Breast Cancer

Surgical Treatment Options for Breast Cancer

Mastectomy was once done for all types of breast cancer until research showed that a less invasive procedure could be done for smaller tumors. Now, many women can choose between lumpectomy and mastectomy because the survival rates for the two options are essentially the same. In addition, reconstructive surgery can help women have a more “balanced” look without the need for breast prostheses.

Lumpectomy

Lumpectomy is also known as breast-conserving or breast-sparing treatment because only the tumor (lump) is removed, along with a small margin of healthy breast tissue surrounding the lump, leaving the breast intact. It is imperative that the breast cancer is removed completely and the surgical margins are clear (have no evidence of cancer). Sometimes, it is necessary to perform a second excision to achieve clear margins. Some axillary lymph nodes (from under the arm) may also be removed. Lumpectomy is usually done for ductal carcinoma in situ (DCIS) or for stage I or II invasive breast cancer (a tumor that is less than 5 centimeters [about 2 inches]).

A lumpectomy is not usually recommended for women who have larger tumors. However, if a woman has a strong desire to save the breast, neoadjuvant chemotherapy (given before surgery) is recommended to shrink the tumor to a small enough size that lumpectomy can be safely done while achieving clear margins.

Mastectomy

A mastectomy is done for larger tumors, especially those that have spread to nearby lymph nodes. It may be necessary to perform a mastectomy after a lumpectomy if the pathologist has reported that the surgical margins are positive; that is, the breast cancer was not removed completely. In other situations, some women with a small breast cancer may wish to have a mastectomy because it offers greater peace of mind about recurrence or because they want to avoid radiation therapy.

Advances in surgical techniques and knowledge about breast cancer have led to mastectomies that are much less extensive and disfiguring than those done several decades ago. Mastectomy once meant removal of the entire breast with cancer, the chest wall muscles underneath the breast, and all the axillary nodes. This type of mastectomy is now called a radical mastectomy, and it is done only for extensive tumors or tumors that have invaded the chest wall. More often, a total or complete mastectomy is done, which preserves the chest wall muscles.

Removal of Lymph Nodes (Axillary Dissection)

Removal of lymph nodes (known as partial axillary dissection) is done to remove nodes to which cancer has spread. The removal of these nodes helps to prevent symptoms in the future as well as further spread of the cancer. Lymph nodes are usually removed only when evidence of cancer has been demonstrated by evaluation of a biopsy specimen of a lymph node. In general, at least 10-15 lymph nodes are removed, but the actual number removed can range considerably.

Sentinel lymph node biopsy has now become the preferred method to determine whether cancer has spread to the lymph nodes in women who do not have any evidence of this based on the clinical examination or findings of imaging studies. The rationale of sentinel lymph node dissection is that cancer is most likely to travel first to the node closest to the tumor, known as the sentinel node. If no cancer cells are detected on examination of the sentinel node or the nodes near it, a partial axillary dissection — along with its side effects — can be avoided, as cancer is unlikely to be present in nodes that are farther away. If cancer is detected in the sentinel lymph node, the surgeon will usually perform a partial lymph node removal for both staging and treatment purposes.

Other Surgery

Other types of surgery may be appropriate for women with breast cancer, especially those in whom hereditary breast and ovarian cancer syndrome has been identified (see page 14). These women have a higher-than-average risk for ovarian cancer or cancer in the contralateral (opposite) breast and may choose to have prophylactic (preventive) removal of the ovaries (ovarian ablation) or of the contralateral breast as a precaution against the future development of cancer. Prophylactic removal of the ovaries or the breast has substantial side effects, such as infertility (the inability to have children), potential risks to bone and heart health, early menopause, and negative body image. These side effects must be weighed against the potential benefits of the surgery.

Breast Reconstruction

Several types of operations are now available to help rebuild the breast after mastectomy, and approximately three-quarters of women who have mastectomy choose to have reconstructive surgery. Reconstruction is done after lumpectomy only when the surgery will cause the breast to appear significantly different from the other breast. Breast reconstructive surgery should be done by an experienced plastic surgeon.

Types of Reconstruction

Breast reconstruction may involve the use of a breast implant, a flap of tissue (usually containing skin, fat, muscle, and blood vessels) from elsewhere in your body, or a combination of these two options. Tissue flaps are referred to by the muscle or other component that makes up the flap (Figures 1 and 2). Flaps can be taken from your lower abdomen (a TRAM [transverse rectus abdominis muscle] flap, DIEP [deep inferior epigastric perforator] flap, or SIEA [superficial inferior epigastric artery] flap), the upper part of your back (a latissimus dorsi flap), the buttock (SGAP [superior gluteal artery perforator] flap), or the inner thigh (a TUG [transverse upper gracilis] flap). The two most commonly performed procedures are the TRAM and latissium dorsi flaps. The choice of a tissue flap depends on several factors, including the size of the breasts, the body type, and preferences regarding scars. Your plastic surgeon can help describe the advantages and disadvantages of each type of tissue flap. Some women prefer to have reconstruction with the use of implants, which involves less surgery than reconstruction with a tissue flap. When an implant is used, the breast tissue must be expanded (stretched) to accommodate the implant. One option is to use an adjustable implant, which can be expanded in your plastic surgeon’s office as you heal from your mastectomy. Alternatively, a tissue expander can be inserted, which slowly expands breast tissue, and a permanent implant is inserted in a second operation (Figure 3). Implants may be filled with either saline or silicone. Again, your plastic surgeon can explain the advantages and disadvantages of each type of implant.

