TREATMENT OF BREAST CANCER
(Also see Article:Types of Breast Cancer Surgery)
Jerry K. Myers, M.D.
Breast cancer occurs in one out of every eight women. This prevalence results in many surgeries (biopsies) being done to prevent missing early or remote cancers.
A breast cancer presents either as a palpable (one that can be felt) nodule or a finding in a mammogram or other test that may or may not be felt. Some nodules are noted on routine exams or mammograms, while others are felt by a woman during a self breast examination. Although some rare, fast-growing cancers (inflammatory for example) are tender, the majority are nontender. Some reveal characteristic changes in the skin and soft tissues, while others show no outward changes at all.
Regardless of the presentation, breast cancer is diagnosed by a breast biopsy. Needle aspirate and needle core biopsies are done in the Breast Center, and open excisional biopsies are done outpatient in the operation room, utilizing either local or general anesthesia. Usually a definitive operative procedure for the cancer is not undertaken at the same sitting as the open biopsy. This decision is usually delayed until all information about the biopsied tumor is obtained, thus allowing a more full and informed decision regarding the definitive treatment.
Once the pathology of the tumor is known, decisions about the type of treatment are discussed. This is usually done at the breast center appointment following the breast biopsy. Once treatment options are discussed, this affords the patient the opportunity to get further opinions about management or to proceed on with treatment as discussed. Surgery is almost always necessary in the management of the cancer. Rarely, some tumors receive chemotherapy without surgery. Most large tumors and/or more aggressive tumors that receive chemotherapy before surgery still require surgery to assure control of the local tumor. These patients usually receive 3-4 treatments (3-4 months) of chemotherapy, followed by the appropriate operation to control the local tumor, and then complete the remainder of the chemotherapy course (usually 3-4 more treatments). Because of the importance in controlling systemic disease (tumor that is spread to other parts of the body), it is not unusual to give chemotherapy first.
Surgery, and in some instances with radiation, is the treatment in controlling local disease (that contained in the breast and chest wall). Chemotherapy is the treatment in controlling systemic disease (tumor in other body areas).
Several types of surgeries are possible in the treatment of breast cancer. The more established, and that which has been considered the gold standard by which all other surgeries are measured is the modified radical mastectomy. The more recent approach is the lumpectomy. When recommended appropriately, these operations result in the same survival statistics.
The modified mastectomy (modified radical) consists of removing the nipple, the entire breast, the sentinel node and/or the lower axillary lymph nodes. This is usually recommended in dealing with large, bulky tumors and tumors involving the nipple complex that do not lend themselves to adequate excision and control via lumpectomy. This also is the operation of choice for the woman who does not want to undergo primary breast radiation, which is a necessary part of lumpectomy, or the woman who simply prefers to remove all breast tissue to limit the potential for local breast recurrence. Some women psychologically do not do well in follow-up of a breast that has the potential for recurrent cancer, and thus desire mastectomy. Even though performed less now than in years past, the modified mastectomy is a good operation for select patients.
The treatment of choice for most women who are surgical candidates is lumpectomy. This removes enough breast tissue to assure complete and free tumor margins. This also includes removing the sentinel axillary nodal tissue and/or the lower axillary lymph nodes, as well as radiation to the breast. External beam radiation begins several weeks after surgery and is usually done daily for 5-6 weeks. Radiation is necessary to aide in the control of potential microscopic tumor remaining in the residual breast tissue.If cancer recurs in the breast treated by lumpectomy and radiation, a mastectomy is usually then indicated. Statistics support that long-term survival is equal for selected lumpectomy/radiation patients as compared to modified mastectomy patients – even though a later mastectomy may be needed to treat recurrent disease in some lumpectomy patients. Also, some patients may benefit from lumpectomy without radiation, this is not the norm and it is a small and highly select group of patients that currently fits this treatment scheme.
The hospital stay is the same for both groups of patients. Some go home the day of surgery, while the majority go home the following morning. Discomfort is usually easily and adequately controlled with oral pain meds. Most patients have at least one surgical drain in place at discharge. Sutures and drains are usually removed at the first office visit.
At the office visit, details of further treatments are usually discussed. Most patients will receive a consult to a medical oncologist (cancer treatment specialist) to consider systemic treatment of the tumor in the form of chemotherapy. In selected patients, metastatic tumor may be suppressed by anti-estrogen medications, so unless contraindicated, these women will take anti-estrogen pills. Also, all estrogen products are to be stopped, since they could stimulate the recurrent growth of cancer. The need for IV chemotherapy is dependent upon several factors as positive axillary lymph nodes, size and type of tumor found, tumor nuclear studies, and tumor hormonal studies. These details will be further discussed by the medical oncologist.
Problems with either of the breast surgeries are unusual. When they occur, they are usually associated with the surgical wound. Infection and hemorrhage are potential problems that can occur with any surgical wound. Usually there are no untoward effects with either, but either or both may require re-operation to take care of the situation. Occasionally, skin healing problems can occur with mastectomy patients (especially in smokers or diabetics because of poor blood supply to skin flaps). These usually heal slowly, over time with adequate wound care, but may require grafting or other procedures to aide in the healing process. Rarely, problems can occur with nerves to the chest wall or back muscles after the axillary dissection. These are uncommon, but if they occur they are usually associated with extensive axillary tumor involvement. Arm and hand lymphedema (swelling of the arm/hand secondary to poor emptying of soft tissue fluid via the lymphatics) is an uncommon but possible problem when lymph tissue is removed and/or radiated. This can be a mild problem requiring minimal care, a moderate problem requiring some form of physical therapy, or a very devastating problem (very rare) virtually making the extremity useless. This uncommon problem occurs more frequently if the axilla is also treated by radiation.
Several smaller problems are common after the axillary dissection. The most common is numbness and/or tingling to the inside of the arm caused from the necessary removal of a skin nerve that goes through the axilla to that area. The other very common nuisance is the accumulation of fluid under the skin flaps or in the axillary space that sometimes requires multiple fluid aspirations during office follow-ups.
The other potential problems that may occur are from the radiation to the lumpectomy patients. These, if they occur, usually result in a skin reaction similar to a sunburn to the affected area radiated. Occasionally, swelling and tenderness also accompany the radiation. Rarely is the reaction a major problem, but severe reactions have been reported that have necessitated breast removal. Other local organ injuries to lung, esophagus, heart, blood vessels, etc. are possible with rare long-term problems occurring.
An excellent Breast Cancer Overview from the Mayo Clinic website: