Breast cancer: treatments
Treatment for breast cancer will generally begin after your condition has been fully evaluated as different types of breast cancer require different treatment. A number of factors need to be considered in selecting the treatment most suitable for you. Samples taken from any biopsies, such as fine-needle biopsies or core biopsies, may be used to find out if the cancer cells have oestrogen receptors and/or progesterone receptors.
The doctors will need to find out whether the cancer has spread to the lymph nodes under your arm or above your collarbone or anywhere else in the body.
Other factors taken into consideration when choosing the most appropriate treatment are the size of the lump and how quickly it is growing. Whether you have been through menopause or not can also affect treatment.
Treatment options include surgery to remove either the lump or the entire breast, radiotherapy and the additional therapies of hormonal therapy and chemotherapy.
Surgery involves either removing the whole breast (mastectomy) or only the lump and an area of normal tissue surrounding it (lumpectomy). A lumpectomy is a type of breast-conserving surgery. Other types of breast-conserving surgery are partial mastectomy or wide excision, in which more of the healthy tissue is removed; and quadrantectomy, in which one-quarter of the breast is removed.
Studies have shown that in early breast cancer, lumpectomy (removal of the tumour) followed by radiation treatment has about the same cure rate as mastectomy (removal of the entire breast). Breast-conserving surgery with removal of the lymph nodes, followed by radiotherapy of the breast, is the most common treatment used for early breast cancer. The idea is to cut out the cancerous cells before they can spread to other parts of the body.
Lymph nodes and lymphoedema
Breast cancer that spreads to the lymph nodes under your arm may spread to other parts of your body. Breast cancer surgery has traditionally involved removal of the tumour plus most of the lymph nodes in the armpit (axillary clearance) on the affected side, to detect and remove any cancer cells that may have spread to the lymph nodes.
An unfortunate side effect of removing the lymph nodes under the arm can be lymphoedema, the predisposition of the arm to swell and go puffy because the normal drainage of lymph (colourless or slightly yellowish body fluid) via the lymph nodes is affected. Radiation treatment to the lymph nodes under the arm can also have this effect. Removing the lymph nodes will not adversely affect your immune system.
Sentinel node biopsy
A relatively new type of surgery involves removing fewer lymph nodes and avoiding the side effects of axillary clearance. In this procedure, special tests are used to work out which lymph node the cancer would most likely first spread to (the sentinel node). This node is then removed and tested to see if it contains any breast cancer cells. If no cancer cells are found, there is very little chance that any of the other lymph nodes contain cancer, so no other nodes need to be removed.
If the sentinel node does contain cancer cells, the surgeon will recommend removing additional lymph nodes from under your arm.
Knowing whether the cancer has spread to the lymph nodes helps determine the risk of spread to other parts of the body and if any further treatment (e.g. chemotherapy or radiotherapy) will be beneficial.
A mastectomy is the removal of all the breast tissue, and the nipple and areola, leaving only the muscle on the chest wall. A radical mastectomy, which is very rarely performed nowadays, is total mastectomy with removal of all lymph nodes from the armpit and also the muscles adjacent to the affected breast. Mastectomy tends to be used for larger tumours, large tumours in small breasts, tumours which have spread within the breast, and particular types of cancer or tumours which involve the nipple or skin.
Mastectomy versus breast-conserving surgery
The surgical techniques of mastectomy and breast-conserving surgery seem to have similar success rates. Your surgeon or breast physician will help you to decide which is more suitable for you. Many women who have a mastectomy choose to have a breast reconstruction carried out — this can be done at the same time as the mastectomy or later.
There are many methods of breast reconstruction and not all will be suitable for every woman. Sometimes a prosthesis may be used, with or without a tissue expander to gradually stretch the skin so that more skin is available for the reconstruction. Often prostheses are used for women with small breasts. Women who have larger breasts may find that an operation is possible to take tissue from the normal breast, or skin and fat from the back. Also, sometimes skin and fat from the abdomen are used to make a new breast.
Radiotherapy involves using high-dose radiation to kill the cancer cells so that they do not come back, and is usually carried out after surgery. It is usually carried out in a hospital by a qualified radiographer and specialist. They may mark your skin so that they know where to direct the radiation machine.
Radiotherapy after breast-conserving surgery has been shown to reduce the risk of the cancer coming back in the same breast. The situation with radiotherapy after mastectomy is not so clear cut and it may help in only some circumstances. Your doctor or surgeon should be able to advise you on this.
If you have radiotherapy to a breast you may find that you become tired during the treatment period and in the second half of treatment the breast skin may look like it is sunburnt. Rib fractures, caused by the ribs becoming brittle, affect less than 2 per cent of women having radiotherapy. Radiotherapy will not cause you to lose your hair.
Chemotherapy and hormone therapy
Hormonal therapy and chemotherapy may be used as additional therapy options after breast surgery, and delay the return of cancer and prolong survival in most cases. Selecting which women will benefit from additional hormonal therapy and chemotherapy is quite complex, but generally those women at higher risk of recurrence gain most benefit.
Hormonal therapy uses drugs to alter the way hormones work or it can mean removing the organs that produce the hormones, such as the ovaries. Your doctor can test your tumour to see if it is receptive to hormones, which means it requires one of the 2 female hormones, progesterone and oestrogen, to grow. The drugs block the action of these hormones, so they can no longer help the cancer grow. You will be a good candidate for hormonal therapy only if your tumour is found to be hormone-receptor positive.
Tamoxifen and toremifene
Tamoxifen (e.g. Nolvadex) works by blocking the effect of oestrogen on cancer cells, stopping the growth of tumours. It can be used in pre- and post-menopausal women. Another hormone therapy available, which is similar to tamoxifen, is called toremifene (brand name Fareston).
Other, newer medications called aromatase inhibitors are also used as hormonal therapy. Some examples available in Australia are anastrozole (brand name Arimidex) and letrozole (brand name Femara). They reduce the amount of oestrogen in breast cancer patients who have gone through menopause.
Other hormonal therapies
Other ways to reduce the amount of oestrogen feeding an oestrogen-receptor positive tumour are: surgery to remove the ovaries; radiation of the ovaries; and a hormone implant called goserelin (brand name Zoladex) which is used in women who haven’t gone through the menopause yet.
There are more than 50 drugs that are used in chemotherapy to kill cancer cells. Combinations of these drugs are usually given to get the best cancer killing effect with the fewest side effects. Chemotherapy is administered by injection, pill or intravenously, depending on the drug. You could be given drugs to take at home or as an outpatient or inpatient in hospital. Chemotherapy is generally given for between 3 and 6 months.
One common type of chemotherapy is called CMF. This is a combination of 3 drugs, cyclophosphamide, methotrexate and 5-fluorouracil. The anthracycline drugs, such as doxorubicin (e.g. Adriamycin) or epirubicin (Pharmorubicin), are other drugs used in chemotherapy. Still more medications used in chemotherapy for breast cancer are the drugs called taxanes. These include paclitaxel (e.g. Taxol) and docetaxel (Taxotere).
There are many short and long-term side effects to take into account when deciding whether to undertake chemotherapy. Common side effects of chemotherapy are temporary hair loss, nausea and vomiting (for which you may be given drugs to help control), and tiredness.
Sometimes, very high doses of chemotherapy are given to kill off the cancer cells, but this also has the unwanted side effect of damaging the bone marrow. To rescue the situation with the bone marrow, blood cells collected before the chemotherapy will have to be infused back into the body. High-dose chemotherapy is considered an experimental practice at this time and is still being evaluated for its effectiveness.
Additional therapies used in breast cancer
Other medicines that can be used in addition to standard therapy for breast cancer include the following.
About 20 per cent of breast cancers are HER2 positive. This means that the breast cancer cells have high levels of a protein called human epidermal growth factor receptor 2 (HER2) on their surface. The HER2 protein stimulates the growth of new cancer cells, and high levels can be associated with a poorer outlook. Women with HER2 positive breast cancer may benefit from treatment with a medicine called trastuzumab (brand name Herceptin) in addition to standard therapy. Trastuzumab targets the HER2 protein, attaching to the HER2-positive cancer cells and stopping them from growing and dividing.
If the cancer has spread from the breast into the bones, sometimes medicines called bisphosphonates, for example, pamidronate (e.g. Aredia), are used to reduce the chance of fractures and of pain.
Support groups allow people to share information, express their fears, empathise with others in the same condition, and to take comfort in the fact that there’s somebody they can reach out to who knows exactly what they’re going through.
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