Breast Cancer Treatment: Section 8.a.

CONTENTS

8.1 The Multidisciplinary Team (MDT)
8.2 Surgery Treatment for Breast Cancer
8.2.1 Breast Conserving Surgery (BCS)
8.2.2 Total Mastectomy
8.2.3 Breast Reconstruction
8.3 Radiation Therapy (Radiotherapy) for Breast Cancer
8.4 Chemotherapy Treatment for Breast Cancer
8.4.1 Anthracyclines
8.4.2 Taxanes
8.4.3 Platinum-based Chemotherapy – Carboplatin and Cisplatin
8.4.4 Other Chemotherapy Agents

This page is section 8A breast cancer treatment. Forward to 8B Breast Cancer Treatment. Back to 7B Breast Cancer Staging.

If you or a loved one are facing breast cancer, always remember to keep your sunny side up, keep yourself beautiful and indulge yourself.

In the U.S.A., breast cancer is the most commonly diagnosed malignancy in women; it is the second most common cause of death from cancer in women; but breast cancer is the leading cause of cancer death in women aged between 40 to 49 years.

World-wide, breast cancer is the most commonly diagnosed cancer in women and is the leading cause of cancer death in women.

This means that breast cancer will touch most women, in some way during their lifetime.

Yes, but there is good news too. Better screening programs detect breast cancers in the early stages, but women must help raise awareness about all aspects of this cancer.

Don’t forget, as well as attending screening, to check your own breasts regularly, or better still get the one you love to check them!

Summary of Treatment for Breast Cancer

The treatment options for breast cancer have developed in the past 30 years from ‘radical’ surgical procedures to more individualized or ‘personalized’ approaches.

These new approaches to treatment for breast cancer have occurred with the realization that every woman’s breast cancer is different and the realization that the breast tumor tissue can reveal likely tumor ‘targets’ for treatment. Indeed, patient participation in clinical trials studying breast cancer has contributed to the advances in treatment for breast cancer.

Every woman’s breast cancer is different, just as every woman’s breasts are different, there’s perfect ( o )( o ) and perky ( * )( * ) and big ( O )( O ) and small (.)(.) anyway, just saying…

As a consequence of ‘breast cancer awareness’ and the breast screening program, most newly-diagnosed breast cancer is at an early-stage and is non-metastatic.

Also, as detection of ductal carcinoma in-situ (DCIS) is more commonly identified due to screening, treatment and management regimes for DCIS have been developed.

Treatment for Breast Cancer

Treatment for breast cancer will depend upon the tumor stage at presentation with most women’s breast tumor (95%) now being in one of the following categories:

Ductal carcinoma in-situ (DCIS): is clinical stage Tis(DCIS).
Early-stage breast cancer: includes clinical stage I, IIA or IIB disease (T2N1).
Locally advanced breast cancer: includes a sub-set of clinical stage IIB (T3N0) and stage IIIA and IIIC disease.

Approximately 5 % of women with newly-diagnosed breast cancer will present with stage IV breast cancer with metastatic spread.

Coffee, chocolate and men; some things are just better rich.

This section on treatment will use the following categories:

DCIS
Early-stage
Locally advanced
Metastatic advanced breast cancer

So, in summary, this section gives an overview of the current treatment options for breast cancer. At the end of this section, there are some key references to the recent literature and links to further patient information.

8.1 The Multidisciplinary Team in the Treatment for Breast Cancer

For every woman with a breast cancer diagnosis, communication with the treating physician is very important, together with access to counselling and support during the treatment process.

One of the most important clinical developments in breast cancer diagnosis and management is the multi-disciplinary team (MDT) approach to each woman’s care. The MDT includes family physicians, oncology physicians, surgical oncologists, radiology and radiotherapy oncology, pathologists, nurses, psychology and social workers.

Well, at least you become part of a team rather than struggling along alone.

Yes, but also remember, individuals play the game, but teams beat the odds!

I’m liking the ‘multi-disciplinary’ bit very..shades of….hmmmmm.

