Breast-Cancer Treatments Options
Treatment for breast cancer almost always begins with a decision about the type of surgery to remove the cancerous tissue, and determine how far the cancer has spread. The options are mastectomy, a procedure that involves removal of the entire affected breast; or lumpectomy, a procedure to remove the malignant lump and a margin of healthy tissue around all edges of the tumor. A lumpectomy also is called breast-conserving therapy, or BCT. When a lumpectomy is performed, it generally is followed by radiation therapy to prevent the cancer from recurring in the same breast. The goal of BTC is to maintain the cosmetic appearance of the breast without decreasing a woman's chance of surviving breast cancer.
Today, it is estimated that up to 80 percent of women with early-stage breast cancer can be treated with BCT. For these women, mastectomy and lumpectomy with radiation offer the same chance of long-term survival. However, women who undergo mastectomy have a slightly lower risk of breast-cancer recurrence, but in most studies, this has not been statistically significant.
A woman is considered a good candidate for lumpectomy if her tumor is localized to one area of the breast. Most women with breast cancer qualify as candidates for lumpectomy. However, there are other considerations:
- Cosmetic results may not be good in women who have relatively large lumps in small breasts.
- If there is more than one lump, there is concern that other areas of the breast could have cancer as well. In this case, a mastectomy is the preferred therapy.
- Women who are unwilling or unable to have follow-up radiation treatments are not good candidates for lumpectomy. Radiation typically is given five days a week for five to six weeks after surgery. Patients who live far from a hospital or medical center that provides radiation therapy may find it inconvenient or impossible to travel back and forth for daily treatment.
- Women who previously have had radiation therapy to their breast or chest area might not be able to undergo further breast radiation. In this case, mastectomy is the preferred therapy.
A mastectomy usually involves removing the breast and some lymph nodes located under the arm. After the lymph nodes are removed, they are examined by a pathologist to check for cancer cells. The information about the presence or absence of cancer cells in the axillary lymph nodes is essential in determining the patient's prognosis and stage, and the need for further therapy.
It's important to consult a plastic surgeon before surgery. This consultation can help women make a better decision about whether to have the reconstruction done immediately (during the surgery) or defer it to a later time. In general, it is very important for every woman who has been diagnosed with breast cancer to attend a multidisciplinary clinic where the disciplines of surgery, plastic surgery, radiation oncology and medical oncology are represented. (If such a clinic does not exist, each patient would have a consultation with each of these specialists, to become better informed of the differing manner in which breast cancer can be treated.)
The number of days spent in the hospital varies. Occasionally, mastectomy without reconstruction may be performed as same-day surgery. After surgery, most women need to do special exercises to overcome stiffness and regain mobility in the arm on the side of the mastectomy. One common side effect is swelling of the arm on the side where the axillary lymph node dissection was performed. Because many of the lymph nodes have been removed, there may be accumulation of fluid in the arm leading to troublesome swelling. Surgeons are trying to avoid this complication by doing more selective sampling of the lymh nodes, so-called sentinel node biopsy, and then determining if there is a need for additional lymph node removal (see below).
The latest variation is a skin-sparing mastectomy, in which the breast tissue is removed through a circular incision around the nipple. The skin thus remains intact so that the breast can be reconstructed immediately by inserting an implant or fatty tissue taken from the abdomen, back or buttocks. With a skin-sparing mastectomy, a separate incision is needed to remove underarm lymph nodes.
Removing Lymph Nodes
Most breast-cancer surgery requires the removal of some axillary (underarm) lymph nodes to check for the presence of cancer cells. The most commonly performed procedure is called an axillary dissection — the removal of a wedge of fat from the underarm that usually contains between 10 and 15 lymph nodes. A newer method, called sentinel-node mapping, relies on identifying and removing only the one or two lymph nodes closest to the tumor. If no cancer is found in the sentinel nodes, then no more lymph nodes are removed. This procedure is under investigation. If further study reveals that sentinel-node biopsies are as sensitive as more extensive biopsies in detecting cancer in the axillary lymph nodes, then it likely will replace the current method of lymph-node removal. At this time, sentinel-node mapping should be performed only by an experienced surgeon who has performed many of these procedures before.
