Breast Cancer Treatment -Chemotherapy Radiation Therapy, Hormonal Therapy

Breast Cancer Treatment

This is the main treatment modality for early-stage breast cancers. It is beneficial for cancer control and pathological examination of the excised breast tissue which can reveal the true stage of breast cancer and guide an appropriate treatment plan and prognosis. Breast cancer surgery consists of 2 parts – surgery of the breast and the dissection of lymph nodes in the armpit. Ancillary procedures such as breast reconstructive surgery are not the primary cancer treatment but can substantially improve a patient’s quality of life.

Breast surgery

Breast surgery can be classified into 2 surgical procedures.

• Total or simple mastectomy is the removal of the entire breast (including the nipple and skin over the tumor). This was a standard treatment modality, but nowadays it is mainly for patients with a large primary cancer, multiple cancerous tumors, or small breasts, and those who are at risk of cancer recurrence or unable to receive radiation therapy after surgery.
• Partial mastectomy or breast-conserving surgery is the removal of the tumor together with a 1-2 cm. margin of normal, surrounding tissues, sparing the nipple, areola, and most of the remaining breast. This surgery is suitable for patients with a single, small tumor in patients with sizable breasts. Postoperative radiation therapy is mandatory in every patient. Partial mastectomy is as efficacious as total mastectomy, retaining the shape of the breast near its natural state.

Lymph node surgery for breast cancer

Lymph node surgery for breast cancer consists of 2 methods.

• Total axillary nodes dissection is the conventional method to deal with the potential spread of cancer to the lymph nodes under the armpit. It is advantageous for regional cancer control, allowing pathological staging of the cancer, and assisting in the formulation of appropriate treatment plans. However, axillary dissection can cause complications such as numbness in the upper inner arm, nerve injury affecting the function of certain muscles, or long-term swelling of the arm and frozen shoulder. The complication rates are higher if patients also need to have radiation therapy. Patients must take good care of the arm on the operated side; they should avoid lifting heavy objects, repetitive use of the arm, injury, or infection to decrease the risk of arm swelling.
  Nowadays, axillary dissection is performed in patients who have palpable, clinically abnormal lymph nodes in the armpit because they have over 70% chance of metastatic cancer in the axillary nodes and in patients with cancer spread to sentinel lymph nodes.
• Sentinel lymph node biopsy is currently the most widely accepted surgical strategy to deal with potential spread of cancer to the axillary lymph nodes. It is suitable for low-risk patients, i.e., patients with no clinically palpable axillary lymph nodes, especially in those with small primary tumors; the risk of cancer spreading to lymph nodes is less than 30%. This procedure locates and excises the first group of lymph nodes to which cancer cells spread to. If no cancer cells are found, the removal of the remaining axillary lymph nodes will not be performed, reducing the chance of lymphedema. If sentinel lymph node is positive for cancer, complete axillary lymph node dissection will be performed.
  Sentinel lymph node biopsy is now the standard approach for patients with early-stage breast cancer to reduce the complications from axillary dissection without untoward adverse effects on the outcome of breast cancer treatment. The type of surgery depends on the stage of cancer, the size of the tumor, the patient’s condition, and the expertise of the surgeon. Often, patients have more than one surgical option; surgeons will recommend and explain each surgical option so patients can choose the most appropriate one.

Since breast cancer treatments are more effective, patients now live longer with less chance of recurrence, especially in those with early-stage cancer. In addition to saving the patient’s life, conserving, and retaining the breast configuration is gaining in importance to build confidence and decrease the psychological effect of organ loss and improve the postoperative quality of life. Many breast reconstruction techniques have been devised to rebuild or replace the excised breast without adverse effects to the breast cancer treatment outcome.

Breast reconstruction

Breast reconstruction is the surgical technique to rebuild the breast with transposed tissue from other body area or breast prosthesis, gaining back confidence in returning to work and resume their daily life. The reconstruction can be immediate or delayed.

• Transverse Rectus Abdominis Myocutaneous (TRAM) flap replaces the removed breast with abdominal skin, fat, and muscles. This surgery takes longer than a mastectomy alone, lasting 3-5 hours, and one-week hospital admission may be required. The patient will have a surgical scar below the bikini line. After the surgery, the strength of abdominal muscles may decrease, but it does not affect the patient’s activities of daily living. Other benefits of this method are the use of abdominal tissues leads to a flatter abdomen and the surgical construction is permanent.
• Latissimus Dorsi Myocutaneous (LD) flap is commonly performed in conjunction with a partial mastectomy procedure, particularly in patients with loss of breast volume more than that required to maintain the shape and beauty of the breast without augmenting with other soft tissues. Tissue around the shoulder blade can be used to reconstruct part of or the whole breast. A breast prosthesis may be used to enlarge the size of the breast. This surgery leaves operative scars in the back which can be hidden under the bra line; it may also affect muscles controlling the shoulder motion.
• Breast prosthesis can be used with partial or total mastectomy. It is available in many shapes, sizes, and materials. The advantage is there are no additional operative scars, but it may not be proper for some patients with an unsuitable breast configuration. In patients who require radiotherapy, there can be complications such as the shrinkage of breast tissues around the implant, causing distortion of the breast shape. Additional cosmetic surgery including breast implant replacement or capsulectomy may be required afterwards.
• Fat grafting or lipofilling is to recontour the distorted breast from partial mastectomy by liposuction or transferring fats from the abdomen or thigh and inject or insert the fats into the intended area.
• Nipple areolar reconstruction in patients after total mastectomy surgery to reconstruct the nipple and areolar complex from nearby skin and medical tattoo. This is usually performed after breast reconstruction.

