Breast Cancer Treatment by Stage: Section 8.c.

CONTENTS:

8.8 Treatment for Early-Stage Breast Cancer (stage I, IIA or IIB [T2N0])
8.8.1 Breast Conserving Therapy (BCT)
8.8.2 Mastectomy for Early-Stage Breast Cancer
8.8.3 Axillary Lymph Node Examination
8.8.4 Radiotherapy for Early-Stage Breast Cancer
8.8.5 Adjuvant Therapy for Early-Stage Breast Cancer
i. Adjuvant Endocrine Therapy
ii. Adjuvant Chemotherapy
iii. Adjuvant Targeted Therapy

This page is 8C breast cancer treatment by stage. Forward to 8D breast cancer treatment. Back to 8B breast cancer treatment.

“…We take as a personal threat, the lump in every friend’s breast”.

And we feel it with deep shock, when we find a lump in our own breast.

8.9 Treatment for Locally Advanced Breast Cancer
8.9.1 Neo-adjuvant Therapy for Locally Advanced Breast Cancer
8.9.2 Surgical Treatment for Locally Advanced Breast Cancer
i. Mastectomy versus Breast Conservation Surgery (BCS)
ii. Axillary Lymph Node Surgery
8.9.3 Adjuvant Therapy for Locally Advanced Breast Cancer
8.10 Treatment for Stage IV Breast Cancer (Advanced or Metastatic)
8.10.1 Surgery for Stage IV Breast Cancer
8.10.2 Palliative Treatment for Stage IV Breast Cancer
8.11 Post-Treatment Surveillance and Prognosis
8.11.1 Recurrence of Breast Cancer
8.11.2 5-Year Survival in Breast Cancer
8.11.3 Prognosis for Synchronous and Multi-Focal Breast Cancer

After the shock, then the anxiety of waiting for doctors to diagnose and begin treatment.

8.8 Treatment for Early-Stage Breast Cancer (stage I, IIA or IIB [T2N0])

Patients with Ductal Carcinoma in Situ (DCIS) and Van Nuys Prognostic Index (VNPI) scores of 4, 5 or 6 may be considered for treatment with surgical excision only. Patients with intermediate scores of 7, 8, or 9 may be considered for treatment with radiation therapy or for re-excision if previous surgical margin width is less than 10 mm, provided that a re-excision is cosmetically feasible.

Patients with DCIS and VNPI scores of 10, 11, or 12 have been shown to exhibit high local recurrence rates, regardless of radiation therapy, and may be considered for mastectomy. (Gilleard et al., 2008). Breast cancer treatment is always individually tailored to each specific case and the treatment suggestions outlined above are research-based guidelines only.

VNPI sounds like VPL – all you ladies will know what I mean by that!

No, I don’t think it has anything to do with underwear, Jessica.

Is VNPI on the test?

There’s no test. You don’t need to know that.

Patients with early-stage breast cancer may undergo primary breast surgery (lumpectomy or mastectomy) and regional lymph node excision with or without radiation therapy (RT).

Adjuvant systemic therapy may be offered, following definitive local treatment, and is based on the characteristics of the primary breast cancer, such as tumor size, grade, number of involved lymph nodes, the status of estrogen (ER) and progesterone (PR) receptors, and expression of the HER2 receptor.

8.8.1 Breast Conserving Therapy (BCT)

Breast-conserving therapy (BCT) includes ‘lumpectomy’ or ‘breast-conserving surgery’ (BCS) plus radiation therapy (RT).

Breast-conserving surgery removes only the cancer and it’s surrounding tissue. It has replaced radical mastectomy as the preferred treatment in early stage breast cancer.

The aim of BCT is to give the patient the survival equivalent of a mastectomy but to provide a better cosmetic result.

Successful BCT requires a complete surgical excision of the breast cancer with negative excision margins, followed by moderate-dose, local radiotherapy (RT) to eradicate any residual tumor.

