Breast cancer treatment

 

What is the treatment for breast cancer?

The treatment for breast cancer varies according to many different factors. These include such things as the type of breast cancer, how early it has been detected (medically known as the staging of the cancer), whether or not the woman has had her menopause, whether the cancer cells have what are called 'receptors' for certain hormones such as oestrogen, progesterone and something called HER2, his or her age and the patient's own wishes.

Just over 44,000 people each year are diagnosed with breast cancer in the UK, over 99% of whom are women and over half of whom are women over the age of 65 although even young women can develop the condition. If detected early there is a good prognosis and over the past few years there have been major advances in treatment which have dramatically improved the outlook for people with breast cancer so that, since the 1980s, breast cancer death rates have fallen by a third.

This fact sheet will describe the usual course followed by a woman who has been diagnosed as having breast cancer including the types of treatment she is likely to be offered at each stage. Generally speaking most women with breast cancer that has been discovered at an early stage will be given a combination of surgery to remove the lump and local lymph nodes, radiotherapy, medication and/or chemotherapy. However it must be remembered that every case is slightly different so treatment will vary from person to person.

 

Initial assessment

The diagnosis of breast cancer will have been made or confirmed by a specialist who will then go on to assess the type of cancer involved, how large it is, whether or not it has hormone receptors as mentioned above and whether or not it has spread. All of these factors are important in helping the consultant advise the woman on the best form of treatment in her particular case.

The assessment usually involves an examination of the breast and a fine needle aspiration (where a small amount of tissue is sucked up into a needle) and often an ultrasound examination of the lump.

Sometimes an examination of bone marrow taken through a needle from the pelvic bone is performed or other investigations such as a bone scan are done to exclude any sign of more distant spread to the bones.

 

Surgery

Surgery is still the most common form of treatment offered to a woman with breast cancer. However, the type of operation has changed over time. Surgeons used to advise a total mastectomy (breast removal) in almost every case. However, it was found that the survival rates for patients with early breast cancer were the same whether they had a mastectomy or just local excision (removal of the lump and surrounding tissue) followed by x ray treatment (radiotherapy).

As a result, most women will be offered the choice between a 'lumpectomy' (local excision) and mastectomy and will frequently be advised to have a lumpectomy especially if the size of their breast lump is small and there is no sign of any spread of the tumour. A full mastectomy may still be suggested if the lump is large or if there is more than one tumour in the breast or in certain types of breast cancer such as one called Ductal Carcinoma in Situ (DCIS). A 'simple mastectomy' means just removal of the breast tissue whereas a 'modified radical mastectomy' means removal of the breast and all the local lymph glands. A 'radical mastectomy', which is now only rarely done, involves the removal, as well, of the muscles of chest wall. Women who have a mastectomy will be offered breast reconstruction done either at the time or at a later date.

During the operation the surgeon usually takes one or more lymph nodes from the armpit on the same side as the affected breast. Radioactive dye may be injected into the area just prior to surgery. This is so that the lymph nodes can be examined under the microscope along with analysis of the breast tissue removed to see if any spread has occurred. This may affect the type of treatment given after the operation and will allow the specialist to give the patient a better idea of the prognosis (outlook). If any of the lymph nodes are affected, the remaining nodes may be removed in an operation called axillary node clearance or some may be removed and the rest treated with radiotherapy.

Removing all the lymph nodes under the arm of the affected side can result in the build up of fluid in the arm called lymphoedema. This can occur some time after the original operation.

 

Radiotherapy

Radiotherapy (x-ray treatment) is almost always given to women who opt for local excision of the lump (lumpectomy) and is sometimes given to women who have a full mastectomy. The main aim of radiotherapy is to kill any cancer cells which have 'escaped' to the surrounding tissue or lymph nodes to try to prevent a recurrence of the cancer. As a result, the risk of local recurrence of breast cancer may be reduced by 30% by the use of radiotherapy in addition to surgery and other treatments.

Radiotherapy usually involves attending a special radiotherapy centre every day for a few weeks. The area to be treated is carefully marked out and the treatment only takes a few minutes to administer and is therefore done on an outpatient basis. With modern radiotherapy techniques side-effects are rare, the most common being reddening and soreness of the breast being treated which may last for a few weeks and some patients report feeling tired towards the end of the course.

Occasionally something called 'internal radiotherapy' is given which involves the placing, under a general anaesthetic, of radioactive wires into the breast tissue. This allows an extra amount of radiotherapy to be given to the area but does involve staying in hospital in a separate room to limit the risk of radioactive radiation to other people.

 

Chemotherapy

Chemotherapy involves the use of anti cancer drugs. These are given to some women and consist of a combination of two or three drugs given intravenously (directly into a vein) as an outpatient as a course of treatment. The aim is to kill any cancer cells that have spread to more distant parts of the body or sometimes chemotherapy is used before surgery to shrink the tumour. Side effects include tiredness, nausea, hair loss and soreness of the mouth and throat although these can often be controlled with medication.

