Breast Cancer Treatment

Despite a rising incidence of breast cancer in developed countries during the last 30 years, the number of deaths from breast cancer continues to fall each year as a result of earlier diagnosis and multidisciplinary breast cancer teams, as well as more effective and targeted treatment.

Your multidisciplinary breast cancer treatment will be coordinated by Professor Wishart. Initial treatment will usually involve a combination of breast surgery (wide local excision/lumpectomy or mastectomy) and lymph node surgery under your arm (sentinel lymph node biopsy or axillary node clearance). The choice of breast surgery will depend on the position of the lump in your breast as well as the size of your breast. Patients with breast cancer arising in more than one site in the breast would usually require mastectomy. In certain cases, you might be advised to have treatment by chemotherapy prior to any surgery.

In addition to surgery, other parts of your breast cancer treatment may include chemotherapy, radiotherapy, hormone therapy and targeted treatments such as Trastuzumab (Herceptin) depending on your individual pathology results. You will be advised by Professor Wishart of the optimal choice of treatment following discussion of your results at a multidisciplinary meeting with specialist breast oncologist(s). By referral to one of our specialist breast oncologists, you will have access to the very best current protocols for chemotherapy and radiotherapy if required.

There are a number of different types of breast cancer surgery including wide local excision (sometimes called lumpectomy) and mastectomy.

Most patients will have a wide local excision of the primary tumour, but if mastectomy is recommended then it can be combined with breast reconstruction at the time of the mastectomy (immediate breast reconstruction) or at a later date (delayed breast reconstruction). Patients having immediate breast reconstruction will have a skin-sparing mastectomy. Previous research studies have shown that the extent of the surgery does not influence the survival from the breast cancer i.e. having more extensive surgery (mastectomy) does not mean a better survival rate when compared with wide local excision.

In determining the most appropriate form of surgery Professor Wishart will take into account the size of the tumour, the position of the tumour (central or peripheral), the number or tumours and the size of your breast.

The majority of patients who require breast cancer surgery will be suitable for wide local excision (WLE). WLE (sometimes called lumpectomy) is usually performed for smaller tumours and the aim of surgery is to remove the tumour together with a margin of “healthy” tissue around the tumour. This will be carried out through an incision close to the tumour itself.

The main reason for performing WLE, rather than a mastectomy, is to achieve a good cosmetic result following surgery +/- radiotherapy. The cosmetic outcome is directly linked to the percentage of breast tissue that is removed during surgery. As a result the removal of small tumours from small breasts, or moderate sized tumours from moderate size breasts, will result in a good cosmetic outcome. In contrast, removal of larger tumours from smaller breasts will result in a poor cosmetic outcome and in these cases mastectomy would normally be advised. Use of surgical techniques to rearrange the breast tissue following WLE can also improve the cosmetic outcome.

WLE for breast cancer is usually combined with some form of axillary surgery and if performed with sentinel node biopsy can usually be performed as a day-case operation or with minimum stay in hospital. WLE is nearly always followed by radiotherapy to the breast, although in a small proportion of cases further breast surgery may be required following the initial WLE.

A mastectomy involves removing at least 95% of the breast tissue, including the nipple and the areola (dark skin around the nipple), and some of the breast skin to leave a flat scar against the chest wall. A mastectomy is often recommended for the following reasons:

• Patients with larger tumours ( >3cm)
• Patients with multifocal tumours (arising in more than one site in the same breast)
• Patients with central tumours (tumours close to or underlying the nipple)
• Patients who prefer to have a mastectomy
• Patients with a recurrence of their breast cancer

The mastectomy will usually be performed in conjunction with some form of axillary surgery that may be carried out either through the mastectomy incision or occasionally through a small separate incision under the arm. The surgery is performed under a general anaesthetic and wound drains are used for up to three days following surgery. The use of radiotherapy following mastectomy is used in a small number of patients.

Patients having immediate reconstruction will have a skin-sparing mastectomy.

This involves caring out the mastectomy though a small circular incision around the nipple and areola which preserves nearly all of the breast skin. Failure to remove the nipple as part of the skin-sparing mastectomy can lead to higher levels of local recurrence and is not usually recommended

The aim of sentinel lymph node biopsy (SLNB) is to provide an accurate assessment of whether tumour cells have spread from the primary tumour to the axillary lymph nodes.

The presence or absence of tumour cells in the lymph nodes is the single most important factor in determining prognosis and planning additional treatment following surgery. The “sentinel” lymph nodes are the first group of lymph nodes under the arm, and are the nodes most likely to contain tumour cells if the cancer has spread.

The lymph nodes are removed through a small incision under the arm (axilla). The operation usually lasts up to 30 minutes and is usually performed as a day-case under general anaesthesia. During surgery, the lymph nodes are detected by an injection of blue dye and a fluorescent dye (ICG) in the skin close to the nipple to help identify the SLN(s). Both dyes will help to identify the lymph nodes during the operation, which are then removed, and sent to pathology for analysis. If there are tumour cells present, then further surgery to remove the majority of the lymph nodes may be required. This is called an axillary node clearance.

Approximately 30% of all patients with breast cancer have tumour spread to the axillary lymph nodes, and it is usually detected by either sentinel lymph node biopsy or ultrasound-guided needle biopsy under local anaesthesia.

