If you or someone you love is diagnosed with Breast Cancer the chances are you have to spend a lot of time in different doctors’ offices, and all the doctors will discuss different types of treatments.
Breast Cancer management relies on a firm foundation of a multidisciplinary team. What that means is that every doctor involved in cancer treatment should be speaking to every other doctor. The intention is that from the start of a patients treatment there is an individual plan, tailored to the exact stage and type of Breast Cancer that the patient has. This team of people involved in care includes the breast surgeon, the reconstructive (plastic) surgeon, a radiologist who carries out mammograms and biopsies, the chemotherapy and radiation specialists (oncologists) as well as a psychologist and survivorship specialist. The most important person is the patient navigator; usually a nurse whose role is to ensure that the patient and family has support and guidance along all aspects of treatment.
Breast Cancer management involves not just the breast but treatment of the whole body. This is because even very early on we know that cancer cells can be found in other organs. It is important to eradicate the cancer not just from the breast, but from the whole body. This is done using four different types of therapy often managed by a different member of the multidisciplinary team (that’s why it’s so important that they talk to each other). Team work to ensure the correct order of treatment is critical to ensure excellent patient outcomes.
Breast Cancer management does not only involve the breast, but treatment of the whole body.
Therapies can be divided into those that affect the breast, to get rid of the cancer present in the breast, or in the nearby lymph glands, and those therapies that seek out and destroy breast cancer cells that may be present elsewhere in the body.
The therapies are:
Local treatments to the breast
Whole body treatments to find any cancer that has spread in the body:
- Receptor-dependent treatments (hormonal)
- Target treatments
- Immunotherapy (usually drugs that manipulate the immune system)
Each type of treatment can be considered independently, but remember that in almost all cancer management the patient will have at least one local and one whole body treatment. This does not mean that they may require all the different treatment methods. It is dependent on the type of breast cancer, patient choices and options made available by the specialists in the MDM.
When you have breast cancer, or think you might be at risk, it is important to see a doctor who is a breast cancer specialist and can advise you on the most modern, safest and most effective ways of curing the disease.
Let’s look at them all individually.
In Breast Cancer management, surgery will take place at some point through the treatment path. Surgery can take place at more than one time, either for diagnosis, treatment or reconstruction. There are three areas of surgery every patient will experience and therefore should discuss with their doctor: surgery to the breast, surgery to the axilla and/or reconstructive surgery.
Some of the operations undergone are:
Sentinel Lymph Node Biopsy
Often this is the first part of cancer treatment, carried out to see if the cancer has spread from the breast to the glands (called lymph nodes) under the arm. On the day of the operation the patient is injected with a radioactive chemical which is not harmful, and the doctor uses a special probe and blue dye to find the first gland the cancer would have spread to (the ‘sentinel’ which means the guard). The surgeon will make a small cut in the armpit under a general anaesthetic and take out this gland.
If the cancer is spread it is called ‘locally-advanced’ and this increases the risk it has spread outside the breast to the rest of the body. Cancer that has spread to the rest of the body is best treated with chemotherapy.
Wide Local Excision or Breast Conserving Surgery
This is a ‘lumpectomy’ operation that can take place if the surgeon believes it is possible to remove the cancer safely without removing the whole breast. This might be because the cancer is small or because the breasts are large enough to allow a big area to be removed. Cancer is never taken out alone, it is always taken out with a big margin, which acts as a fire break between the cancer and normal breast tissue. It reduces the risk that the cancer may come back in the same place.
There are some important safety measures that have to happen with breast conserving treatment (BCT). The first is that the surgeon must be sure that all the cancer can be removed safely. Then the patient must be able and willing to have radiation treatment, because BCT is not safe if you do not have radiation. Finally it is important that the BCT be carried out with help from a surgeon skilled in reconstructive techniques. Normally this is a different surgeon from the Breast Cancer surgeon.
It is important that the BCT be carried out with help from a surgeon skilled in reconstructive techniques.
The oldest and most well-known method of surgically treating Breast Cancer is a mastectomy. This is a procedure where the whole breast is removed from the body, and the patient is left with a flat chest and one scar. Very often, immediate reconstructive surgery can be carried out so that the patient has only one operation and is left with a similar breast mound to before the operation.
Sometimes a woman may decide to have both breasts removed during the operation, but this is only after intense discussion of all the options and a realistic assessment of the risk of further cancer in the other breast.
Axillary lymph node dissection
If the cancer has spread to the glands, all of the glands under the arm will need to be removed. Unfortunately this can cause some pain and stiffness around the arm after the operation and in 1 out of 10 ladies, the arm may swell up after the operation (called lymphedema), because there is no longer a clear passage for fluid to flow from the arm back to the body. Most often an axillary dissection is done at the same time as the breast operation, through the same cut or a different one. If the sentinel lymph node biopsy is negative however, an ALND may not be required.