 

Hormonal Therapy

Certain hormones can cause the development or 'feed' the growth of breast tumours so these tumours are called oestrogen receptor positive (ER+) or progesterone receptor positive (PR+). If the patient's cancer has so-called receptors for a particular hormone, blocking those receptors can significantly reduce the chance of the cancer recurring. The best-known oestrogen blocking treatment is a drug called Tamoxifen, which is usually given daily for five years.

More recently a group of drugs called the aromatase inhibitors (AIs) have been developed. These block development of oestrogen in the tissues rather than the production of oestrogen in the ovaries so are not usually indicated in pre-menopausal women (those who have yet to have the menopause). These drugs include Anastrazole, Examestane and Letrozole and are given in a similar way to Tamoxifen i.e. following surgery to remove breast cancer to prevent recurrence. They are specifically used in postmenopausal women who have ER+ve breast cancer.

Zoladex (Goserulin) is a drug, which reduces the amount of oestrogen in the body by acting on the pituitary gland, a gland at the base of the brain that stimulates the ovaries to produce oestrogen, and is therefore sometimes used as part of the treatment of oestrogen receptor positive breast cancer. The same effect can be produced in pre-menopausal women by removing or destroying their ovaries with radiation. However, either of these methods are likely to produce the sudden onset of the menopause with symptoms such as hot flushes, night sweats and vaginal dryness.

 

Biological Therapy

Herceptin(Trastuzumab). A substance called Human Epidermal Growth Factor (HER2) occurs normally in the body but some types of breast cancer have receptors for HER2 which then has the effect of increasing the growth of the cancer cells. Herceptin has the effect of blocking this growth stimulation present in one in five women with breast cancer who are HER2 +ve.

Herceptin treatment should be offered as an option for women with early-stage HER2-positive breast cancer after they have had surgery and chemotherapy (and sometimes radiotherapy). It is also given to some women with advanced breast cancer (breast cancer which has spread) either on its own or in combination with another drug called paclitaxel. It is given via an intravenous (directly into the vein) infusion but it is important to stress that it is not suitable for everyone since people with certain heart problems may not be able to have the treatment even if they are HER2 +ve.

 

Can the breast be re-built after surgery?

In most cases the affected breast can be reconstructed. This can either be done with careful reconstructive surgery using the patient's own tissues or with a prosthesis (implant). This is sometimes performed at the time of the original operation (especially if a mastectomy is done) or when all the initial treatment has been completed.

What follow-up will occur?

Initially the woman will be seen in outpatients by the specialist(s) involved with her treatment to make sure the operation wound has healed satisfactorily and to check on any treatment. The patient is then usually seen at regular intervals to look for any sign of a return of the cancer so that any necessary further treatment can be given at an early stage. The other breast will often be closely monitored since women who have had breast cancer have a higher risk of developing cancer in the opposite breast than other women. Some specialists advise annual mammography instead of the usual three yearly interval.

In addition to the routine follow-up the woman may feel the need for psychological support. Several studies have shown that breast cancer patients often need emotional support. About 20% of breast cancer patients develop depression within a year of diagnosis and about the same number have sexual problems and worries about their body image. Help can be obtained from a number of areas including the GP and breast cancer nurse specialist as well as those listed at the end of this factsheet.

 

What treatment exists for breast cancer which has spread?

Even if the cancer has spread to other parts of the body treatments are available to slow down the progression of the disease. This now includes the use, in suitable cases of Herceptin (see above). Treatment aimed at relieving symptoms is called 'palliative treatment'. Specialist doctors and nurses are now able to control most symptoms resulting from cancer in a variety of different ways.

When breast cancer spreads it most frequently goes to the bones, lungs, liver, brain or skin. Bone spread tends to cause pain which can be reduced in many cases with the use of radiotherapy to the affected area of the skeleton as well as the use of a variety of painkillers. Chemotherapy is sometimes used to shrink any areas of spread to other parts of the body and to slow down the advance of the illness.

 

What advances are being made in the treatment of breast cancer?

Since breast cancer is one of the most common serious illnesses in this country it is an area where there is a great deal of research and advances are being made all the time to improve the treatment and outlook for this disease. For instance, the use of Herceptin in the treatment of some cases of breast cancer was the result of such research. Many women who are being treated for breast cancer are entered, with their full consent, into trials in order to improve on treatment regimes.

 

Where can I get further information?

In addition to the GP, breast care nurse and specialist, the following organisations can be helpful:

Cancerbackup
3 Bath Place
Rivington Street
London
EC2A 3JR
Telephone 0808 800 1234 (freephone helpline 9am-8pm)
Website: www.cancerbackup.org.uk

Breast Cancer Care
5-13 Great Suffolk Street
London
SE1 0NS
Freephone 0808 800 6000
Telephone 0845 0920800
E mail: info@breastcancer.org.uk
Website: www.breastcancercare.org.uk