Breast Cancer

Treatment Options

Receiving a breast cancer diagnosis can be overwhelming and can lead to many emotions, questions and concerns. The promising news is that you are not alone. A skilled medical team will help you face this diagnosis by developing a specific treatment plan for you. Your plan will be determined by the stage of your disease, the tumor’s subtype, genetic markers, gene mutations, hormone receptors, menopausal status, your age and overall health. Ask your doctor questions so that you completely understand your specific cancer, your tumor’s characteristics and the treatment options available to you.

Many treatment options exist for breast cancer including surgery, radiation therapy, chemotherapy, hormone therapy and targeted therapy. Discuss all of your options, including clinical trials, as well as all treatment risks and benefits with your doctor.

Surgical Options

Some form of surgery is the most common treatment for breast cancer and is often the primary one for Stages 0-III. For patients diagnosed with advanced breast cancer/Stage IV disease, the treatment plan may be non-surgical, such as chemotherapy, hormone therapy and/or targeted therapy. These options can shrink tumors or prevent their growth for some period of time, improving quality of life.

Breast cancer surgery can be categorized as either breast-conserving, also called breast-sparing or breast-saving (lumpectomy), or breast-removing (mastectomy).

Lumpectomy

Lumpectomy is a breast-conserving or breast-sparing treatment because only the tumor is removed along with a small margin of normal-appearing tissue around the tumor. It is used for early-stage breast cancers detected as small tumors (see Figure 1). This includes Stages 0, I and II. If your tumor is relatively small and you wish to spare as much of your breast as possible, this procedure may be an option. Radiation therapy is almost always delivered after lumpectomy to kill the microscopic cancer cells that may remain. It is important for you to discuss the likely cosmetic outcome with breast-conservation surgery because radiation can cause some shrinkage of the breast. Patients that have a relatively larger tumor compared to their overall breast size may end up with a less satisfactory cosmetic result following a margin-negative lumpectomy and breast radiation. Other features that can influence breast conservation options include tumor location (cancers located immediately beneath the nipple may require sacrifice of the nipple-areolar skin with the lumpectomy); baseline mammogram (patients with multiple cancers located far apart in the breast may require mastectomy); and other medical conditions (patients that have received prior radiation to the breast).

Mastectomy

A mastectomy is often performed to remove larger tumors, especially when they occur in a smaller breast (see Figure 2). Several types of mastectomy exist, including total mastectomy, radical mastectomy, modified radical mastectomy and others. Total mastectomy is the surgical removal of the whole breast. A modified radical mastectomy means that the total mastectomy is being performed (with the chest wall muscles left in place) along with removal of a block of underarm/axillary lymph node tissue. Most mastectomy patients will be candidates for breast reconstructive surgery performed by plastic surgeons, which often is performed immediately after the mastectomy surgery under one anesthesia. Mastectomy patients undergoing immediate reconstruction may be eligible for enhanced cosmetic approaches, such as skin-sparing or nipple-sparing mastectomy. After the incisions have healed, the patient undergoes outpatient radiation treatment to the breast, usually over a six-week period.

Chronic nerve pain, known as post-mastectomy pain syndrome (PMPS) is a possible side effect from a mastectomy. The most common areas to feel this pain are in the chest, armpit and/or arm. Symptoms of PMPS include tightness, burning, tingling or itching in these areas. In addition, the surgical site may also have numbness or be extra sensitive.

Tell your doctor about your pain or disability so you can begin to receive treatment. Keep your doctor informed about your pain level to ensure your PMPS is being managed as effectively as possible. PMPS will not go away without treatment. Your doctor may recommend the following.

  • Physical therapy to preserve range of motion and reduce stiffness, followed by additional exercises to build up your strength and increase flexibility. Physical therapy is an essential part of treatment as PMPS can cause you to not use your arm the way you typically would. This can eventually lead to a decrease in strength and the limited ability to use your arm normally.
  • Pain medications to help manage the pain. Common medicines used to treat pain, such as opioids (narcotics), do not always work for treating PMPS, so your doctor may prescribe a neuropathic pain medication.
  • A nerve block to stop the affected nerve from sending pain signals to the brain if physical therapy and pain medicines fail.

After breast surgery, several options are available to you. These may include reconstructive surgery to rebuild the breast or wearing a breast prosthesis. Choosing one of these options is a personal decision and requires much consideration, so talk to your treatment team and learn about other women’s experiences.

Breast reconstruction is an option for many breast cancer patients. Performed by an experienced plastic surgeon, it can either be done immediately (at the same time as your mastectomy) or later (within months after your mastectomy). Immediate reconstruction can be done for early-stage breast cancer, but it’s usually best to wait if you have more advanced breast cancer. Reconstructive surgery is typically only done after a lumpectomy when the surgery will cause the breast to appear significantly different from the other. Reconstruction requires a long healing period, which could delay the start of chemotherapy or interfere with potential radiation therapy. If you’re considering reconstructive surgery (even if it will be done later), discuss this with your cancer surgeon and a plastic surgeon before the mastectomy so they can properly plan your treatment.