New data suggests that some women may not need to have an ALND, even if their glands are positive for cancer. This may change surgical practice in the future, but at present further research is required.
All patients who have or have had breast surgery should have the opportunity to have reconstruction. This surgery can restore two equal breast mounds to a woman’s chest. This may be part of breast conserving surgery or after a mastectomy, either during the operation or at a later date.
Plastic surgeons can use tissue from other parts of the body to reconstruct the breast and they may also use prostheses, made of materials such as silicon, to give the shape of a breast under the skin and muscle, if there has been a mastectomy.
All women have a right to be considered for reconstructive surgery, even if your operation was a long time ago.
Radiation is also a method of killing rapidly dividing cells such as those in Breast Cancer. It works in a local area however, not throughout the body like chemotherapy.
Radiation treatment is given by directing a beam of radiation, made up of thousands of X-rays, which attacks any cells which may be cancerous. It helps to reduce the risk of a cancer coming back after surgery; especially if the cancer is large or close to the rim of normal tissue removed. All cancer surgery, even the best, has a risk of leaving behind a few isolated cancer cells. If those cells start to divide again, the cancer can recur. Radiation ‘mops up’ any cancer cells that surgery may have left behind. There are a number of circumstances that increase the risk of cancer recurrence and in these situations we know radiation is beneficial.
- When a cancer is very big (greater than 5cm)
- When a cancer has involved a lot of glands under the arm, or the glands are heavily involved
- When any breast tissue is left behind (radiation is always required in breast conserving treatment)
- When the multidisciplinary team is concerned that the margin of normal tissue around the cancer was too small (not a big enough ‘fire break’). If there is true cancer at the margin however, the cancer should be removed with surgery not radiation.
Chemotherapy uses medicines that attack cancer cells to kill the cancer in your body. These medicines may be given through a drip or in tablet form.
We know that cancer cells multiply more quickly than most of the body’s cells. Because of that, they are working very hard and are in the duplicating phase of the cell cycle almost constantly. Chemotherapy finds cancer cells by looking for all the rapidly dividing cells in the body. It then attacks them by preventing them duplicating.
This works well, but also affects normal cells in the body which also divide quickly, such as the cells of hair and gut. Because these cells die too, patients can suffer from hair-loss or gut symptoms such as nausea, vomiting or diarrhoea.
If the Breast Cancer is greater than 1cm or has spread to the glands we know that the risk that the cancer is in the rest of the body is great. Only chemotherapy can find and attack cancer cells outside of the breast and so it is given to all patients with these types of cancer. There are genetic methods of determining whether a patient will benefit from chemotherapy, which use samples of the Breast Cancer tissue to analyse how aggressive it is. These tests are expensive, but may be beneficial in ensuring the correct patients get chemotherapy.
Breast Cancer is one disease, but has many faces. If you stand in a room of Breast Cancer survivors, the differences in the types of tumour will be as different as the sizes, shapes and personalities of the people they belong to. Some cancers talk easily to the other cells of the body, others ignore any interactions. The way that cancers ‘talk’ to the body is through hormones and receptors.
If a Breast Cancer has receptors on it, some of the body’s hormones and other factors can influence it. Doctors can use hormone and receptor blockers to prevent anything encouraging the cancer to grow, or encourage any other potential cancer cells to develop. There is still so much we don’t know about receptors, and lots we are learning, but there are some receptors we know how to block:
Oestrogen receptors (ER) and Progesterone receptors (PR)
If the cancer is positive for these receptors, it means that oestrogen (the female hormone) can encourage the cancer cells to grow and divide. By preventing oestrogen influencing the cells, drugs are used to block the receptor. The most common medicines are Tamoxifen and blockers called Aromatase Inhibitors.
Her2 receptor over-expression
This is the newest abnormality to be found in Breast Cancer, and has changed the treatment of Her2 positive cancers which were often aggressive and may be ER/PR negative. All cells have Her2 receptors which encourage growth of normal cells. Some Breast Cancer cells have too many Her2 receptors, which mean that they promote the growth of cancer cells. Treatments that specifically target Her2 include Trastuzumab (sometimes known as Herceptin). This can be given with chemotherapy, with ER-blockers or by itself.
Much of the research into Breast Cancer care is around finding more receptors so that more medicines can be developed to block them. Often new treatments are being tried out in current cancer patients and patients can take part in a trial of a new treatment.
When you have Breast Cancer or think you might be at risk, it is important to see a doctor who is a Breast Cancer specialist and can advise you on the most modern, safest and most effective ways of curing the disease.