The lymph nodes can be removed in the course of a mastectomy. With lumpectomy, a separate incision usually is made to remove the wedge of fat that contains the nodes. Either way, most patients wake up from surgery to find a drain emerging from the underarm area to remove any fluid that accumulates.
After the lymph nodes are removed, they are examined under the microscope to check for the presence of cancer cells. The need for additional treatment after surgery depends on whether some nodes are positive for cancer.
Several potential complications are associated with lymph-node removal. The most serious is lymphedema, a swelling in the arm caused by the accumulation of fluid that doesn't drain properly. Lymphedema is very rare since the current surgical techniques involve the removal of fewer lymph nodes than the more extensive procedures of the past. Swelling can range from barely noticeable to an obvious enlargement of the arm. It can be either painless or painful. Sometimes, lymphedema is triggered by an infection, but other times, the cause is unknown. Some women develop it right away, and others develop it some time after surgery. In some cases, the lymphedema is transient and resolves on its own. In other cases, it may be a chronic problem. There are special exercises and precautions that can be followed after surgery to decrease the chance of developing lymphedema. Examples include wearing gloves whenever gardening, avoiding constricting clothing and jewelry and shaving your underarms with an electric razor. Treatments are available if lymphedema does occur.
Another potential complication is some loss of sensation under your arm. When the surgeon makes an incision in your skin, it can damage nerves in the area. The numbness won't affect the use of your arm, but you will have to be very careful when shaving because part of the area under your arm will lack sensation.
Radiation therapy (sometimes called radiotherapy) almost always is recommended after lumpectomy to destroy any cancer cells left behind and to prevent local recurrences in the breast. Without radiation therapy, the odds of a local recurrence increase by about 25 percent. These recurrences can predict cancer spread to other parts of the body, especially when they occur within the first three years after surgery. Radiation therapy is also sometimes recommended after mastectomy, depending on the size and other characteristics of the breast tumor.
Although many patients worry that radiation treatment can cause cancer, this is extremely rare with today's high-tech machines. There is no risk of becoming radioactive or losing your hair due to radiation treatments. Fatigue is a common side effect of radiation, and many women experience swelling or a sensation of heaviness of the breast. Most of these changes in the breast are temporary and will go away within a few months to a year. Some women, however, notice that their breasts are smaller and firmer after the treatment, and this can be permanent. Radiation therapy is not given to pregnant women because it can cause birth defects.
After surgery, certain patients will be offered chemotherapy (anti-cancer drugs) to improve their chance of survival. In other cases, chemotherapy may be recommended before surgery to shrink the tumor before it is removed. Before recommending chemotherapy, your doctor will consider the stage of your cancer and the prognosis. If your cancer recurs, chemotherapy usually is recommended. If chemotherapy is necessary, treatment typically is given over a period of three to six months. The drugs can be given by injection or in pill form. Treatment can be given once every three or four weeks to allow patients to recuperate in between. Most chemotherapy for breast cancer involves a combination of three drugs, but the specific combination depends on the individual case.
Chemotherapy commonly causes side effects, but the severity and type of symptoms experienced varies with each person and with the type of drugs given, the dosage of the drugs and the length of time the patient is treated. Fatigue is the most common side effect associated with chemotherapy. The gastrointestinal tract often is damaged temporarily by the chemotherapy drugs, so nausea, vomiting, mouth sores and decreased appetite are common. Many patients also experience hair loss and menstrual irregularities. Chemotherapy also can increase your risk of infection (by decreasing the number of your infection-fighting white-blood cells) and bleeding (by causing your platelet counts to drop). A variety of new chemotherapy agents have been used for the treatment of breast cancer, including a family of drugs called the taxanes and a newer class of drugs called the epothilones. These agents are of great importance because they may continue to be effective in treating the cancer even if prior chemotherapy programs have lost their effectivness. As with all chemotherapy agents, these new agents also have side effects, such as lowering white blood cell counts and causing some nerve damage that can be bothersome. If nerve damage is present, patients will often complain of numbness and pain in the fingers and toes.
