Breast Cancer Treatment
Deciding on treatment options once you have been diagnosed with breast cancer can be a very challenging experience. Not only are you dealing with the emotions of a new diagnosis of cancer, but trying to decide between a seemingly infinite number of treatment options can be overwhelming. You will be supported by many people during this process, including your treatment team of surgeon(s), medical oncologists, radiation oncologists and navigators, and, of course, your family and friends.
There are two main approaches to treating breast cancer: Systemic treatment and loco-regional treatment.
Systemic treatment is generally used when tumor cells have spread beyond the breast and nearby lymph nodes. These tumor cells are called metastasis and are usually detected on imaging studies. Only patients with metastasis can benefit from systemic treatment.
Types of Systemic Treatment
There are three types of Systemic Treatment: Chemotherapy, Hormonal therapy and targeted therapy. Together with a Medical Oncologist, patients will discuss which systemic treatment is right for them.
Chemotherapy attacks rapidly growing cells throughout the body
Hormonal therapy (endocrine therapy) is usually given as a pill which interferes with tumors that are positive for estrogen and/or progesterone receptors
Targeted therapies specifically attack breast cancer cell and generally have fewer side effects than chemotherapy.
Systemic Treatment can be given before or after surgery. If therapy is given after surgery it is called adjuvant therapy. Sometimes it is given before surgery to help shrink more advanced disease and this is referred to as neoadjuvant therapy.
Loco-regional treatment treats the breast tumor itself and the nearby areas, including the rest of the breast and regional lymph nodes. Although there are multiple lymph nodes around the breast and chest area, breast cancer treatment is primarily concerned with the lymph nodes in the armpit, called axillary nodes.
Types of Loco-regional Treatment
There are two treatment options that address loco-regional disease, surgery and radiation therapy (XRT). These can be used separately but often are used together.
Although the breast and regional lymph nodes are usually treated together, it is often easier to understand the different options by separating out the treatment of the breast from treatment of the lymph nodes.
To treat a breast cancer, generally there are two options:
Mastectomy: Remove the entire breast surgically
Lumpectomy: remove only the tumor, plus a narrow “rim” of normal breast tissue, leaving the rest of the breast in place.
Other terms commonly used are partial mastectomy or breast conservation surgery (BCS). Although there can be exceptions, usually XRT is done in combination with a lumpectomy, and this is referred to as breast conservation therapy (BCT).
Usually the first, and often most difficult, decision a patient will need to make is whether to have a mastectomy or BCT. There are certain situations where one is potentially better than the other and your surgeon or oncologist will discuss these with you if these apply. For most breast cancers however, these two treatment options have essentially the same outcomes, both in survival and recurrence of disease.
A few basic considerations in determining your treatment are:
A mastectomy is the most aggressive surgical option. The entire breast is removed, but generally all of the muscles are left behind. This is the most disfiguring of the options, unless it is combined with a breast reconstruction. There are many different types of reconstruction and they can be done either at the time of mastectomy, or done at a separate operation after mastectomy. The type and timing of reconstruction is determined by how much skin (potentially even the nipple) can be left during the mastectomy. This option almost always requires at least an overnight stay in the hospital and placement of one or more drains that you will likely go home with. Often, XRT is not required after a mastectomy, but not always.
Breast conservation therapy (BCT), which is a lumpectomy combined with XRT, is a more minor surgical procedure and usually can be performed as an outpatient procedure meaning you go home the same day, and usually doesn’t require any drains. It generally has a good cosmetic outcome without any need for reconstruction. Usually there is only a small scar and the breast essentially retains its normal shape. The smaller the tumor and the larger the breast, the more likely a very good cosmetic result will occur. But sometimes even large tumors can be made to shrink with neoadjuvant therapy allowing for a very positive result with BCT.
It is important to remember that these two surgical options have very similar outcomes.
Management of the axillary lymph nodes has changed significantly over the past few years. This is a more complex issue that depends on the specific details of your breast cancer.
If you have large, bulky nodes in your armpit, even after neoadjuvant therapy, a procedure called an “axillary lymph node dissection (ALND)” is generally recommended as the best option. Fortunately, many patients don’t have large nodes (referred to as a clinically negative axilla) and have multiple alternatives to ALND.
Although our understanding and staging of breast cancer is rapidly evolving, in many instances it is still helpful to know if the axillary lymph nodes contain any cancer. This was historically done by removing most of these nodes (ALND) and looking at them under the microscope. This was helpful in staging patients, however, many patients had no lymph node involvement. These patients likely had little benefit from removing these nodes, but were subjected to the potential complications of the procedure, such as swelling of the arm (lymphedema) and/or chronic shoulder pain. Fortunately, an alternative to ALND was developed to evaluate the axilla called sentinel lymph node biopsy (SLNBx). With this procedure, only a few nodes are removed which are thought to be the first nodes that the cancer cells would spread to. If these nodes are negative, then the remaining nodes are likely to be free of cancer as well. These nodes are identified after injecting the breast prior to or at the time of surgery, generally with two substances, a radioactive tracer and a blue dye. This is a much less invasive alternative to ALND, and like a lumpectomy, usually can be done as an outpatient procedure and without any drains. If the SLN is positive, several options exist, including more surgery to remove additional nodes, XRT, systemic therapy, or perhaps no additional treatment at all. The advantages and disadvantages of each method depend on your specific circumstances and should be discussed with your surgeon and the other members of your care team. SLNBx can be done with either a mastectomy or a lumpectomy.
Note: This is a very general overview of some of the treatment options currently available. Many details and concepts have been overly simplified and some completely omitted to make the evolving approach to breast cancer care more understandable. It is important to remember that you need to make a decision that you will be the most comfortable with. This decision does not need to be made urgently and you should take as much time as you need. We are available to assist you through this entire process.