Axillary node clearance will remove the majority of lymph nodes under the arm (axilla) and is a very effective treatment that reduces the risk of a local recurrence under the arm in the future. Although axillary node clearance is an extremely effective treatment, it does have several recognised complications including lymphoedema and shoulder stiffness.

Despite optimal local treatment of breast cancer (surgery +/- radiotherapy) a proportion of patients will develop spread to other organs in the body in the future.

This indicates that these cells must have spread by the time that the cancer was removed from the breast. The chance that breast cancer cells may have spread can be predicted by the pathology results, as well as the Predict model (http://www.predict.nhs.uk) and further treatments such as chemotherapy may be used to try to kill or control these tumour cells.

Chemotherapy is one of the breast cancer treatments that have been shown to improve survival. These additional treatments are often called adjuvant or systemic therapy. Chemotherapy is the use of drugs to kill undetectable cancer cells, wherever they are in the body, in an attempt to stop these cells causing problems in the future. There are particular combinations of chemotherapy drugs that are very effective in breast cancer and most are given by intravenous injection every two to three weeks as an outpatient and the entire course may last up to six months. If you require chemotherapy, your oncologist will provide you with a full explanation of possible complications and side effects of this treatment.

Chemotherapy is most effective in younger (pre-menopausal) women although it may still be of benefit up to 75 years of age. Your personal survival benefit from chemotherapy can be calculated using the Predict model developed by Professor Gordon Wishart in Cambridge.

Herceptin is a monoclonal antibody that interferes with the way that some breast cancers grow and divide. It works by binding to the HER2 protein that is found in approximately 12% of all breast cancers.

Herceptin is only effective in women who have high levels of the HER2 protein, and is usually given in combination with chemotherapy. Herceptin is normally given as a short intravenous infusion every three weeks for up to 12 months.

Despite optimal local treatment of breast cancer (surgery +/- radiotherapy) a proportion of patients will develop spread to other organs in the body in the future.

This indicates that these cells must have spread by the time that the cancer was removed from the breast. The chance that breast cancer cells may have spread can be predicted by the pathology results and further treatments such as hormone therapy may be used to try to kill or control these tumour cells. Hormone therapy works by blocking the effect of Estrogen (ER) and/or Progesterone (PR) Receptors in the tumour cells and is an effective treatment for the majority of patients with breast cancer.

Hormone therapy is one of the breast cancer treatments that have been shown to improve survival. These additional treatments are often called adjuvant or systemic therapy. Hormone therapy is the use of drugs to kill or control undetectable cancer cells, wherever they are in the body, in an attempt to stop these cells causing problems in the future. A number of hormone therapies are now available including Tamoxifen, Anastrazole (Arimidex), Letrozole (Femara) and Exemestane (Aromasin). In addition, the function of the ovaries can be blocked by medication (Zoladex) or by surgical removal (oophorectomy).

All these hormone treatments decrease the chance of tumour recurrence and improve survival following breast cancer surgery. They will also significantly reduce the risk of cancer in the other breast. Your personal survival benefit from hormone therapy can be calculated using the Predict model developed by Professor Gordon Wishart in Cambridge

Radiotherapy is used to kill any cancer cells that may remain undetected in the breast following a wide local excision, and can reduce the risk of local recurrence (chance of tumour recurring in the breast) by 60-70%. Cancer cells are more sensitive to radiotherapy than normal cells and therefore will be killed at a greater rate.

The total radiation dose is split into small daily fractions for 3-5 weeks depending on exactly which protocol is used. Recent radiotherapy developments include Intensity Modulated Radiotherapy (IMRT), which has been shown to reduce the risk of significant side effects (view clinical paper). Breast radiotherapy does not usually cause any significant side effects, but some patients may experience tiredness and a sunburn-like reaction on their skin.

Chest wall radiotherapy, sometimes called post-mastectomy radiotherapy, is not routinely used following mastectomy but may be recommended by your breast surgeon and oncologist. Chest wall radiotherapy is often advised in patients with larger tumours, node-positive tumours or tumours that are close to the skin or underlying muscle.

Radiotherapy is used to kill cancer cells that may remain undetected in residual tissue following mastectomy, and can reduce the risk of local recurrence in the skin, subcutaneous tissue or muscle. Cancer cells are more sensitive to radiotherapy than normal cells and therefore will be killed at a greater rate.

The total radiation dose is split into small daily fractions for 3-5 weeks depending on exactly which protocol is used. Recent radiotherapy developments include Intensity Modulated Radiotherapy (IMRT), which has been shown to reduce the risk of significant side effects. Breast radiotherapy does not usually cause any significant side effects, but some patients may experience tiredness and a sunburn-like reaction on their skin. In patients who have a breast reconstruction using an implant, there is a greater chance of a firm capsule forming around the implant if radiotherapy is used following mastectomy and reconstruction. This condition is called capsular contracture.

Information Sheets

Axillary
Clearance

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Duct
Clearance

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Excision
Biopsy

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Mastectomy
Information

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Re-Excision
Information

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Sentinel Lymph
Node Biopsy

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Wide Local
Excision

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Post-Operative
Wound Care

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