Breast Cancer Treatment
What are the stages of breast cancer?
Breast cancer is staged with the TNM staging just like other tumours; looking at the size of the tumour, the nodes involved and whether there are metastases or distant spread of the cancer. It is grouped into stage 1, 2, 3 and 4. Stages 1-3 are early breast cancer and can be treated with surgery with or without chemotherapy, radiation and/or hormonal therapy. Stage 4 breast cancer is metastatic breast cancer and it is usually not able to be cured. The treatment for Stage 4 usually consists of chemotherapy.
How is breast cancer treated?
Breast cancer is first treated surgically, the primary tumour is excised or removed, and the lymph nodes from the axilla or the armpit are removed as well to be analysed for cancer. The next step, depending upon the size of the tumour, how the tumour looks under the microscope, if lymph nodes were involved, and depending upon the risk of relapse based upon that initial surgical information, there may be a role for adjuvant chemotherapy to reduce the risk of relapse.At the time of primary surgery there may be cancer cells that are outside of the breast and outside of the armpit, that may grow without being treated and so chemotherapy has a role in reducing the risk of relapse from those cancer cells that may have been left behind.After adjuvant chemotherapy there may be a role for radiation because if a lumpectomy was performed, if only a small portion of the breast was removed, or if the primary tumour was larger than 5 centimetres, or if there were more than 4 lymph nodes that were positive for metastatic in the armpit, then there may be a role for radiation for reducing a local recurrence, in other words, the breast cancer from coming back in the chest or in the armpit. Following that there may be a role for hormonal therapy, if the breast cancer has receptors for estrogen or progesterone, there may be a role for temoxaphen or for an aromatase inhibitor which are both hormonally mediated medications which can reduce a woman's risk of relapse of an hormonally sensitive cancer.
How soon will my breast cancer treatment begin?
Once a woman is diagnosed with breast cancer, the first determination is whether she needs surgery right away or whether the tumour needs to be shrunk with chemotherapy first. Once that determination is made, the woman starts her treatment relatively soon after the diagnosis. Usually, most individuals get surgery first. After the surgery, the chemotherapy starts within four to six weeks if a woman is a candidate for adjuvant chemotherapy; in other words, if her risk of relapse is great enough to warrant adjuvant chemotherapy and if she if fit enough and strong enough to undergo chemotherapy. That chemotherapy, again, will usually begin within four to six weeks after the surgery to give her time to heal and time to get stronger before beginning that therapy. After that, if there's a role for radiation, then that will usually begin within three weeks of finishing her chemotherapy. After that, if there's a role for hormonal therapy, she usually will begin that fairly quickly; within a week or two after the radiation.
Is most breast cancer treatment inpatient or outpatient?
In regards of breast cancer, in general, the treatment for breast cancer is outpatient as opposed to inpatient. For surgery, sometimes women need to be hospitalized for a day; if there are complications, sometimes a little bit longer. However, most of the treatment is given on an outpatient basis and the chemotherapy is all outpatient. The radiation, the hormonal therapy, is all outpatient too. Occasionally, there can be complications from chemotherapy, like infections or other side-effects that can require a woman to be hospitalized. But, that's the exception rather than the rule, and most women are able to be treated at home, living their lives at home, rather than in the hospital during their treatment.
What is the difference between a "lumpectomy" and a "mastectomy"?
Regarding breast cancer treatment, the difference between a lumpectomy and a mastectomy is that a lumpectomy is where the tumor is small enough that the surgeon is able to just remove the area of the breast that's affected by cancer, and the rest of the breast tissue is left behind. Whereas a mastectomy is where the entire breast is taken off, going down to the muscle. The skin is often left behind, in skin sparing mastectomies, and then women can then have reconstruction done afterwards, to recreate their breast. For lumpectomies, women will need adjuvant radiation treatment after their breast treatment because there is a risk of a local recurrence of cancer cells that may be just outside the area that was excised or removed. For mastectomy, there is usually not a role for radiation because the entire breast tissue is removed with the surgical specimen. The outcomes between lumpectomy and mastectomy in terms of breast cancer survival and breast cancer cure are identical these days as long as the lumpectomy is combined with radiation. So, oftentimes it comes down to cosmetics; in other words, is the tumor able to be removed while maintained a good cosmetic outcome on the breast, or does too much of the breast tissue need to be taken out for it to look like a normal breast? At that point, if it is, then a mastectomy is recommended, with reconstruction afterwards.
How does tumor size affect breast cancer treatment?
With regards to breast cancer treatment, the larger the tumor size, the greater the risk is of relapse and the greater the risk of having micrometastatic disease. This means that the greater the chance for cancer cells outside the breast already. The larger the tumor, the greater the risk of relapse and the greater the benefit of any further chemotherapy or other cancer treatment after surgery is done.
If my surgeon cuts into a tumor, instead of around it, will my cancer spread?
In general, surgeons attempt to avoid cutting through a tumour. There is a theoretical concern that if the tumour is cut through it could potentially cause seeding of the breast cancer. However, we have had many years of experience of surgeons cutting margins around a tumour that they end up cutting through and they have to go back and to take a wider margin. It does not appear to increase a woman's risk of a local relapse from a breast cancer. Having said that, surgeons do everything that they can to avoid cutting through the tumour.
What are "Tamoxifen" and "Raloxifene"?
With regards to breast cancer treatment, Tamoxifen and Raloxifene are both selective estrogen receptor modulators. They are medications which act on the estrogen receptor. Both Tamoxifen and Raloxifene have been compared head-to-head for their benefits of preventing breast cancer, and they were found to both be just as efficacious at preventing breast cancer. However, Raloxifene had decreased the incidence of endometrial cancer, decreased the incidence of blood clots, and, overall, was tolerated better than the Tamoxifen. So potentially, it is a better medication for preventing breast cancer than Tamoxifen. Having said that, Raloxifene has only been studied in post-menopausal women, it has not been studied in pre-menopausal women. Furthermore it is not currently FDA approved for breast cancer prevention, currently they are undergoing FDA review for breast cancer prevention indication. Tamoxifen is approved for breast cancer prevention. In pre-menopausal women, or women less than fifty, there is no significant increased risk of endometrial cancer, no significant increase risk of blood clots. So, for women less than fifty who are at a high enough risk for developing breast cancer to warrant a medication to reduce their risk, Tamoxifen can be a good choice, and it's important to talk with your doctor about that.
What is a "sentinel lymph node test"?
Testing for a sentinel lymph is something that a surgeon does at the time of surgery to remove a breast cancer, and it's trying to determine exactly which lymph nodes are the lymph nodes that are first draining that part of the breast. These are the lymph nodes that the cancer is going to go to first. It's been shown that if the sentinel lymph nodes are negative for cancer, you do not need to do a full axillary lymph node dissection and remove the other lymph nodes from the armpit. This is a good thing, because removing too many lymph nodes from the armpit can increase a woman's risk of postoperative complications, with fluid collecting in the arm, with lymphoedema or swelling and pain in the arm happening for months to years after the surgery, which can impair a woman's functioning and ability to do her normal activities of daily life. So, if a sentinel node is negative for cancer, you do not have to remove those other lymph nodes. If it's positive, you do need to do an axillary dissection, just to make sure there's no cancer that's left behind, because you want to improve the chances of a cure as best as you possibly can.
