CMedEd | Understanding Breast Cancer

Treatment

Treatment for breast cancer depends on its specific type, its stage and the patient's overall health. The specific type of breast cancer is determined by the tumor’s histologic type (i.e. ductal carcinoma, lobular carcinoma and other rare types - see Types of Breast Cancer), hormone receptor status and HER2/neu status. Treatment usually involves surgery to remove the primary tumor, and may also include radiation therapy, chemotherapy, hormone therapy or targeted therapy. The doctor may give treatments before surgery (neoadjuvant therapy), to shrink the tumor. Or, the doctor may give additional treatments after surgery (adjuvant therapy), to destroy any remaining cancer cells in the body.

Surgery

Most women with breast cancer have breast-conserving surgery or a mastectomy to remove the tumor, along with lymph node surgery to check the lymph nodes for cancer that may have spread. Some women may also decide to have reconstructive surgery after undergoing breast cancer surgery to remove the tumor.

Breast-conserving Surgery (Lumpectomy, Partial Mastectomy)

Mastectomy

The surgeon removes the entire breast, and may also remove nearby tissues. There are five different types of mastectomy the doctor may recommend:

Simple mastectomy

The surgeon removes the entire breast, including the breast tissue, breast skin, nipple, and areola, but not the underarm lymph nodes or muscle tissue beneath the breast.

Skin-sparing mastectomy

In this procedure, the surgeon removes the breast tissue, nipple, and areola, but leaves the breast skin intact for women considering reconstruction.

Nipple-sparing mastectomy

In this procedure, the surgeon removes the breast tissue, but not the breast skin, nipple, or areola. This procedure may be a good option for patients with smaller, early-stage tumors that are not near the nipple.

Modified radical mastectomy

This procedure consists of a simple mastectomy with the addition of removal of underarm lymph nodes.

Radical mastectomy

This is considered an extensive operation. The entire breast, underarm lymph nodes, and the pectoral (chest) muscles are removed.

Lymph node surgery

The doctor may remove one or more underarm nodes and have them examined under a microscope for any signs of cancer.

Sentinel lymph node biopsy (SLNB)

In cases where there is no evidence of cancer that has spread to the lymph nodes prior to surgery, the surgeon removes only the sentinel lymph nodes, which are the first draining lymph nodes of the breast. These are the nodes most likely to test positive for cancer cells if the cancer has started to spread. These lymph nodes are identified by injecting dye into the breast prior to surgery. One or more lymph nodes may be removed during surgery, depending on how many lymph nodes take up the dye. If cancer is identified in the sentinel node or nodes, axillary lymph node dissection may be required.

Axillary lymph node dissection (ALND)

The surgeon removes anywhere from 10 to 40 lymph nodes from the underarm area. This is necessary in some, but not all cases when cancer has been found in the axillary lymph nodes.

Reconstructive surgery

After a mastectomy, some women may have reconstructive surgery to rebuild the breast mound and restore the breast’s appearance. There are two types of reconstructive surgery: implant and autologous. The specific type of reconstructive surgery often depends on factors such as the woman's age and body type. The choice of immediate or delayed reconstruction requires consideration of multiple factors including specific details about the women's cancer and the anticipated treatment plan. The final decision is made by the woman with input from her oncologist(s) and her reconstructive surgeon.

Implant Reconstruction

In an implant reconstruction, the doctor uses an implant filled with salt water or silicone gel, to rebuild the breast. The doctor picks an implant size and shape that is best suited to the woman, and places the implant either under or in front of the pectoral muscle in the chest. An implant reconstruction may be a good option for thinner women who do not have very much extra tissue in other parts of the body.

Autologous Reconstruction

In an autologous reconstruction, the doctor uses skin, fat, and muscle tissue from another part of the body to rebuild the breast. Tissue from the abdomen, buttocks, inner thighs, and back resembles breast tissue, and makes a natural substitute. The doctor will shape the tissue to match the patient's breasts and attach it to the chest.

Latissimus Dorsi Flap Reconstruction

In this procedure, the doctor uses tissue from the upper back to rebuild the breast mound. The doctor tunnels skin, fat, and muscle tissue underneath the skin to the breast region, preserving its original blood supply.

TRAM (traverse rectus abdominus muscle) Reconstruction

In this procedure, the doctor uses skin, fat, and muscle tissue from the lower abdominal wall to rebuild the breast mound. The doctor moves only skin, fat, and muscle tissue, and the blood vessels remain attached to their original blood supply in the abdomen.

DIEP (deep inferior epigastric perforators) Reconstruction

In this procedure, the doctor uses tissue from the lower abdominal wall to rebuild the breast mound. Additionally, the doctor removes blood vessels with the tissue from the abdomen and carefully attaches them to blood vessels in the chest. Unlike in a TRAM flap reconstruction, the doctor does not remove any muscle tissue. This allows the patient to retain normal use of the abdominal muscles.

Oncoplastic Surgery

Oncoplastic surgery combines the latest plastic surgery techniques with breast for cancer. When a large lumpectomy is required that will leave the breast distorted, the remaining tissue is sculpted to realign the nipple and areola and restore the natural appearance to the breast. The opposite can also be modified to create symmetry. This is a good option for patients who are candidates for breast conserving surgery (lumpectomy). At the time of your lumpectomy, the surgical oncologist will remove the tumor and, if necessary, the lymph nodes. The plastic surgeon may remove additional breast tissue from the cancerous breast and may also modify the normal breast. These procedures generally involve an incision around the nipple and areola, a vertically incision from the nipple to the fold under the breast, and a horizontal incision in the fold under the breast.