Breast reconstruction may involve the use of a breast implant or a flap of tissue (usually containing skin, fat, muscle and blood vessels) from elsewhere in your body, or a combination of the two (see Breast Reconstruction Options below). The use of a tissue flap depends on the size of your breasts, your body type and preferences regarding appearance.

Some women prefer implants (saline or silicone), which involve less surgery than a tissue flap. When an implant is used, the overlying chest wall muscle and skin must be stretched to accommodate the implant. This is usually accomplished by inserting a temporary placeholder under the muscle called a tissue expander. The tissue expander is gradually inflated with fluid injections through the skin until the breast reaches the desired size.

A breast prosthesis is another option. Made of artificial materials that make your breast look natural and symmetrical, an external breast prosthesis is worn inside the bra or an implantable prosthesis can be placed under the skin or muscles in the chest.

 

 

Figure 1
Figure 2 Figure 3

 

Lymph node removal

Breast cancer can spread to lymph nodes, particularly in the underarm area, which are called axillary lymph nodes. Your doctor will need to determine if your lymph nodes have been affected for staging and treatment purposes. A procedure that many breast cancer patients undergo to determine whether the cancer has spread to lymph nodes is called a sentinel lymph node biopsy. It involves injection of a small quantity of a blue dye and/or a radioactive substance into the breast prior to the operation. The surgeon then uses a probe and visual inspection to identify the radioactive and/or blue-stained lymph nodes. If the sentinel nodes contain a tumor, sometimes a bigger operation to remove additional tissue from the underarm may be necessary, and this is called an axillary lymph node dissection (see Figure 1). Some patients will have cancerous axillary lymph nodes detected by needle biopsy. If a needle biopsy reveals a metastatic lymph node, then neoadjuvant (preoperative) chemotherapy may be recommended. In some circumstances after a lumpectomy, if the patient is receiving radiation therapy and systemic therapy after surgery, no further axillary surgery is recommended even when there are metastases in the sentinel node.

Breast Reconstruction Options

Breast Reconstruction Techniques
There are two surgical methods for flap surgery. A pedicled flap is one in which the muscle is the carrier of the blood supply. A free flap contains one or two blood vessels that are attached to blood vessels in the breast area. Types of flap surgeries are listed below.
 
DIEP: deep inferior epigastric perforator flap
SIEA: superficial inferior epigastric artery flap
TRAM: transverse rectus abdominis muscle flap
LSGAP: lateral septocutaneous perforating branches of the superior gluteal artery perforator flap
SGAP: superior gluteal artery perforator flap
TUG: transverse upper gracilis flap

 

DIEP Flap Breast Reconstruction

 

Expander Implant
Implants may be used for breast reconstruction. With this option, a tissue expander is inserted at the time of the breast cancer surgery. The expander slowly expands breast tissue, and a permanent implant is inserted in a second operation.

Radiation Therapy

Radiation therapy uses high-energy X-rays to kill cancer cells or keep them from growing. It can be used before or after surgery. It may be used as neoadjuvant treatment (before surgery) to shrink a tumor so it can be surgically removed. Or, it may be used to shrink a large breast tumor so that you might have more surgical options, including lumpectomy and breast irradiation therapy. External-beam radiation therapy (EBRT) is given with the use of a radiation machine and is similar to a conventional X-ray, except the radiation beams are strong enough to kill cancer cells. EBRT is the most common form of radiation therapy given to people with breast cancer. However, internal radiation, or brachytherapy, is another option that may be used either alone or in combination with EBRT after breast-conserving surgery (see Figure 3 above). This type of therapy involves the placement of radioactive “seeds” through a catheter in the breast to deliver radiation directly to the area where the tumor was removed.

As noted in the section on lumpectomy, radiation therapy is usually recommended with a breast-conserving strategy for reducing the chances of the cancer growing back in the breast (local recurrence) by killing the microscopic cancer cells hiding in the remaining breast tissue. Breast radiation after lumpectomy is now often given as a hypofractionated schedule, which is radiation divided into large doses, requiring as few as three weeks rather than the conventional six weeks. However, some patients have a very low risk of having a local recurrence and can avoid radiation after a lumpectomy.

Radiation therapy is sometimes necessary after a mastectomy and is typically recommended for individuals at high risk for cancer recurrence on the chest wall, such as women with cancer in multiple axillary lymph nodes.

Radiation therapy may also be used after specific operations to help shrink tumors that may have developed in other parts of the body from metastatic breast cancer or to relieve symptoms caused by metastatic tumors (known as palliative radiation).

Medical Therapies

Medical therapy is the use of medications that work throughout your entire body. One or a combination of the following therapies may be used to treat breast cancer.

Chemotherapy

Chemotherapy is the use of drugs to stop the growth of cancer cells either by killing them or preventing them from dividing and growing. Chemotherapy drugs are usually given over a specific time period called a regimen. For early-stage breast cancer, chemotherapy may be given as a combination of two or three drugs together or one after the other.

Chemotherapy may be given before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy). When given prior to surgery, it is used to shrink the tumor, which may be inoperable, or to reduce the tumor’s size in order to do a lumpectomy rather than a mastectomy. Adjuvant chemotherapy is given to destroy cancer cells that may remain after surgery, some of which may be too small to detect with laboratory testing or imaging studies. This can be life-saving and decrease the risk of recurrence in higher-risk patients.

