Breast Cancer

What are the Treatment Options for Breast Cancer?

The treatment of breast cancer depends on whether it is the non-invasive (DCIS or LCIS) type or not. We will discuss the treatment of invasive type breast cancer first, and then move on to the treatment of the non-invasive type.

As mentioned earlier, the aim of breast screening is to detect the cancer at an early stage in women who appear well and do not have any symptoms of the disease. The earlier that a breast cancer is detected, the more likely it is to be treatable. 'Early' breast cancer implies that the cancer lump is relatively small, has not invaded the overlying skin or underlying chest wall, and that the lymph glands in the armpit are not involved at all (or are only minimally involved). It also means that the cancer has not spread (metastasised) to any other part of the body.

Before any treatment is begun, the breast specialist must first be certain as to whether or not the cancer has spread beyond the breast by arranging various tests called 'staging investigations' (discussed in the next section). Once the specialist has the results of these tests, the best treatment option for that particular patient can be determined.

Types of treatment for breast cancer include:

Surgery
Radiotherapy
Chemotherapy
Hormone therapy

Staging Investigations

As mentioned previously, in order to provide the most effective treatment for a breast cancer, the specialist must know if that cancer has spread beyond the breast. Various tests are carried out to do just this and include the following:

Blood tests
Chest X-ray - to find any tumours in the lungs
Bone scan - to find any tumours in the bones
Ultrasound scan - to find any tumours in the liver

Most breast specialists will arrange routine blood tests and a chest X-ray for all patients with breast cancer. However, a bone scan and ultrasound are only usually carried out if the patient has symptoms to indicate possible metastatic spread, the cancer is locally advanced or the lymph glands in the armpit are grossly involved. Staging tests are not necessary if the breast cancer is of the non-invasive type.

Surgery - What are the Surgical Options?

Each patient should play an active role in selecting the appropriate surgical treatment with the specialist.

Studies have shown that removal of the whole breast (mastectomy) does not prolong life when compared with removal of the cancer lump alone (lumpectomy). As lumpectomy preserves more of the breast, it is associated with a better body image compared with total mastectomy.

If you have a successful lumpectomy i.e. the lump was completely excised with clear margins, then radiotherapy to the whole breast is usually required. In some cases (approximately one third) mastectomy is the preferred treatment option.

It is also advisable to remove some lymph glands from the armpit (this is called axillary dissection - axilla means 'armpit') if the cancer is invasive. If the lymph glands do not contain cancer, then the outlook for the patient is very good. However, the more lymph glands that contain cancer and the bigger the cancer is, the greater the chances are that the cancer may come back after treatment. This helps the specialist to predict the behaviour of the breast cancer, and to know if more aggressive treatments, such as chemotherapy, are needed.

Removal of the lymph glands increases the chances of arm swelling (lymphedema), arm stiffness and pain. Therefore it is preferable to remove the minimum number of glands. The Sentinel Node Biopsy technique allows accurate sampling of the glands. Patients with invasive breast cancer who do not have enlarged glands in the armpit on clinical examination are suitable for this technique. It involves the removal of approximately two glands using a blue dye and/or a radioactive isotope tracer) through a small cosmetic scar. The sentinel glands (blue and/or hot) can be examined by the pathologist while the patient is under anesthesia. If these sentinel glands are clear then no further armpit surgery is needed and the patient can be spared the potential adverse effects of complete glands clearance which occur in 10% of patients. However if the sentinel glands contain cancer cells then all the armpits glands should be removed. This is usually needed in 25% of patients with invasive breast cancer. This technique is a new standard of care for the management of the armpit and requires that the surgeon is familiar with the technique and the armpit glands are not enlarged on clinical examination.

Once the breast cancer and the armpit lymph glands have been removed, they are then examined under the microscope by a specialist called a pathologist. The pathologist will determine the following:

Exactly what type of breast cancer it is?
How big is the cancer?
Has the cancer been completely removed?
Do the lymph glands contain cancer?
Does the cancer have hormone receptors?

The pathologist will also decide the severity of the cancer according to its appearance under the microscope and how much it has spread. In practice, the cancer is assessed (or staged) on a scale of 0 to 4 (Table 6).

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