Radiation therapy

Radiation therapy uses waves of high energy beams to target and kill cancer cells. Doctors often give radiation after surgery (adjuvantly) to reduce the chance that the cancer will return. There are two primary types of radiation therapy: external and internal.

External Beam Radiation

This is the primary type of radiation therapy for women with breast cancer. The doctor aims radiation at the tumor from a large machine outside of your body. Doctors usually give external beam radiation for a few minutes at a time, five days a week, for three to four weeks.

Three-dimensional conformal radiation therapy (3D-CRT)

3D conformal radiotherapy uses CT images to map out or “simulate” the tumor and normal tissues so that a few X-ray beams can be shaped to conform to the target. The radiation dose to the tumor and normal tissues can be measured as a function of volume. Because of the limited number of X-ray beams, some nearby normal tissues may receive the same dose as the tumor.

Intensity-modulated radiotherapy (IMRT)

Intensity modulated radiotherapy (IMRT) uses even more X-ray beams and beam angles to permit variations in the dose pattern so that the tumor will receive a higher total dose than the normal tissues.

Internal Radiation Therapy (Brachytherapy)

Brachytherapy is another form of radiation therapy in which radiation is delivered to the tumor from inside the body. A catheter is used to place small radioactive pellets into the breast tissue near the cancer. There are two main types of brachytherapy: Interstitial and Intracavity.

Interstitial brachytherapy

A surgeon or radiation oncologist places several catheters in the breast near the primary tumor and leaves them in place for 7-10 days. Radioactive pellets are placed into the catheters twice a day for 5 days to administer radiation.

Intracavitary brachytherapy

A surgeon or radiation oncologist places a device into the breast cavity left after breast-conserving surgery. The device is left in place for 7-10 days, and radioactive pellets are placed into the device twice a day for 5 days.

Interoperative Radiation Therapy (IORT)

Please refer to Radiation Therapy for Breast Cancer for more information about preparing for treatment, what to expect, possible side effects and tips to manage side effects.

Chemotherapy

Chemotherapy is the use of drugs to target rapidly growing cells to destroy cancer cells. Doctors give chemotherapy to shrink the tumor before surgery (neoadjuvant therapy) and destroy any traces of cancer left after surgery (adjuvant therapy). In more advanced stages in which the cancer has spread, chemotherapy may be the best treatment option to relieve symptoms and improve survival. Chemotherapy can be given intravenously, as a shot, or as a pill or liquid. Doctors usually use a combination of chemotherapy drugs and give the treatment in cycles. This means that each round of treatment will be followed by a rest period of one to three weeks. Your doctor may discuss Oncotype DX a genomic test for breast cancer that evaluates a patient's risk of reoccurence and likely response to chemotherapy.

Endocrine Therapy/Hormone Therapy

Some women have breast cancer that is hormone-receptor positive. In these women, estrogen and progesterone hormones may cause the tumor to grow more aggressively. Endocrine therapy blocks the effects of these hormones or lowers their levels, preventing the hormones from fueling cancer growth. Doctors often give endocrine therapy to reduce the risk of the cancer returning after surgery.

Targeted Therapy

HER2/neu is a protein that is present in breast cancer cells that helps control how a cell grows, divides, and repairs itself. In about 1 in 5 cases of breast cancer, the HER2 gene doesn’t work correctly and makes too many copies of itself. This HER2 over-expression makes the cancer grow more aggressively and uncontrollably. Targeted therapy specifically targets these HER2 proteins, stopping or slowing the growth of breast cancer.

PARP inhibitors work by preventing cancer cells from repairing themselves, allowing them to die. PARP inhibitors preferentially kill cancer cells at the BRCA mutation over normal cells. Your doctor may recommend a PARP inhibitor for maintenance therapy after initial therapy or for treating recurrence.

Immunotherapy

Immunotherapy is a new cancer treatment that stimulates the body's immune system to attack cancer cells. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or biologic therapy. The area has evolved with complexity. Furthermore, these treatments are combined in many different ways.

Bone-directed Therapy

Doctors use bisphosphonates (Zometa, Pamidronate) to treat breast cancer that has spread to the bones. Bisphosphonates strengthen bones that have been weakened by cancer cells and reduce the risk of fractures and breaks. Bisphosphonates can reduce cancer-related bone pain and hypercalcemia (elevated calcium levels in the blood), and may help prevent thinning of the bone (osteoporosis).

Clinical Trials

Clinical trials allow patients to try a new treatment before it is available to the general public. In some cases, this may be a new drug that has not been used in humans before, or it may be a drug or drug combination that is not currently used for that specific type of cancer. Early phase clinical trials are often used to test side effects of a drug or drug combination, while later phase clinical trials are used to see how effective a new treatment might be for a certain type of cancer. Clinical trials allow doctors and researchers to improve the treatment of cancers with possibly more effective therapies. A clinical trial may be a new, groundbreaking drug or it may have no effect. It is important to talk with your doctor about the pros and cons of clinical trials for your particular situation.

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Understanding Breast Cancer