All breast reconstruction surgeries do not adversely affect breast cancer treatment outcomes; however, it is important to select an appropriate candidate by considering the stage, size, and location of cancer and the patient’s clinical condition, readiness for surgery, and reaction to anesthesia. Surgeon must clearly explain the pros and cons of each method to patients.

Breast cancer surgeries are invariably done under general anesthesia and take 1.5-2 hours; surgeries are longer when immediate breast reconstructions are performed.  After surgical dissection is complete, the surgeon will close the wound with subcuticular, absorbable sutures to bury the stitches, obviating the need for suture removal. Patients are required to wear a medical compression bra to press down the wound against the chest wall muscles to prevent excessive blood and lymph accumulation and mitigate pain from breathing and moving.  1-2 small plastic tubes will be inserted to drain the blood and lymph from the operative field; they will be removed on the second postoperative day or when there is scant blood and lymph drainage. Patients usually stay 2-3 days in the hospital before returning home for further recovery. After one week, patients will meet with the doctor to remove the wound dressing. If the incision is well healed, patients can resume taking a shower as usual. In some patients, pockets of lymph fluid collection may occur; the doctor will drain it with a needle aspiration. This is not harmful and does not lead to any complications.

Chemotherapy

This involves administering drugs to kill or stop the proliferation of cancer cells. Chemotherapy is a systemic treatment, as opposed to surgery, which is a local treatment. Chemotherapy increases the chance of a cure and extends the patient’s life. However, chemotherapy not only kills cancer cells but also affects fast-growing normal cells such as the bone marrow (producing blood cells and platelets), intestinal mucosal, hair, and egg cells in the ovaries. Some of these cells may be damaged, causing side effects. However, normal cells can recover and regrow; hence, these side effects are temporary. After the course of treatment is completed, the body will recover to a near normal state.

Nowadays, it is preferable to administer multiple drugs concurrently because of better efficacy. Medications to counter the drugs side effects will be given. There is no need for overnight stay in the hospital during chemotherapy. Patients can receive the therapy in the morning and go home in the late afternoon. Each cycle of chemotherapy may last from 3 to 4 weeks depending on the regimen sandwiched between rest periods for recovery. The complete course of chemotherapy may last 3-6 months, or 1 year in some cases, depending on the doctor’s discretion. Patients receiving chemotherapy can continue their activities of daily living, go to work, live with their families, and socialize with friends as usual.

Every chemotherapy drug has side effects. Some patients may not experience any adverse reactions, but some may have mild, and others severe side effects. It depends on the individual's response and reaction to the type and dose of the drugs. However, side effects usually occur on the day chemotherapy is given, or a few days afterwards. The side effects will gradually fade away without requiring any treatments.

Some medications patients may be taking can interact with chemotherapy. It is important to inform doctors or nurses about your current medication.

Nausea and vomiting are common side effects of most chemotherapy drugs. Patient should take the prescribed antiemetic drugs for symptom relief; eat foods that are easy to digest in small and frequent meals. If you do not feel better, please consult your doctor.

Some chemotherapy drugs can cause dry mouth and throat or mouth sores. Drinking plenty of water can prevent the symptoms. However, if you develop a mouth sore, eat liquid diet such as congee, rice soup, certain fruits, and ice cream which are easy to swallow. Chemotherapy drugs may affect the functioning of the bone marrow, which produces white and red blood cells and platelets. White blood cells are crucial in infection prevention. If the level is low, patients will be at increased risk of infection.

Scalp and body hair loss may happen, but this is temporary. The hairs will regrow once chemotherapy is completed. Patients should not be overly worried over this issue.

In patients who are still menstruating, chemotherapy may cause menstrual irregularity. Some patients may cease to have menstruation altogether and may experience menopausal symptoms such as hot flashes. However, pregnancy is still possible, though rarely occur. Since chemotherapy is harmful to the fetus, patients should practice contraception during the treatment. They should consult with the doctor for the most suitable contraception method. Breast cancer patients should not use birth control pills or contraceptive injections because they contain hormones which can stimulate the proliferation of cancer cells.

