was the drug of choice for this patient group.
However, following a series of results from clinical trials indicating that an aromatase inhibitor either alone or following tamoxifen was more effective than tamoxifen alone,
As such it is now recommended that, provided there are no contraindications, an aromatase inhibitor should be used at some point during a women’s hormone breast cancer treatment.
After the menopause, the ovaries cease to produce oestrogen.
However, a level of production is maintained by the conversion of androgens (male hormone) from the adrenal glands to oestrogen.The enzyme aromatase, found in peripheral fatty tissues, is needed as a catalyst for this process and aromatase inhibitors either temporarily or permanently block the production of aromatase.
There are three main aromatase inhibitors:Anastrazole (or Arimedex) , Exemestane (or Aromasin)and Letrozole (or Femera).
There is no evidence to support the superiority of one drug over the other, and there remains some debate as to the most effective way to use these drugs .
Some women receive aromatase inhibitors following surgery. This is called an upfront strategy, which starts after any other recommended adjuvant treatment such as chemotherapy and or radiotherapy, lasting for five years,
Others take tamoxifen for two to three years and then switch to an aromatase inhibitor. This is called a switching strategy. It is used in patients with low risk breast disease who are post menopausal
Some women, particularly those who started tamoxifen treatment before the introduction of aromatase inhibitors, will receive five years of tamoxifen and then continue on an aromatase inhibitor. This is called extended treatment as it lasts for up to ten years.
Side effects associated with aromatase inhibitors tend to take the form of menopausal
symptoms. Joint pain is another common side effect, and can occasionally be so severe that treatment has to be stopped. As aromatase inhibitors reduce dramatically the amount of circulating oestrogen, there may be long-term side effects including loss of bone density, thus increasing the number of musculoskeletal events
The effects of aromatase inhibitors on bone may influence oncologists’ preference to give patients two or three years on tamoxifen before commencing an aromatase
inhibitor. It is common practice for patients taking aromatase inhibitors to undergo a baseline bone density scan before treatment, with repeat scans every two years if the bone is thin or osteopenic. Patients with osteopenia should be provided with lifestyle advice about exercise and diet. Calcium-rich foods and calcium and vitamin D supplements may be recommended. Bone strengthening preparations such as bisphosphonates may also
After initial treatment you will be followed up by the surgeon in the breast oncology clinic every six months for three years. In addition you will be invited for a check mammogram every year for 10 years. During this time you do not need to attned the National Breast screening mammograms.
Mr Linforth runs his Oncology clinic on Thursday mornings at the Clinical Research Facility at the BRI.
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