It's important to keep in mind that these side effects are treatable. A variety of medications are available to minimize nausea and vomiting. In addition, several medications are available to stimulate the production of blood cells, which can be inhibited by chemotherapy.
Hormonal therapy works by inhibiting tumor growth that is stimulated by hormones. Tumors that are estrogen- or progesterone-receptor positive are more likely to respond to hormonal therapy than are tumors without these hormone receptors. The estrogen receptor can be blocked by the drug tamoxifen. Premenopausal and postmenopausal women with early state breast cancer that is estrogen-receptor positive are typically treated with daily tamoxifen therapy for five years to reduce the risk of cancer recurrence. Tamoxifen can be taken orally, and it is generally well tolerated, though it can cause hot flashes. Tamoxifen also increases the risk of blood clots and uterine cancer. Other drugs to block the estrogen receptor are also under study.
For patients with metastatic breast cancer, hormonal therapies are often given to prolong life expectancy, in addition to chemotherapy. Premenopausal women are often treated with tamoxifen and a second medication to suppress hormonal production by the ovaries. Postmenopausal women may be treated with a variety of medications to block the estrogen receptor, including taxoxifen, anastrozole, letrozole, or exemestane.
Tamoxifen has also been shown to be effective in decreasing the risk of breast cancer for high-risk women, and it now has FDA-approval to be used for this purpose. A recent major research trial, called the PI study, demonstrated that women who had increased risk of breast cancer because of age (greater than 60) or other risk factors were nearly 50 percent less likely to develop breast cancer after taking tamoxifen.
There have been several new advances in both understanding how a patient's cancer is going to behave and improved diagnostic procedures.
Genetic profiling: One very important advance deals with the specific genes that are associated with the cancer. Physicians now have the ability to determine the specific DNA or genetic material that is present in the cancer cell and determine if the cancer is likely to recur after conventional treatment. This concept is important, since many women who have small tumors and no evidence of lymph node spread may often be thought to have an excellent prognosis. However, a certain proportion of these patients will have a recurrence of their cancer in the months or years following the diagnosis, and physicians, up until now, could not determine who was at risk. By looking at the specific genes that make up the cancer, women can now be selected for treatment based on the presence or absence of these specific genes and hopefully prevent or treat the cancer cells that are yet undetectable before they ever become problematic. One test that is commercially available that provides this information is called Oncotype DX.
Bone marrow micrometastases: Women with Stage I breast cancer are often treated with surgery or lumpectomy and thought to have received a curative treatment. However, in a significant proportion of these women, cancer recurs at some later date. How is this possible, especially if the lymph nodes were negative? Recent sophisticated tests can now determine the presence of single cancer cells that reside in the bone marrow of these women — cells that escaped from the breast cancer itself — well before the cancer could be diagnosed. Several studies show that women who have these so-called micrometastases in the bone marrow are more likely to develop recurrent cancer. Patients in whom micrometastases are present may be candidates for more aggressive treatment, even though routine studies do not show any abnormalities.
Breast magnetic resonance imaging: Even though routine mammography and breast ultrasound are excellent means for detecting abnormalities and breast cancers, recent data have shown that the addition of breast imaging using MRI machines may increase the detection rate, especially in women with a strong family history of breast cancer, those with an already established diagnosis of breast cancer, and women who carry genetic abnormalities in whome the incidence of breast cancer is high, such as BRCA gene carriers. This is a exciting development and may help diagnose women at particularly high risk more easily than conventional mammograms do. The use of breast MRI, however, is not currently recommended for all women who are undergoing screening and who do not have a heightened risk of breast cancer development.
Aetna Member: If you are a female member of an HMO-based plan and would like more information about breast cancer and breast cancer prevention, please call (888) 322-8742.
Miembros de Aetna: Si tiene un plan HMO y desea más información sobre el cáncer de seno y la prevención del cáncer de seno, por favor llame al 1-888-322-8742.