Factors that may exclude patients from BCT include:

A large breast tumor in relation to breast size.
Multi-centric breast cancer.
Diffuse ‘malignant’ micro-calcifications seen on imaging.
A previous history of thoracic radiotherapy.
Positive excision margins.

The use of neo-adjuvant therapy may be considered in women who are unsuitable for BCT.

8.8.2 Mastectomy for Early-Stage Breast Cancer

Mastectomy is performed for women who are not suitable for Breast Conserving Therapy (BCT) or who prefer to have removal of the breast.

It must be such a difficult decision to have to choose between having a breast lump removed or a mastectomy.

I know Jessica, but sadly a very personal decision that far too many women still have to face.

There are always the specialists to guide you with a few facts and figures and sometimes a bit of TLC too.

TLC did somebody just mention Tomatoes, Lettuce and Cheese? It’s a yes please from me.

8.8.3 Axillary Lymph Node Examination

The likelihood of breast cancer metastasis to the axillary lymph nodes depends upon the primary cancer type, grade, size, location and the presence of lymphatic invasion in the primary tumor.

In all patients presenting with breast cancer and who have clinically suspicious axillary lymph nodes, the pre-operative clinical work-up will include axillary ultrasound and possibly fine needle aspiration cytology (FNAC) of any suspicious lymph nodes or core needle biopsy (CNB).

Basically, whether or not the lymph nodes are involved in the disease is a very important factor and can tell us a lot about both the nature of the cancer and the risk of spread.

Any patient with positive axillary lymph nodes that are found pre-operatively will have axillary lymph node dissection during definitive surgery.

If the pre-operative assessment of the axillary lymph nodes is negative, a sentinel lymph node (SLN) only will be removed at the time of definitive surgery.

8.8.4 Radiotherapy for Early-Stage Breast Cancer

breast cancer by stage Radiotherapy is performed following Breast Conserving Therapy (BCT) or mastectomy in patients who are considered to be at greater risk of recurrence. ‘High risk’ tumors have a high grade (2 or 3), large size (≥ 2 cm), lymph node involvement and may have ‘high risk’ genes or gene profiles.

The decision to use post-mastectomy radiotherapy will affect the choice of the type of mastectomy and the type and timing of any breast reconstruction.

Survival studies have been done for women who have had axillary lymph node dissection and mastectomy, with and without radiotherapy. In a recent meta-analysis study of more than 3,700 women with invasive breast cancer who have had mastectomy and axillary lymph node clearance, there was a reduction in cancer recurrence in those who had received post-mastectomy radiotherapy (EBCTDG, 2014).

8.8.5 Adjuvant Therapy for Early-Stage Breast Cancer

‘Adjuvant therapy’ for breast cancer is given after surgery in cases that are more likely to recur or relapse. Before deciding to give adjuvant therapy, the oncologist or surgeon takes an evidence-based approach for each patient to improve symptoms and survival.

‘Neo-adjuvant therapy’ is given before surgery or definitive treatment for breast cancer The most common reason for neo-adjuvant therapy is to reduce the size of the tumor, to facilitate breast surgery.

Oh, Some of these adjuvant therapies have quite rough side effects, I think.

Yes, that is true.

Adjuvant therapy includes chemotherapy, endocrine therapy and /or ‘targeted’ biologic therapy.

The tissue characteristics of the breast cancer will determine which patients may be likely to benefit from the different types of adjuvant therapy.

i. Adjuvant Endocrine Therapy

Patients with estrogen receptor (ER) and progesterone receptor (PR) –positive breast cancer may benefit from the use of hormone therapy.

What on earth do those troublesome hormones, that cause me so much strife, have to do with a breast lump?

Hormone receptors for both estrogen and progesterone are proteins, found in and on breast cells, that pick up signals that tell the cells to grow. A cancer can have these hormonal receptors and that means it may grow more rapidly.

