Treatment of breast cancer often involves more than one therapy, and may be a combination of therapies.
Treatment recommendations depend on factors such as the cancer type, stage of the cancer, size of the tumour in relation to the breast size, whether breast preservation is desired and the patient’s general health.
Personal preferences determine certain choices, if the option is available, such as the options for the type of surgery. Being diagnosed with breast cancer and having to decide on the treatment options may be difficult. The support of friends and family during the consult and discussion on the results of tests and treatment is recommended.
In early breast cancer, surgery is the first treatment of choice. Chemotherapy, targeted and hormonal therapy may be used before surgery (neoadjuvant therapy), or after surgery (adjuvant therapy). Radiotherapy is usually given after surgery.
In stage IV cancer, the goal is to stabilise the disease with systemic therapy. However, local treatment of tumours with radiation therapy or surgery may be recommended when symptoms need to be alleviated.
Surgery for breast cancer is considered in two parts: breast and axillary lymph nodes.
The two broad options are breast-conserving surgery (BCS) or mastectomy.
Image-Guided Localisation for Surgery
For non-palpable tumours that need to be removed with surgery, localisation with a hookwire or a localising substance under image guidance done prior to the surgery is needed.
This procedure is performed under local anaesthesia, prior to surgery. Mammogram, ultrasound or MRI guidance is used to accurately locate the site for surgery.
A fine wire (hookwire) is inserted or a radioactive substance is injected into the breast, within or in close proximity to the lesion of interest, which will be removed during the surgery.
Mastectomy is the removal of the whole breast (incorporating the breast tumour). In general, there are two types of mastectomy:
Skin, fat and sometimes muscle (a flap) from another part of your body may be used to make into a breast shape. This operation takes about 6 to 8 hours and requires a hospital stay of between 1 to 2 weeks. Several drains are used and removed after 1 to 2 weeks. Flaps may be from the following areas:
Additional procedures to improve the look of the breast after the initial surgery may include adding a nipple, surgery to the opposite breast to create a good match, or refining the shape of the recreated breast.
Silicone implants may be used to create a new breast and the operation takes about 4 to 5 hours. There are usually 2 to 3 drains inserted and the hospital stay is 2 to 5 days.
A 1-stage procedure is when the permanent implant is inserted at the time of mastectomy. A 2-stage procedure is when a temporary expander is placed at the time of mastectomy and gradually expanded to stretch the skin. The expander will be exchanged for a permanent implant at a later surgery.
Sentinel Lymph Node Biopsy (SLNB) is recommended for early-stage breast cancer when the lymph nodes in the armpit do not appear to have cancer.
Sentinel lymph nodes (SLN) are the first few lymph nodes in the armpit where the lymphatic vessels from the breast drain to. These will be removed during surgery and examined under the microscope (frozen section) to determine if cancer has spread to the SLN.
This is done under general anaesthesia (GA). A blue dye or a radioactive substance is injected around the cancer site or at the nipple prior to surgery to locate the SLN. The radioactive substance will be injected before the operation. The blue dye will be injected during the operation.
If cancer is detected in the SLN, lymph nodes in the axilla will be removed. If no cancer is detected in the SLN, no further surgery is needed.
The final histology (microscopic assessment) will be reviewed about 1 week after surgery. In up to 5 percent of cases, the final assessment of the SLN may be different from the initial frozen section result and a second operation may be recommended.
If the dye or radioactive substance is not able to identify the SLN, removal of all the lymph nodes (axillary clearance) will be done.
Axillary Clearance is the removal of all lymph nodes from the underarm when the lymph nodes are found to have cancer cells.
Side effects of axillary clearance include shoulder stiffness and numbness of the inner part of your upper arm. Lymphoedema (swelling of the arm) may occur in 10 to 15 percent of women. This is because lymph nodes drain fluid from the arm and their removal may cause fluid to accumulate in the arm on the operated side.
A separate axillary incision is often needed for patients undergoing breast conserving surgery.
As with all surgical procedures, complications can occur. Risks of general anaesthesia include allergy to anaesthetic agents, heart attack, stroke and deep vein thrombosis, especially for longer surgeries.
Our anaesthetists will assess all patients before surgery to ensure they are optimised and prepared for surgery to minimise these risks.
Surgical complications include:
After surgery is planned, referral to the Breast Care Nurse (BCN) Service is necessary. Our Breast Specialist Nurse will explain and explore concerns and issues pertaining to breast cancer and the treatment options, and plan pre-operative, operative and post-operative management to ensure successful treatment and recovery.
Consult time for individual patients vary from 30 to 75 minutes. A personal contact number will be provided for convenience and the BCN will be a resource person for patients and their families in the coordination of the various appointments before and after surgery in the treatment journey.
Post-operative services include wound and drain care, rehabilitation, education programmes and prosthesis-fitting.
Radiation therapy, also called radiotherapy, is a form of local treatment that uses high-energy X-rays to kill cancer cells in a part of the body. It aims to reduce the risk of cancer returning in the area where radiation was given, and together with surgery and other treatments, increases the chance of you staying cancer free. Radiation can be delivered through External Beam Radiotherapy (EBRT) or Intra-Operative Radiotherapy (IORT).
Radiotherapy is almost always recommended after breast-conserving surgery and often in patients with high risks disease after mastectomy. This include patients with large tumours and those where the cancer has spread to involve multiple lymph nodes. Almost always, radiotherapy is performed after surgery and chemotherapy, when needed.