Timing of Reconstruction

Breast reconstruction can either be done immediately — at the same time as mastectomy — or later (within months after mastectomy). Immediate reconstruction can be done for early-stage breast cancer, but it is usually best to wait for reconstruction when breast cancer is more advanced. In such cases, the longer healing time needed for reconstructive surgery would delay the start of chemotherapy. Also, if there is a potential need for radiation therapy, it is best to wait until that treatment has been completed. If you are to have a mastectomy and think you will want reconstructive surgery, it is best to discuss your choice with your cancer surgeon and a plastic surgeon before the mastectomy so they can properly plan your treatment, even if the reconstructive surgery will not be done until later.

Reconstructive surgery cannot be done for all types of breast cancer. Women who do not want or cannot have reconstructive surgery can be fitted with a breast prosthesis. This prosthesis is a breast form (made of artificial materials) that you put in your bra to make your breast look natural and balanced.

Breast reconstruction is a personal decision and requires much consideration. You should talk to members of your health care team about the various options, and it is especially helpful to learn about other women’s experiences with reconstruction.

Chemotherapy

Chemotherapy, also known as systemic therapy and cytotoxic chemotherapy, is the use of strong drugs to kill cancer cells. Chemotherapy is most often used as adjuvant therapy, or treatment given after primary treatment (usually surgery), and may also be used as neoadjuvant therapy, or treatment given before primary treatment. Chemotherapy as primary treatment is usually reserved for metastatic disease, as the drugs will reach other parts of the body where cancer cells may be located.

Adjuvant Chemotherapy

The purpose of adjuvant chemotherapy is to destroy cancer cells that may remain after surgery or that may be too small to be detected with laboratory testing or imaging studies. Adjuvant chemotherapy decreases the risk of recurrence, which can help extend survival. Adjuvant chemotherapy is typically recommended for women in whom cancer was found in lymph nodes and for women who have aggressive types of breast cancer. The issue of whether to use adjuvant therapy is often challenging for women with early-stage disease, as studies have shown that chemotherapy offers benefit to some women but not to others. Thus, adjuvant therapy is most appropriate for women with a high risk of recurrence (greater than 10%) and can be safely avoided for women with a low risk.

In deciding whether adjuvant chemotherapy is the best option for your particular tumor, your doctor may use one or more of several tools available to help predict the likelihood of cancer recurrence. Adjuvant! Online is a Web-based decision-making aid that estimates the risk of recurrence. Two new tools are now available to help women and their doctors determine the risk of breast cancer recurrence. These tools, Oncotype Dx and Mammaprint, provide a profile of the activity of genes in the tumor; these genes are ones that research has shown to be related to breast cancer recurrence. The Oncotype DX assay has been recommended by both the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) for predicting the risk of recurrence for women with newly diagnosed estrogen receptor (ER)-positive breast cancer that has not spread to lymph nodes. In general, women with a low risk of recurrence according to the assay can avoid the side effects of chemotherapy and be treated safely with hormone therapy (tamoxifen or aromatase inhibitors) alone. Women with a high risk can be treated with adjuvant chemotherapy to help reduce the risk of recurrence and can be monitored closely to help ensure early intervention if cancer does recur.

Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy may be used to shrink a tumor that is inoperable so that it can be surgically removed. In addition, a woman with a large breast tumor may choose to have neoadjuvant therapy to shrink the tumor enough to allow for breast-conserving surgery rather than mastectomy.

How Chemotherapy is Given

Chemotherapy is usually given as a combination of two or three drugs, sometimes given together and sometimes given after one another (sequentially). Most chemotherapy drugs for breast cancer are given through an injection in a vein (intravenously), with the infusion lasting 30-90 minutes, depending on the drug. Chemotherapy is typically given in the doctor’s office or an outpatient clinic.

Chemotherapy is given in cycles, which consist of a treatment period (usually 1 day) followed by a recovery period (usually 3 weeks). The recovery period allows the noncancer cells in your body to repair themselves from damage caused by chemotherapy before you receive more treatment. Some cycles may be shorter or longer (such as 7 or 28 days). A typical course of treatment is four to six cycles, but the number of cycles can vary depending on the type of treatment and the response.