Some countries have adopted guidelines for multi-dicsciplinary team (MDT) meeting organization, and this has been the basis for a more consistent approach to patient care. In the U.K., the widespread introduction of MDTs began with the publication in 1995 of the Calman–Hine report. There is now almost 20 years of experience from implementation of MDT approaches to the care of patients with breast cancer. (Kesson et al., 2012).

Who’s in the team? Is there a prize? Can I be in the team?…Oh no, maybe there’s a test and you know how I feel about tests!

Unless you’re one of the professionals listed below, or you or your loved one has been diagnosed with breast cancer then you probably won’t make the team.

Studies prove that the MDT approach to the care of patients with breast cancer is more likely to be evidence-based, more cost-effective, better co-ordinated, more consistent and more patient-focused. In addition, the MDT approach reduces time from diagnosis to treatment (Saini et al., 2011; Kesson et al., 2012).

The Pathologist

The Pathologist attends the MDT meeting is there to present the microscopic findings of any cytology (FNA) or histology (CNB) findings before the planning of any definitive treatment.

The Radiologist

The Radiologist uses their breast imaging expertise in the diagnosis and sampling of breast abnormalities. Like the Pathologist, the Radiologist is a core member of the multi-disciplinary breast cancer team. The Radiologist and Pathologist will interact as the diagnostic part of patient care, with an important aspect of the MDT being the correlation between the Radiologist’s imaging findings and the Pathologist’s histologic or microscopic findings.

It’s true, wine improves with age; the older I get, the more I like it.

The Family Practitioner

The Family Practitioner may attend the MDT meetings, but if not then they will receive information about the findings on their patients.

Surgeon

The Surgeon or Surgical Oncologist will attend the meeting as part of the assessment of the patient’s surgical management.

Radiotherapists will attend the meeting as part of the assessment and planning of the patient’s clinical management.

They say that 40 is the new 30, but try telling that to a speed camera.

The Oncologist

An Oncologist is a physician with training in the care of cancer patients and who usually has overall responsibility for clinical care of the patient from diagnosis onwards.

Specialist Nurses

Breast cancer nurses are a key point of contact between oncologists and patients and are important for the continuity of care of breast cancer patients. In addition, specialist nurses will commonly attend MDT meetings.

It is also usual for Clinical Psychologists and Social Workers to attend breast cancer MDT meetings.

Well, that seems like a fairly impressive team to me!

Saumurai warrior, he say, ‘only by binding together as a single force will we remain strong and unconquerable’.

You’re always so spiritual and wise Brittany.

So are you Jess, you just don’t know it yet!

8.2 Surgery for Breast Cancer

Surgical treatment for breast cancer is done to remove the primary cancer from the breast. Breast cancer surgeons will remove and microscopically examine lymph nodes under the arm to look for metastatic cancer cells.

8.2.1 Breast Conserving Surgery (BCS)

Breast conserving surgery (BCS) removes the cancer but preserves as much normal breast as possible. BCS includes several components:

If you are facing, or have had breast surgery, here’s a quote I like, ‘some people see scars, and it is the wounding they remember. To me they are proof of the fact that there is healing’.

i. Lumpectomy

This surgical procedure removes the tumor and a small amount of surrounding normal breast.

ii. Partial Mastectomy

Partial mastectomy surgery removes part of the breast. However, there is a wider excision margin or ‘clearance’ of normal breast tissue from around the tumor, in comparison to a lumpectomy.

There’s a lot of surgical options, isn’t there?

That’s what the multi-disciplinary team is for, to help you make the best treatment choice.

iii. Segmental Mastectomy

This is a partial mastectomy but with the removal of the surface of the muscles that cover the chest wall.

iv. Lymph Node Dissection

A separate incision is necessary to remove some lymph nodes from the axilla. The surgeon sometimes performs lymph node dissection at the same time as breast surgery, and sometimes after. The pathologist examines the lymph nodes to exclude metastases.

8.2.2 Total Mastectomy

A total mastectomy removes the entire breast, with removal of the breast cancer and all possible normal glandular tissue. A ‘simple mastectomy’ is another name for this procedure.