Hormone therapy

Hormone therapy, also called endocrine therapy, works by reducing or blocking estrogen, which is known to drive the growth of breast tumors. This therapy is used to treat tumors that are estrogen- and/or progesterone-receptor positive (noted as ER+/PR+).

Several types of hormone therapies may be used depending on the stage of the cancer and your menopausal status. A class of drugs known as selective estrogen-receptor modulators (SERMs) lowers or blocks estrogen receptors that are present on the cancer cells, as well as other organs in the body, and can help prevent the cancer from returning. Aromatase inhibitors (AIs), sometimes recommended for postmenopausal women, reduce the estrogenic substances that are manufactured by the body. Estrogens and synthetic androgens (similar to male hormones) may be used to manage symptoms related to advanced breast cancer, but they are used less often than SERMs and AIs.

Removal or suppression of the ovaries (by surgery, medication or radiation therapy) is another option because it substantially reduces the production of estrogens in premenopausal women. Luteinizing hormone-releasing hormone (LHRH) analogs are drugs that provide an equivalent alternative to surgical removal of the ovaries in premenopausal women. Hormone therapy drugs differ in how they work, who can use them and what side effects can result. As with chemotherapy, the schedule of treatment is fixed (typically 5-10 years) when used as adjuvant therapy for breast cancer that has not spread. The drugs used in adjuvant therapy should be discussed with your doctor.

Targeted therapy

Drugs that block the cell pathways that can lead to many types of cancer are known as targeted therapies. These drugs block the signals that proteins and other molecules send along signaling pathways, which are systems in the body that direct basic functions, such as the growth, division and death of cells. Effective targeted therapy depends on identifying targets that play an important role in the growth and survival of cancer cells, and in developing agents that can attack those targets.

About 20 percent of breast cancer tumors make extra copies of the HER2 gene, which promotes cell division. Targeted therapy drugs made to treat HER2+ breast cancer are known as anti-HER2 agents. Anti-HER2 agents are continually being developed, in addition to new combination targeted therapy treatments.

Table 1. Targeted Therapy Options

Targeted Therapy
abemaciclib (Verzenio)
ado-trastuzumab emtansine (Kadcyla)
everolimus (Afinitor)
lapatinib (Tykerb)
neratinib (Nerlynx)
olaparib (Lynparza)
palbociclib (Ibrance)
pertuzumab (Perjeta)
ribociclib (Kisqali)
trastuzumab (Herceptin)
trastuzumab (Ogivri)

Table 2. Chemotherapy Options

Chemotherapy
capecitabine (Xeloda)
carboplatin (Paraplatin)
cisplatin
cyclophosphamide
docetaxel (Taxotere)
doxorubicin (Adriamycin)
epirubicin (Ellence)
eribulin (Halaven)
fluorouracil (also known as 5-FU)
gemcitabine (Gemzar)
ixabepilone (Ixempra)
liposomal doxorubicin (Doxil)
paclitaxel (Taxol)
protein-bound paclitaxel (Abraxane)
vinorelbine (Navelbine)

Table 3. Hormone Therapy Options

Premenopausal
fluoxymesterone
goserelin (Zoladex)
leuprolide (Lupron)
megestrol acetate (Megace)
tamoxifen
Postmenopausal
anastrozole (Arimidex)
ethinyl estradiol
exemestane (Aromasin)
fluoxymesterone
fulvestrant (Faslodex)
letrozole (Femara)
megestrol acetate (Megace)
tamoxifen, toremifene (Fareston)

 

Treating Bone Metastasis

When breast cancer metastasizes (spreads) to the bones, it may be treated with bone-modifying agents to help prevent or delay bone fractures or other symptoms related to the presence of bone metastases.

  • Bisphosphonates slow the loss of bone mass that can occur from cancer or from other treatments.
     
  • Radiopharmaceuticals are intravenous drugs that give off low levels of radiation intended to travel directly to the area in the bone to which cancer cells have metastasized.
     
  • Targeted therapy inhibits a protein that is responsible for bone loss and helps increase bone mass and strengthen bones.
     
  • External beam radiation can target and kill symptomatic bone metastases.

Clinical Trials

Many advances in cancer treatment that are helping save lives today are products of clinical trials. Depending on your diagnosis and other factors, research studies known as clinical trials may be a treatment option to consider.

Clinical trials are conducted all over the United States, in large cities and small towns. Some take place in cancer centers and hospitals, others in doctor’s offices.

Trials for many types of treatments are underway including immunotherapy. Immunotherapy uses the body’s own immune system to fight cancer cells. Although no immunotherapies have been approved to treat breast tumors, success in treating other cancers has encouraged researchers to evaluate its effectiveness through clinical trials.

To participate in a clinical trial, you must meet certain qualifications, such as the type and stage of cancer you have, your age, overall health condition and response to past treatments. Ask your doctor if a clinical trial may be right for you, and use the resources on here to research more about clinical trials on your own. It’s important to understand what they are, in general, and what they may mean for you.

Additonal Resources

 

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