I was told that I have hormonal issues, I don’t think that’s true, it’s everybody around me that has an attitude problem.

ii. Adjuvant Chemotherapy

Adjuvant chemotherapy may or may not be added to hormone therapy or targeted therapy, in patients who have breast cancer with ‘high risk’ factors for recurrence.

Patients with triple-negative breast cancer (TNBC) which is ER, PR and HER2 negative, may be offered chemotherapy and radiotherapy.

iii. Adjuvant Targeted Therapy

Patients with HER2-positive breast cancer can benefit from treatment with a HER2 targeted drug such as trastuzumab (Herceptin®), with or without pertuzumab (Perjeta®). If the patient’s tumor is > 1 cm in diameter. However, the treatment of small breast cancers that measure ≤ 1 cm in diameter is controversial, with any benefit remaining unproven.

8.9 Treatment for Locally Advanced Breast Cancer

Locally advanced breast cancer is non-metastatic, with the staging classification as stage IIB, IIIA to IIIC (T3, N0) but has a high risk of local recurrence and metastasis. This is why the current management of locally advanced breast cancer combines local surgical treatments with systemic treatments for most patients.

The multiple therapeutic approaches for each patient are made possible by the co-ordinated approach of the Multi-disciplinary team (MDT).

Some patients may be considered for primary surgery, but most will be treated with neo-adjuvant therapy first.

Life tip #1: When nothing is going right..go to bed.

8.9.1 Neo-adjuvant Therapy for Locally Advanced Breast Cancer

‘Neo-adjuvant therapy’ is given before surgery or definitive treatment for breast cancer The most common reason for neo-adjuvant therapy is to reduce the size of the tumor, to facilitate breast surgery and to increase the chances of successful breast conservation surgery (BCS)

Studies have shown that neo-adjuvant therapy for locally advanced breast cancer can increase long-term disease-free survival and increase overall survival when compared to primary surgery followed by adjuvant therapy.

I’m confused, what’s the difference between neo-adjuvant and adjuvant therapy?

Neo-adjuvant means “lets add a special treatment BEFORE the main treatment”. And Adjuvant means, “AFTER the main treatment, we will add some special treatment later”.

The choice will be between chemotherapy or endocrine therapy as neo-adjuvants. For patients with HER2 –positive breast cancer, a HER2 targeted agent (trastuzumab [Herceptin®] with or without pertuzumab [Perjeta®)]) may be given with chemotherapy.

HER2 or Human Epidermal Growth Factor Receptor 2 is a protein caused by a gene mutation in cancer cells that promote growth.

The use of endocrine therapy in the neo-adjuvant role in patients with ER- and PR- positive breast cancer is controversial but may be considered if there are clinical contraindications to the use of chemotherapy.

8.9.2 Surgical Treatment for Locally Advanced Breast Cancer

Surgery is advised for all patients following neo-adjuvant therapy for locally advanced breast cancer. Even if there is a complete radiological or clinical response, surgery will be done.

i. Mastectomy versus Breast Conservation Surgery (BCS)

Following neo-adjuvant therapy, the surgical choice will be to perform either mastectomy or breast conservation surgery (BCS). The decision will be made based on treatment response and the size of the residual tumor in relation to breast size.

Patients with large, T4 breast tumors will usually undergo mastectomy.

If you’re facing, or have already had, surgery remember that ‘scars are not injuries. A scar is a healing. After injury, a scar is what makes you whole’.

ii. Axillary Lymph Node Surgery

Following neo-adjuvant surgery, all patients with locally advanced breast cancer will have a surgical evaluation of the regional lymph nodes.

8.9.3 Adjuvant Therapy for Locally Advanced Breast Cancer

Post-operative systemic adjuvant therapy is determined by the clinical status of the patient and the characteristics of the breast cancer.

Patients who did not receive pre-operative neo-adjuvant therapy will receive post-operative adjuvant therapy.