In younger patients, the menstrual cycle typically returns 6 months or longer after treatment. A patient can get pregnant, and the baby is not affected. However, it is recommended to continue the birth control for a minimum of 2 years to ensure that the chance of recurrence is relatively low. Those who are nearing menopause may no longer have periods and simply enter full menopause. The chemotherapy does not lead to sexual dysfunction. After the completion of chemotherapy, patients can resume sexual activity.

Radiation Therapy (Radiotherapy)

Radiation therapy utilizes highly sophisticated medical devices emitting high-energy radiation to stop the growth and division of cancer cells. The radiation beam kills both cancer and rapidly proliferating normal cells. However, since cancer cells proliferate much faster than normal cells, they are more severely affected. Normal cells can divide and grow to replace the damaged cells so that tissues and organs retain their normal functions.

For breast cancer, radiation therapy is commonly given to patients after breast-conserving surgery. It may be used as an adjuvant treatment for patients after total mastectomy with unfavorable features, i.e., tumors larger than 5 cm, cancer involvement of the skin or the chest muscles, and those with extensive axillary lymph nodes metastasis.

Normally, patients receive radiation therapy 5 days a week for 4 weeks. The radiotherapy sessions run Monday to Friday, skipping Saturday and Sunday to give the skin and the irradiated normal tissues time for repair. It is recommended to complete the course of treatment; otherwise, the dose of radiation would be too little and ineffective. Each radiotherapy session takes just a few minutes and is entirely painless.

Radiotherapy for breast cancer is directed to shallow body parts, with little penetrating to deep vital organs. Therefore, there are seldom any serious side effects.

During radiotherapy, some patients may experience weakness and fatigue. You should take as much rest as possible and adopt a mild exercise routine. Irradiated skin changes such as redness, darkening, itching, and burning sensation may occur. Patients should take care of the skin gently and carefully. Avoid wetting the skin or just use a soft damp towel to gently dab the area. Do not rub on the skin because it can cause peeling, leading to a wound. Try to avoid anything that can irritate the skin. Do not use soap, cosmetics, perfume, topical medicines, or heat. Avoid direct sunlight exposure or cold places. If shaving is required, please do it with extreme care. The safest way is to use an electric shaver. Do not scratch if you are itchy because it can cause skin abrasion and infection. Try to keep the irradiated area dry.

Radiation to the armpits can cause frozen shoulders or arm swelling. During radiotherapy, patients should perform regular shoulder exercises and follow the instructions to prevent arm swelling. Because radiation technology has advanced phenomenally in terms of medical equipment, technology, and the expertise of radiologists, the treatment outcome is much better with fewer side effects. Patients should have a positive attitude toward radiotherapy as it is efficient with minimal side effects. Patients can continue their daily life as usual. If your doctor recommends radiotherapy, you should be receptive to the treatment for the best results.

Hormonal Therapy

As we have long known, breast growth and function are hormone-dependent. Later it is discovered that the proliferation of some breast cancers is hormone-dependent as well. This can be determined by special tissue staining and examination by a pathologist for the presence of hormone receptors. If the cancer is hormone-receptor-positive, it will be responsive to anti-hormone therapy. According to Thailand’s statistics, 2 out of 3 breast cancer patients respond to anti-hormone therapy. If a doctor determines that this is an appropriate treatment, he/she will consider the age of patients, whether patients are premenopausal; how long, postmenopausal; or without menstruation due to hysterectomy because different medications will be prescribed.

Hormonal therapy medicines can be divided into 2 groups including medicines blocking the hormonal effects and drugs blocking hormone production in the body.

1. Medicines blocking the hormonal effects known as tamoxifen can be prescribed to both premenopausal and postmenopausal women. It may cause vaginal bleeding, so patients are recommended to have pelvic exams every year. It should not be prescribed to patients with a medical history of blood clots in the leg or brain. The risk of deep vein thrombosis and cerebral venous sinus thrombosis is higher when taking tamoxifen.
2. Medicines blocking hormone production can be prescribed only for postmenopausal women. They can adversely affect bones and muscles. Prior to starting the medication, patients are advised to have a bone densitometry to check for osteoporosis. Medications to increase bone density may be given.

Management of hormonal therapy is easy and convenient because it is taken by mouth. Patients will be placed on the medications for 5-10 consecutive years. They cause minimal, mild side effects. If patients experience any abnormal symptoms, please consult the doctor.

Targeted therapy

This is a new class of medications such as anti-HER2. The drug’s mechanism of action differs from other medications. Cancerous breast cells in some patients express HER2 receptors on the cell membrane surface, enabling anti-HER2 to detect and bind to the receptors and kill the cancer cells. Hence, cells not expressing HER2 receptors will not be affected. Though this targeted therapy is very effective -- targeting specific receptors with fewer side effects; it has certain limitations. It can only be used in a few selected patients and the price is exceedingly high. Therefore, this targeted therapy is not widely used. Always consult your doctor before considering this drug.