Radiotherapy is performed over a period of time, which may vary in duration between 1 to 6 weeks. The actual treatment duration will be determined following a consultation with your specialist based on an assessment of your needs.
Following this consultation, an appointment will be made for scans to be performed of the part of the body to be irradiated. This process is called CT-Simulation. During this session, you will meet with our team of Radiation Therapists who will determine the best treatment position for you and obtain a CT scan of the area to be treated.
Your doctor and team of specialists will then perform a personalized planning for radiotherapy according to your needs. Computerized treatment planning is used to optimise the delivery of high radiation dose to the treatment area, while reducing radiation dose to vital organs like your heart and lungs.
Radiotherapy is delivered every day, 5 days a week for the duration of the treatment. Daily treatment lasts between 30 to 60 minutes and is performed on an outpatient basis. Treatment is entirely painless and without any perceptible sensation.
Radiation affects both cancer and their surrounding normal cells. Cancer cells are typically more sensitive to radiation than normal cells, and are less able to repair themselves after being damaged by X-rays. Hence, they die off after radiation. Even though the surrounding normal cells can be affected by radiation, they often recover with time. This can manifest as side effects that originate from the site of treatment, many of which are short-term and temporary, although there are some cases where long-term complications may also occur.
Early side effects can occur during radiotherapy, typically 2 weeks into the treatment. Such side effects are usually temporary and show gradual improvement in 8 weeks upon completion of treatment. However, some may take a longer time to resolve. Examples of such early side effects include fatigue, skin changes such as redness, pigmentation, dryness and itching, or discomfort from temporary breast swelling.
Late side effects are uncommon and may occur only many months or years after treatment. A small proportion of patients may experience progressive hardening of the breast and the overlying skin which may lead to a shrinking or distortion of the breast or chest wall. Other late complications to the heart and lungs are much rarer and your doctor will advise you further as the risks vary between patients.
Intraoperative Radiotherapy (IORT) is a specialized form of radiotherapy used in the treatment of breast cancer. Like all radiotherapy, high energy radiation is used to damage and kill cancer cells, so as to reduce the amount of cancer in your body and increases the chance of you staying cancer free.
IORT is performed only in patients undergoing breast-conserving surgery. Additionally, IORT is suitable only for patients with early stage cancers and meet conditions that your radiation oncologists will advise you on.
In suitable patients, IORT is performed during the cancer surgery immediately upon removal of the tumour. A specialized applicator will be placed into the excision cavity to irradiate the immediate breast tissue from inside out hence limiting the dose to the rest of the involved breast and normal organs. As patients will remain under anesthesia, IORT is completely painless.
For most patients, this single fraction IORT will be the only radiotherapy they require, hence the treatment burden in well selected patients can be reduced. Occasionally, the surgery and subsequent examination of the cancer may reveal additional information about the cancer which may lead to your doctor recommending for the use of additional external beam RT after IORT.
Patients will experience the usual symptoms relating to breast cancer surgery. In addition, some patients may experience a slower resolution of the seroma associated with the surgical cavity. A smaller group of patients may find localized hardening of the breast tissue and skin in the region of the operation. Rarely, this may lead to a distortion of the breast in the long term.
This treatment uses anti-cancer drugs to prevent cancer cells from growing and reproducing themselves. These drugs are usually given by injection through veins into the blood stream to all parts of the body.
It is usually given over 3 to 6 months and may be used alone, before surgery (neoadjuvant) or after surgery (adjuvant) therapy, or together with targeted therapy to increase the effectiveness of the treatment, depending on the type and stage of cancer.
Chemotherapy is given in cycles. Each cycle consists of a treatment period followed by a resting (recovery) period. As cancer drugs also affect normal cells, the resting period is to allow the body to recover before the next treatment cycle starts.
Breast cancers are also tested for special receptors. One such receptor is the Human Epidermal Growth Factor 2 (HER2) receptor. This receptor is over-expressed in about 25 percent of all breast cancers; the presence needs to be confirmed by laboratory tests performed on the biopsy specimen before the treatment is given.
The aim of the treatment is to reduce and hopefully eliminate existing cancer cells in the human body while minimising side effects on normal cells.
Trastuzumab, also known as Herceptin®, targets the HER2 (Human Epidermal Growth Factor 2) receptors on cancer cells to prevent cell growth and division.
Herceptin® has been shown to prolong survival in breast cancer patients with early and advanced disease (Stage IV) when used in combination with chemotherapy.
An increasing number of targeted drugs are becoming available for the treatment of breast cancer, including Lapatinib (which targets HER2 and EGFR) and Bevacizumab (which targets a factor associated with new blood vessel formation in tumours.
Breast cancers are tested for oestrogen receptors (ER) and progesterone receptors (PR) on their surfaces as such cancers can be stimulated by oestrogen or progesterone to grow.
Hormonal therapy is aimed at blocking this effect. The drug recommended is dependent on the menopausal status of the women.
Hormonal therapy can cause some side effects, and they are dependent on the type of drug taken and can vary from one patient to another.
Regular follow up by the doctor after treatment is recommended due to the risk of developing breast cancer again.
This will include physical examination of the chest, underarms, neck, and the other breast with periodic mammograms.
Changes to look out for include:
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