8.2.3 Breast Reconstruction

So the surgeon will plan the type of treatment with the patient. So in this planning stage the surgeon may discuss breast reconstruction The surgical reconstruction gives a good cosmetic appearance.

The breast reconstruction process uses the patient’s own tissue from outside the breast. In addition, the surgeon may implant material full of silicone gel or saline.

The surgeon may perform breast reconstruction at the time of definitive surgical treatment or a later date. Some women choose not to have breast reconstruction.

Whilst breast reconstruction achieves some really good results, it’s still a very personal choice for women whether to have it or not.

Why would you choose not to?

Many reasons. Around 20 % of women choose to ‘go flat’ or ‘live flat’ as it is known.

8.3 Radiation Therapy (Radiotherapy) for Breast Cancer

High energy X-rays and other forms of radiation therapy destroy cancer cells or stop them from growing. Radiation therapy is an important form of treatment for women with a new diagnosis of non-metastatic breast cancer.

breast cancer treatment

Radiation therapy consists of the delivery of radiation beams comprised of electrons or photons. Photon therapy will pass through tissues of the body, so the photon beams are set at an angle so that they pass through the tumor and avoid normal tissue. Electrons will travel through tissue only to a specific depth and it is the energy that generates the electrons that determine the depth.

Radiation therapy for breast cancer takes two main forms:-

External Radition: directs the radiation towards the breast cancer from an external machine
Internal Radiation: The radiologist implants radiation therapy adjacent to the cancer using needles, wires or implants.

Depending on the extent of breast cancer, radiation therapy may also be necessary to the breast, the chest wall, the supraclavicular and internal mammary lymph nodes and the axillary lymph nodes.

NOTE: Radiation treatment is THE MOST POWERFUL AND EFFECTIVE treatment. Don’t skip it. It’s amazing.

8.4 Chemotherapy for Breast Cancer

Chemotherapy as a treatment for cancer uses drugs that either kill the tumor cells or stop them from growing. Patients take chemotherapy either by mouth or by an infusion into a vein. As ‘systemic chemotherapy’ these drugs can access malignant cells throughout the body. ‘Regional chemotherapy’ is placed directly into an organ or body cavity.

The word Chemotherapy, scares people.

And sometimes scares people into refusing it, which is tragic.

So lets call it, ‘the amazing medicines that can cure cancer’.

Chemotherapy is a single-agent, sequential therapy. However, combination chemotherapy may be necessary when the higher chance of response outweighs the risks of therapy toxicity. There is no prospective data to support the use of combination chemotherapy to improve overall patient survival in comparison to a single agent, sequential cytotoxic chemotherapy.

Chemotherapy is a treatment for breast cancer that treats or controls metastatic disease. The most common chemotherapy agents for treatment for breast cancer are anthracyclines and taxanes.

My auntie said that she had ‘chemo brain’ when undergoing treatment, which is a bit like ‘mommy brain’ during pregnancy and just after.

Yes, many patients refer to the cognitive side effects as ‘chemo brain’. These are real symptoms and include, forgetfulness, trouble concentrating and remembering things, trouble in multi-tasking and taking longer to finish tasks.

Don’t Worry, I have all of those without the chemo!!

8.4.1 Anthracyclines

Anthracyclines are first-line and adjuvant, single-agent chemotherapeutic agents used to treat metastatic breast cancer. Patients can not have had treatment with anthracyclines in the past. Because the specialist can adjust the dose, Anthracyclines are useful in breast cancer patients mild or moderate hepatic dysfunction.

Do some of these drugs have any adverse effects?

Anthracyclines are can weaken the pumping strength of the heart. That can lead to feeling tired and sometimes ankle swelling. But after a while, the heart recovers.

Anthracyclines have a side effect of cumulative cardiac toxicity, which may limit the duration of therapy.

In other words, the chemo nurses are pros, keeping a lookout for heart symptoms, and stopping the anthracyclines when necessary.

i. Doxorubicin

Doxorubicin (Adriamycin) is the most common anthracycline in the U.S. and can be given weekly or every three weeks.

ii. Epirubicin

Epirubicin (Pharmorubicin ®) is the most common anthracycline in Europe for treatment of metastatic breast cancer.

iii. Pegylated Liposomal Doxorubicin

Pegylated Liposomal Doxorubicin is a newer anthracycline that potentially has fewer cardiac side-effects.