Patients with breast tumors that are ER and PR+ positive may receive hormone therapy post-operatively to reduce the risk of recurrence. The type of hormone therapy given depends upon menopausal status of the patient.

Patients with breast tumors that are negative for ER and PR may not receive adjuvant hormone therapy but may proceed to ‘post-treatment surveillance.’

Life tip #2: Life is not a fairytale, if you lose a shoe you’re probably tipsy.

Patients with HER2-positive breast cancer may receive a year’s post-operative treatment with trastuzumab (Herceptin®) instead of chemotherapy.

Patients who have been given pre-operative neo-adjuvant hormone therapy may continue with this as post-operative neo-adjuvant therapy, with or without adjuvant chemotherapy.

8.10 Treatment for Stage IV Breast Cancer (Advanced or Metastatic)

With the implementation of the breast screening program, it has become rare for patients to present with Stage IV metastatic breast cancer. This presentation is now seen in less than 5% of newly-diagnosed patients.

Patients with metastatic breast cancer are unlikely to be cured of their disease. Complete remissions when systemic chemotherapy is used are uncommon, and only a fraction of complete responders remain progression-free for a prolonged period.

The rarity of stage IV breast cancer is really good news and shows the importance and effectiveness of the breast screening program.

For patients diagnosed with stage IV breast cancer, the median survival is 18 to 24 months, although the range can be from only a few months to several years.

In 2012 the 5 year survival rate for women diagnosed with Stage IV breast cancer was 22%. For a full, up-to-date post click on the following link Survival Rates for Stage IV breast cancer.

Remember, survival rates are general and each case is individual.

If you’re facing a Stage IV diagnosis belief in recovery is essential, as is a good diet and lots of sleep.

Suits me. The only words I understand in the morning are, ‘go back to sleep’ and ‘bacon’.

There is a sub-group of women with stage IV, metastatic breast cancer who have a low-grade and small-volume metastatic cancer; this is known as a ‘low tumor burden’ or ‘indolent metastatic disease.’

8.10.1 Surgery for Stage IV Breast Cancer

Follow-up studies have shown that between 5 % and 10 % of patients with stage IV metastatic breast cancer survive for 5 years or more and between 2 % and 5 % become long-term survivors (Greenberg et al., 1996). These long-term survivors with stage IV breast cancer tend to be young, with limited metastatic disease. For these patients, combined therapy, including surgery, may provide an improved long-term, progression-free survival (PFS) than chemotherapy alone.

‘Long-term survivor’ – now that’s a phrase any woman should be proud to be called.

8.10.2 Palliative Treatment for Stage IV Breast Cancer

Palliative treatment is given when curative treatment is not possible. The goals of palliative treatment are as follows:

Control of symptoms;
Prolonged survival;
Improved quality of life (QOL).

Once the diagnosis of breast cancer has been made on cytology or biopsy and tumor metastases have been identified, systemic treatment approaches may begin.

However, resection of the primary tumor in the breast in stage IV breast disease can provide prevent or limit bleeding, ulceration or infection (Carmichael et al., 2003).

Treatment of stage IV metastatic breast cancer may include the following:

Hormone therapy and/or chemotherapy, with or without trastuzumab (Herceptin®).
Targeted therapy with trastuzumab (Herceptin®) and Pertuzumab (Perjeta®) combined with chemotherapy.
Tyrosine kinase inhibitor (TKI) such as lapatinib (Tykerb®) with trastuzumab (Herceptin®).
Surgery with radiation therapy for pain control.
Bisphosphonate therapy to reduce bone pain due to bone metastases.
Participation in clinical trials for new targeted therapy, chemotherapy or hormone therapy.

8.11 Post-Treatment Surveillance and Prognosis

Breast cancer patients who have completed treatment will undergo regular clinical follow-up to exclude symptoms and signs that may indicate recurrence or metastasis.

Annual mammography will also be performed in patients who have had breast-conserving therapy (BCT).