What Chemotherapy Drugs Are Used

Many chemotherapy drugs are available, and some may be more effective treatment options for an individual breast cancer. Choosing a chemotherapy regimen involves considering not only whether there is benefit but also how much benefit in relation to the side effects. In addition, certain drugs or types of drugs may be more effective for tumors with specific characteristics. Researchers continue to study various combinations of chemotherapy drugs, as well as the genetic make-up of tumors, to determine which regimens offer the best chance of a long period of disease-free living and overall survival for women with specific types of tumors.

Learning the names of chemotherapy drugs can be challenging because some are better known by their generic name, while others are better known by their trade name (Tables 1 and 2). But names of drugs and the abbreviations for combinations soon become familiar to women with breast cancer.

Table 1. Names of Chemotherapy Drugs

Table 2. Chemotherapy Regimens

Radiation Therapy

Radiation therapy (also known as radiotherapy) has an important role in the treatment of breast cancer. Radiation given from a machine outside the body, known as external-beam radiation therapy, is the most common type of radiation therapy used for breast cancer.

When Radiation Therapy Is Given

Radiation therapy is usually used after surgery, with a goal of decreasing the likelihood of cancer recurrence by destroying any cancer cells that may have been left in the surgical area. Radiation therapy is almost always done after lumpectomy to make sure that any remaining cancer cells are destroyed. Studies have shown that women with a small tumor who have a lumpectomy followed by radiation therapy live as long as women who have mastectomy. Radiation therapy is considered to be part of primary therapy when given after lumpectomy.

Radiation therapy can be safely avoided by many women who have mastectomy. Radiation therapy after mastectomy, known as adjuvant radiation therapy, is typically recommended for women at high risk for cancer recurrence. The risk of recurrence is determined primarily by the number of involved lymph nodes, as well as the size of the tumor and whether cancer cells were found in the margin of healthy tissue around the tumor. For women at high risk, adjuvant radiation therapy can reduce the risk of recurrence by as much as 70%. Decision-making is more challenging for women who have a moderate risk for recurrence; these women should talk to their doctors about the benefits and risks of radiation therapy to help determine if this type of treatment is the best option.

Women with metastatic breast cancer may have radiation therapy to shrink metastatic tumors in other parts of the body and/or to relieve symptoms caused by metastatic tumors. Radiation therapy given solely to relieve symptoms is known as palliative radiation. The timing of radiation therapy varies with respect to other types of treatment. If adjuvant chemotherapy is part of the treatment plan, it is usually the first treatment given after surgery; radiation therapy would then begin about 2-4 weeks after the last dose of chemotherapy. Radiation therapy is given directly after surgery when chemotherapy is not part of the treatment plan or was administered before surgery. Radiation is usually given before hormone therapy is begun.

How Radiation Therapy Is Planned and Given

A radiation oncologist will have oversight of your radiation therapy. The radiation oncologist will determine the dose of radiation to be used at each session and will carefully calculate the optimum delivery of x-ray beams to target the tumor while minimizing the effect of radiation on nearby healthy tissue.

Before you begin actual treatment, your radiation oncologist will meticulously plan your radiation therapy in a planning session. During this session, the radiation oncologist will work with a radiation technologist to map out the area that needs treatment by identifying the part of your body to be treated. They will position your body precisely on the radiation table and then use a special x-ray machine, called a simulator, to help set up the treatment fields, or the areas that will receive radiation. The radiation oncologist will use special ink to mark the corners of the treatment fields to ensure that the exact area is treated in every radiation therapy session.

Some women may benefit from intensity-modulated radiation therapy (IMRT), an advanced way of delivering x-ray beams. With IMRT, the intensity of the radiation delivered to the breast is varied and targets the tumor more exactly. IMRT may be especially helpful for reducing the risks of skin-related side effects (peeling, burns), which can be more common for women with larger breasts. Once radiation therapy begins, it is usually given 5 days a week for 3-7 weeks; each treatment session lasts 30 minutes or less and is painless. Radiation therapy for breast cancer will not make you radioactive.

Research on Radiation Therapy

Cancer investigators continue to explore ways to make radiation therapy for breast cancer more effective and/or more convenient for women with the disease. Accelerated partial breast irradiation, also known as brachytherapy, involves implanting a small catheter (plastic tube) in the area where lumpectomy was done. A tiny radioactive seed inserted into the catheter will deliver the exact amount of radiation directly to the tumor area. This approach requires fewer treatment sessions, with treatment usually given twice a day for only 5 days. Accelerated partial breast irradiation is still being studied in clinical trials to determine the long-term effects and the survival rates compared with standard radiation therapy. The American Society for Radiation Oncology has recommended that the use of this type of radiation therapy be restricted to women who are 60 years or older with early-stage, invasive breast cancer.

Other studies, done primarily in Canada and the United Kingdom, have shown that shorter radiation therapy regimens (also known as schedules) with higher daily radiation doses can control breast cancer recurrence as effectively as the standard schedules among women who have no clinical evidence of cancer in the lymph nodes. Again, the outcomes for this approach are still being investigated.