Remember all you extraordinary ladies, ‘extraordinary people survive under the most terrible circumstances and they become more extraordinary because of it’.

8.4.2 Taxanes

Taxanes are first-line, single-agent chemotherapeutic agents used to treat metastatic breast cancer. They inhibit cell mitosis in rapidly proliferating cells, such as breast cancer.

i. Docetaxel

Docetaxel (Taxotere ®) may be given weekly or every three weeks and is often given with the steroid, dexamethasone, to reduce the side-effect of fluid retention.

There are so many different types.

The oncologists know these medicines, like their own children.

And they are proud of them, because they work. The drugs, that is, not the children.

ii. Paclitaxel (Taxol®)

Paclitaxel (Taxol®) Physicians will administer this drug weekly or every three weeks. Specialists usually administer Paclitaxel initially with steroid pre-medication to reduce the risk of allergic reactions.

iii. Nab-Paclitaxel

Nab-Paclitaxel (Abraxane®)

Has similar activity to other taxanes but without the incidence of allergic reactions.

8.4.3 Platinum-based Chemotherapy – Carboplatin and Cisplatin

Breast cancer specialists have used platinum-based chemotherapy, carboplatin and cisplatin for decades as a treatment for metastatic breast and gynecological cancer.

Oh Yes, this is the one that I’d choose – I would definitely go for the Platinum package.

Oh Jess! Pay attention, it’s not a ‘Platinum Package’! It’s a platinum-based chemotherapy treatment.

In the past, platinum-based agents were used as single-agents but there is now interest in using them as part of combination regimens. Clinicians are examining platinum-based agent for treating metastatic breast cancer in patients with BRCA1 mutations and for patients with triple-negative breast cancer (TNBC).

8.4.4 Other Chemotherapy Agents

There are a number of other chemotherapeutic agents that may be useful in the treatment of metastatic breast cancer.

i. Vinorelbine

Vinorelbine (navelbine ®) is a single-agent chemotherapy that is given intravenously once a week. It is associated with fewer side-effects and can be given to heavily pre-treated patients.

ii. Eribulin

Eribulin (Halaven®) is a newer chemotherapy agent for use in metastatic breast cancer. It inhibits micro-tubule formation in rapidly dividing cancer cells. In clinical trials, it has been found to have fewer side-effects.

iii. Gemcitabine

Gemcitabine (Gemzar ®) is used in combination with paclitaxel (Taxol®) as first-line chemotherapy in patients with metastatic breast cancer; it is also used as a single-agent therapy. Because gemcitabine crosses the blood-brain barrier, it is used to treat brain metastases.

iv. Ixabepilone

Ixabepilone is used for treatment in patients with taxane-resistance.

v. Etoposide

Etoposide (VP-16, Etopophos ®, Vepesid ®) is a chemotherapy that can be taken orally and is used in patients with more indolent forms of metastatic cancer.

References

Kesson, E.M., Allardice, G.M., George, W.D., Burns, H.J., Morrison, D.S. (2012). Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 344, e2718. (Retrieved November 26^th 2014)

Saini, K.S., Taylor, C., Ramirez, A-J., et al. (2011).Role of the multidisciplinary team in breast cancer management: results from a large international survey involving 39 countries. Ann Oncol 23, 853–859. (Retrieved November 26^th 2014): https://www.ncbi.nlm.nih.gov/pubmed/21821551

More references for this section are on this page

Patient Information

American Cancer Society. Breast Cancer. (Retrieved December 13 ^th 2014): http://www.cancer.org/cancer/breastcancer/

National Caner Institute (NCI) Learn About the Types of Surgery. (Retrieved November 26^th 2014): https://www.cancer.gov/types/breast/surgery-choices

More patient information for this section is on this page

This page is section 8A breast cancer treatment. Forward to 8B breast cancer treatment Back to 7B breast cancer staging.