Having a mammogram is stressful at the best of times but waiting for the results, especially after cancer treatment, must cause a lot of anxiety.

I always take a female friend and make an annual outing of having a mammogram. Book your mammograms and go together for a bit of mutual support is my advice to all women.

Oh yes, and after, lunch….and shopping….and…..

Exactly! Now you’re getting it. Don’t forget to repeat the whole process on getting the results (whatever they turn out to be).

The routine use of breast magnetic resonance imaging (MRI) or whole-breast ultrasound is not usually recommended for breast cancer survivors because of the lack of evidence of patient benefit.

Patients with early-stage breast cancer have a better prognosis than those with locally advanced disease.

Younger age (< 35 years) and older age (≥ 65 years) at diagnosis are associated with a poorer prognosis (van de Water et al., 2012).

There is no evidence that follow-up laboratory tests or whole-body imaging in breast cancer patients, who have survived and who are asymptomatic, is beneficial.

Life tip #3: If the music is good….dance.

8.11.1 Recurrence of Breast Cancer Recurrence

Studies have shown that some breast cancer recurrences occur much later than 5 years; the recurrence rates for stage I, II and III after 5 years and 10 years have been reported as 11 % and 19 %, respectively (Brewster et al., 2008). In general terms the prognosis for patients with recurrent breast cancer has improved over the last 25 years. (Giordano et al., 2004)

That must be really tough – to have beat cancer once only for it to come back again many years later.

On the other hand….if you have beaten it once…you know you can beat it twice!

On diagnosis of recurrent breast cancer that returns after treatment and is found in the breast or chest wall, may be treated in the following ways:

Modified radical mastectomy, and/or
Radiation therapy.
Chemotherapy and/or
Hormone therapy.
Targeted therapy and/or
Trastuzumab (Herceptin®) with
Chemotherapy

8.11.2 5-Year Survival in Breast Cancer

According to TNM stage, studies have calculated the 5-year relative survival rates for breast cancer by stage.

Figure 8.2 5 Year Relative Percentage Survival Rate by Breast Cancer Stage 2012 data

breast cancer treatment by stage

The above bar graph is the latest information that we could find on breast cancer 5 year relative survival rates by stage of the disease. The figures were taken from the National Cancer Institute SEER Cancer Statistics Review for 2012.

8.11.3 Prognosis for Synchronous and Multi-Focal Breast Cancer

For patients who present with synchronous breast cancer (bilateral breast cancer diagnosed simultaneously), the prognosis has been recently shown to be no different from that of patients presenting with unilateral breast cancer.

For patients who present with multi-focal breast cancer (invasive tumors identified within the same breast quadrant) or with multi-centric breast cancer (invasive tumors identified in separate breast quadrants) some reports have shown poorer and others have shown no difference in prognosis (Nichol et al., 2011).

“Fight each round take it on the chin and never never never ever give in.” Lyrics from Olivia Newton John’s song ‘Why Me?’ her personal tribute to her own battle with breast cancer.

References

Giordano, S.H., Buzdar, A.U., Smith, T.L., et al. (2004). Is breast cancer survival improving? Cancer 100(1), 44. (Retrieved November 26^th 2014): https://www.ncbi.nlm.nih.gov/pubmed?term=14692023

Lynch, S.P., Lei, X., Chavez-MacGregor, M., et al. (2012). Multifocality and multicentricity in breast cancer and survival outcomes. Ann Oncol. 23(12), 3063. (Retrieved November 26^th 2014):
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3501230/

More references for this section are on this page.

Patient Information

Centers for Disease Control and Prevention. Breast Cancer. (Retrieved December 5 ^th 2014). http://www.cdc.gov/cancer/breast/

National Caner Institute (NCI) Breast Cancer Treatment Patient Information: (Retrieved November 26^th 2014): https://www.cancer.gov/types/breast/patient/breast-treatment-pdq

More patient information for this section is on this page.

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