For the creation of cancer treatment specialists from various departments like surgical, medical oncology, radiation and chemotherapy and even palliative care work together to bring about a comprehensive plan. This is referred to as a multidisciplinary team. For women older than 65 years, even a geriatric oncologist will be involved. The behavior and biology of breast cancer helps in charting out the exact plan.
Surgery is usually recommended at an early stage of invasive breast cancer. For larger ones or the one where the cancer is spreading rapidly a systemic treatment having chemotherapy or hormonal therapy before undergoing a surgery is recommended.
Surgery: The types of surgeries involved in breast cancer treatment are outlined below:
Lumpectomy: The tumor and a small cancer free margin of healthy tissue surrounding the tumor is removed. Here most of the breasts remain intact. For the remaining region radiation therapy is recommended if the tumor was the invasive type.
Mastectomy: In this case, the entire breast has to be removed surgically and there can be quite a few types of surgeries. Patients can discuss with the surgeon to preserve the skin making it a skin-sparing mastectomy or the nipple called a total skin sparing mastectomy.
Removal of lymph nodes and their analysis: In some cancers the cells could be found in axillary lymph nodes. It is pertinent to find out whether any of the lymph nodes around the breast contain cancer or not. It is the information used for determining treatment and prognosis.
Sentinel lymph node biopsy: The lymph nodes that receive drainage from the breasts are removed under the armpit. In this way multiple lymph node removal can be avoided and associated side effects can be avoided. Usually lymphedema can happen where there is some numbness, trouble in hand movement and swelling can be observed. However, if they continue it spoils the quality of life. The nodes are observed by a pathologist for cancer cells. A dye is usually injected to track the sentinel node which is the first that changes color. If the sentinel node is found to be cancer free, then mostly all other nodes will also be free of that and further nodes are not required to be removed.
Axillary lymph node dissection: Many lymph nodes are removed from the underarms and examined for traces of cancer. With early stage breast cancer, an axillary lymph node dissection is not required.
Reconstructive plastic surgery: Breast reconstruction is considered for women who have undergone mastectomy. In this kind of a surgery tissues can be taken from another part of the body or synthetic implants may be used. A plastic surgeon is involved and if required can do the reconstruction right at the time of mastectomy called immediate reconstruction or the patient may undergo the surgery sometime in future.
Radiation therapy: High energy x-rays or other particles are used to destroy the cancer cells in breasts. The external beam radiation therapy where therapy happens through a machine kept external to the body is most common. A probe is also used in the operating and it is called intraoperative radiation therapy. In another kind a radioactive substance or source is placed into the tumor and this is called brachytherapy. The latter two procedures are not so commonly used. This kind of treatment usually brings down the rate of recurrence. The therapy can be given before (neoadjuvant radiation therapy) and after a surgery (adjuvant radiation therapy).
It can include side effects like swelling of the breast, fatigue, hyperpigmentation or skin discoloration in the skin where radiation was received. For these, topical medication can bring about relief. Earlier the heart was at risk from radiation therapy, but nowadays that has been taken care of.
Radiation therapy has to be continued with a very fixed set of schedules and can be of the following types.
Partial breast irradiation: It is directed only to the tumor region and not to the entire breast. It is usually done after a lumpectomy. The safety and effectiveness of the technique are still being looked into. It can also be coupled with brachytherapy. This is useful for smaller and lesser aggressive kinds of tumors.
Intensity modulated radiation therapy: This is a more advanced form compared to external beam radiation therapy. The radiation is spread evenly throughout the breast and the side effects are usually low and is useful for women with medium or large breasts. This kind of therapy is not recommended for everyone.
Proton Therapy: This makes use of x-rays to kill cancer cells. At very high energy they are given to destroy the cancer cells. The radiation dose can be reduced in this case compared to photon therapy which is more commonly used.
Radiation therapy is usually advised to be stopped for women who are more than 70 and have an early stage tumor to deal with.
Systemic therapy: This treatment is usually taken through vein or mouth and then it reaches the bloodstream to attack the cancer cells. For early stage and locally advanced breast cancer there are three kinds of therapies available and they are chemotherapy, hormonal therapy and targeted therapy.
Chemotherapy: The use of drugs to attack cancer cells is called chemotherapy. This aims to end the growth and division process of cancer cells. Intravenous tube is placed and an injection is given under the skin or under the muscle to inject the drug or the patient is asked to swallow a capsule or pill directly.
It can be given just before a surgery to reduce the size of a large tumor and given after surgery to reduce the chance of tumor reappearing. Some of the common drugs used for the treatment are:
- Carboplatin (Paraplatin)
- Capecitabine (Xeloda)
- Cisplatin (Platinol)
- Cyclophosphamide (Neosar)
- Doxorubicin (Adriamycin)
- Docetaxel (Taxotere, Docefrez)
- Epirubicin (Ellence)
- Pegylated liposomal doxorubicin (Doxil)
A patient can receive one type of drug or a combination of many drugs during chemotherapy. Side effects of chemotherapy are too many like risks of infection, hair loss, loss of appetite, diarrhea, vomiting and it all depends on the dosage and frequency. Most of them usually die down after the treatment is over and the woman slowly gets to lead a normal life.
Hormonal therapy: This is an effective option for those whose tumors test positive for either progesterone or estrogen receptors. They make use of hormones for the fueling of their growth. Blocking them can prevent breast cancer recurrence. It can be again given before surgery to make it easy or given after surgery.
Tamoxifen: This drug can block estrogen hormone from binding to the cancer cells. This is effective in lowering the recurrence chance. The pill can be taken daily by mouth. Vaginal dryness and hot flashes are some of the common side effects.
Aromatase inhibitors (AIs): It is effective in reducing the amount of estrogen made in the tissues. They also change weak male androgen hormones into estrogen when ovaries stop making them after menopause is reached by women. They are mainly in the form of pills that must be taken. The side effects include muscle and joint pains and hot flashes with dryness experienced in vagina. This is usually not recommended to those who have already reached their menopause.
Targeted therapy: In this kind of therapy the proteins, tissue environment and specific cancer genes are targeted which helps in growth of cancer and survival. Tests will be conducted on the specific proteins and genes to identify them.
Bone modifying drugs: These kinds of drugs help in the destruction of bone and aids in strengthening them further. This is for those kinds of breast cancer that have started destruction of bone. Some of the drugs like Bisphosphonates are useful for tackling recurrence as well.
Systemic therapy concerns for the patients who are old: Older patients are usually at a risk of contracting heart ailments after they have received combined chemotherapy.
Palliative care is very important from the early stage since it prepares the patient and her family members to stay strong and be in a positive state of mind. It can make use of relaxation techniques, counselling, physical and musical therapies, and yoga to improve the quality of life.
Palliative care usually starts before the treatment and it helps prepare the patient with the facts and real outcome scenario of their treatment options.