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Home Treatment Options Overview Breast Cancer Treatment Options

Breast Cancer Treatment Options

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Approaching the numerous options, combination, and emerging studies of breast cancer therapy can stressful and all together confusing. However, you are never alone in the process. You and your doctor will work together on deciding and creating a personalized treatment plan based upon your diagnosis. In this article, we will help walk you through the different treatment options that are available and the factors that determine how you and your doctor will choose a plan of therapy.

Staging

The first step in determining initial treatment is staging, or the extent of the disease. Staging can be further divided into clinical and pathological. Clinical staging is based on the size of the tumor, the appearance, and the presence of enlarged lymph nodes. The clinical stage can help decide between mastectomy verse conservative breast therapy and the need for additional treatments such as chemotherapy. However, it has been shown that the physical exam is often unreliable. Up to one third of women who had no palpable lymph nodes had metastases and one third who did have enlarged lymph nodes, the nodes turned out to be negative for cancer. Therefore, it is important to consider all the factors before determining a therapy route. Pathological staging, on the other hand, is determined by the biopsy or surgical results, in which a pathologist will review a tissue sample of the tumor and determine the tumor type, border, and other characteristics included in the pathology report. The pathological stage of the cancer can help determine the prognosis and the need for what is termed adjuvant therapy (additional systemic treatment in addition to primary surgical options).

Factors in deciding treatment options:

There are many factors that contribute to the discussion of therapy plans. Here are a few of the most important ones that can be discussed with your physician.

Lymph node involvement:

As mentioned above, one of the most important factors in staging breast cancer is lymph node involvement. The body has two forms of circulation, the blood and the lymphatic circulation. Lymphatic circulation carries lymph fluid, which is composed of nutrients, white blood cells, bacterial waste, among other components. Lymph fluid can also pick up and circulate cancer cells, spreading it to other parts of the body leading to cancer metastases. Lymph fluid from the breast tissue primarily drains into the lymph nodes under the armpit, known as the axilla. A biopsy of these nodes can determine if any of the cancer cells have spread to these draining sites. Spread into the lymph node, termed node positive breast cancer, is an indication that the cancer has or will likely spread to other organs. It is also an indication that the cancer is more likely to return in the future. Therefore, systemic therapy in addition to local therapy will be required to treat possible metastases and prevent reoccurrence. Adjuvant therapy includes chemotherapy, radiation, hormone therapy, or antibody therapy such as trastuzumab. (Refer to the expanded discussion on adjuvant therapy below.)

Size:

Size is another important factor in the prognosis of breast cancer. The larger the tumor the more likely it is to recur. In some cases, chemotherapy is given before surgery to shrink tumor size or to shrink tumors that have spread into the chest wall, making surgery more difficult.

Histology:

A breast tissue biopsy pathology report will include what is known as the histology, which describes the cell type and characteristic of the tumor. While it is important to understand the different cell types of cancer, it makes little difference in therapy approach. In terms of treatment, the concern is between invasive and non-invasive, known as in-situ breast cancer. Because less than 1% of non-invasive breast cancer spread, in many of these cases, a surgical removal of the tumor itself, called lumpectomy, is sufficient. Furthermore, chemotherapy is not recommended in-situ breast cancer.

Hormone receptors:

Breast tumors can have what are known as hormone receptors. This means that the tumor can grow and change in response to the normal hormones in your body, such as estrogen and progesterone. These are known as hormone receptor-positive tumors. Women with tumors that are positive for these receptors may benefit from endocrine treatment after surgery. Endocrine therapy help suppress these hormones to prevent tumor reoccurrence or growth. Some examples include tamoxifen or anastrozole. Different drug options and their side effects are based on your menopausal status and can be discussed with your doctor. Women who have hormone receptor-negative tumors do not need and usually do not benefit from additional endocrine therapy.

Types of therapy

Now that we have discussed some of the factors that help decided on therapy options, we will introduce the different types of treatment options and what each entails.

Surgery

There are two standard options available: mastectomy verses conservative breast therapy (BCT). BCT is the removal of the tumor without removal of any normal surrounding breast tissue. This allows the patient to keep the cosmetic integrity of the treated breast while still lowering the cancer recurrence rate. Studies have shown that compared to mastectomy, a removal of the tumor with the entire breast, BCT survival rates were equal for both treatment options [1]. BCT is also usually followed with radiation therapy. While BCT is an option, most physician recommend against it if it is determined that there is a greater than 10-15% chance of the cancer returning within 5-10 years. There are also some absolute contraindications to BCT including prior radiation therapy to the treated breast, pregnancy, and the presence of more than one primary tumor, among many other factors to consider when deciding between BCT and mastectomy. Remember that BCT is chosen ,Breast radiation treatment will become

necessary.

Radiation therapy

Radiation therapy usually accompanies BCT or after a mastectomy. Radiation therapy is used to remove any remaining cancer and decrease the chances of the cancer returning. There are several options in how the radiation is delivered.

  • One side whole breast radiation therapy : this is the usual standard following a BCT
  • Partial breast irradiation : a shorter radiation course
  • Shorter course RT : a shorter course of radiation that could be an option for node-negative patients
  • Post mastectomy RT : for postmastecomy patients with tumors great than 5cm or node positive tumor. [2]
  • RT and chemotherapy : Combinations of radiation and chemotherapy at the same time can have increased risk of side effects. Therefore, there is a usual six month delay between chemotherapy and radiation treatments.

Adjuvant Therapies

  • Endocrine Therapy: the goal of endocrine therapy is to suppress hormones that would promote the growth of tumors that respond to these hormones. This includes estrogen and progesterone that stimulate tumor cells in estrogen and progesterone receptor positive tumors.
  • Chemotherapy : The standard adjuvant therapy for women who need adjuvant therapy (due to spread to lymph node , or large tumor size) but are estrogen receptor negative.

Chemotherapy before Hormones may become necessary if tumor is aggressive.

There is still a lot more to consider when it comes to how to choose which treatment course is right for you. However, knowing your options and understanding them is the first step in being a part of the discussion and planning process with your doctor.

Bianca Tran

References

[1.] Hayes, D. An overview of breast cancer and treatment for early stage disease. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.

[2.] Clarke, M, Collins, R, Darby, S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Early Breast Cancer Trialists Collaborative Group. Lancet 2005; 366:2087.

[3.] Harris, JR, Halpin-Murphy, P, McNeese, M, et al. Consensus statement on postmastectomy radiation therapy. Int J Radiat Oncol Biol Phys 1999; 44:989