Breast Cancer Treatment
How is breast cancer treated?
The overall treatment plan and standard of care for breast cancer varies, depending on the following factors:
- The type of breast cancer
- The subtype of breast cancer (according to applicable hormone receptor status
- (ER/PR) and HER2 status)
- The patient’s BRCA1/BRCA2 status
- The stage of the disease
- Genetic markers
- The patient’s age
- The patient’s general state of health
- The patient’s menopausal status
Formats of Breast Cancer Treatment:
Breast cancer treatment, in general, uses different combinations of treatments like surgery, radiotherapy and chemotherapy. Breast cancer treatment can vary (as explained above), depending on the patient’s unique medical conditions. However, on a broad level, the following treatment formats are available to treat a variety of breast cancer types, subtypes and stages:
Surgery is the first mode of treatment in a majority of breast cancer patients. Surgery is undertaken either in the form of mastectomy (removal of the complete breast), modified radical mastectomy(removal of the entire breast along with axillary lymph nodes) or lumpectomy (removal of tumour with margins). After mastectomy reconstruction can be considered, based on the patient’s preferences. In lumpectomy, if the tumour is removed with a clear margin along with axillary lymph node dissection it called breast conservation therapy (BCT).
[See more about breast cancer surgery and operation here]
Chemotherapy Treatment for Breast Cancer:
It is the intravenous administration of medicines that targets the cancer cells. Chemotherapy medicines identify cancerous cells by virtue of rapid divisiveness, which means that they sometimes also attack and kill healthy cells that divide normally. In case of locally advanced breast cancer where upfront surgery is not feasible Chemotherapy is given before surgery in order to decrease the size of tumours, so that surgical intervention can be performed later. Chemotherapy in early stage diseases is administered after surgery to prevent microscopic spread and with an aim to prevent recurrence .
[See more about breast cancer chemotherapy treatment here]
Radiotherapy or Radiation Therapy Treatment for Breast Cancer:
Radiotherapy uses exposure to high-intensity X ray beams to kill cancerous cells. The intent of radiation therapy is to minimize the chances of local recurrence. Radiation is advised after mastectomy, depending on the post-surgical pathological findings and after breast conservative surgery radiation therapy is mandatory. In case of metastatic diseases to bone radiation is considered for pain management.
[See more about breast cancer radiation therapy treatment here]
Hormonal Therapy Treatment for Breast Cancer:
This type of treatment is specific to patients who have been identified as hormone receptor positive, i.e. ER/PR positive. The choice of hormonal agent depends on the menopausal status of the patient. For premenopausal women, adjuvant Tamoxifen is used at a dose of 20 mg, to be taken once daily , for a duration of five years after the completion of chemotherapy and radiotherapy. For postmenopausal women, the preferred drug is Anastrozole (a type of aromatase inhibitor), delivered at a single dose of 1mg every day, for a duration of five years.
[See more about hormone therapy for breast cancer here]
Targeted Therapy Treatment for Breast Cancer:
This type of treatment either targets specific genes or proteins found inside cancerous cells that make up a tumour, or the tissue environment that enables the growth and survival of cancerous tissue. Targeted therapies are extremely focused, and work differently when compared to chemotherapy. Targeted therapies can control the growth and spread of cancer cells, while causing less damage to the healthy cells.
[See more about breast cancer targeted therapy here]
Treatment of recurrent breast cancer (cases of breast cancer relapse):
For cases of recurrent breast cancer, the treatment depends on the history of initial treatment (treatment that was given when the cancer first appeared), and on the other characteristics of the cancer, such as the size of the relapsed tumour, location of relapse site (this can be anywhere in the breast tissue, not necessarily the same location as the original site of the tumour), extent of spread to lymph nodes and/or other organs in the body, the status of hormone receptors (ER/PR/HER2), and the original, diagnosed status of BRCA1/BRCA2.
Extraction and analysis of lymph node tissue
In cases of some locally advanced or invasive cancers, cancerous cells are usually present in the axillary lymph nodes. Therefore, it becomes important to extract a sample of the lymph node tissue, in order to determine the right treatment plan and prognosis.
Sentinel lymph node biopsy
In a sentinel lymph node biopsy, surgical oncologists extract a few lymph nodes from under the armpit(s). These are usually taken from regions that have been affected first with lymph drainage from the breast(s). By doing a sentinel lymph node biopsy, surgeons are able to avoid removing multiple lymph nodes dissections, most of which will be free from cancer. There are possible long-term side effects to lymph node extraction procedures, such as lymphedema (swelling of the arm), numbness, risk of restricted arm movement and motion-range restriction, which can be avoided by performing smaller lymph node procedures.
Examination of lymph node tissue sample after a sentinel lymph node biopsy
A pathologist examines the extracted lymph node tissue sample under a microscope, to look for the presence of rapidly dividing (malignant) cells, which are indicative of cancer. To identify the sentinel lymph node, surgeons inject a tracer (either an inert dye or a radioactive marker) behind the nipple or in the area surrounding the nipple. This injection may cause some mild discomfort for 10 to 15 seconds. This dye makes its way to the sentinel lymph node by traveling across the lymph node tissue. Surgeons are able to find the sentinel node when the dye color is seen, or in the case of a radioactive tracer, when the dye shows signs of radiation.
If the sentinel lymph node is found to be free of cancer, it is mostly seen that the remaining lymph nodes are also free of cancer, and indicates that lymph nodes do not need to be surgically removed. If lymph nodes are found to contain cancer cells, then axillary dissection will be recommended.
Axillary lymph node dissection
For this process, surgical oncologists remove multiple lymph nodes from the armpit area, and these are sent for pathological examination. The number of lymph nodes that are needed to be removed may be different for each patient. Patients with tumour of small sizes, with less than 2 cancerous sentinel lymph nodes, may avoid this process. As explained above, having a smaller amount of lymph node tissue removed can reduce the risk of possible side effects, without affecting post-treatment survival rates.
Both sentinel lymph node biopsy and axillary lymph node dissection become optional if the patient is aged more than 65. The requirement to perform either of these procedures also depends on the general health of the patient, and how likely they are to be affected by the surgical outcomes. For patients of invasive breast cancers who are scheduled to undergo a complete mastectomy, a sentinel lymph node biopsy, or a partial or full axillary lymph node dissection is usually advised before the main surgery. This is done because it is difficult to find sentinel lymph nodes after a mastectomy (because there is nowhere left to inject the dye).
Reconstruction of breasts after breast cancer surgery
Women who undergo a complete mastectomy might want to get a breast reconstruction (re-creation) process done to retain their natural appearance. Reconstructive surgery uses either synthetic breast implants or tissue which is extracted from a different part of the body. This is usually performed by a plastic surgeon and is traditionally outside the purview of oncology, once breast cancer treatment is complete.
Breast reconstruction can be scheduled either immediately after surgery, or it can be delayed, as per the advice of the treating surgical oncologist. The feasibility of breast reconstruction depends on the recovery timelines for each individual patient.
Oncoplastic surgery refers to the process of simultaneous lumpectomy and reconstruction. Many breast cancer surgeons are equipped to perform this type of surgery without the assistance of a plastic surgeon. This is done depending on how healthy the other breast or the remaining breast tissue is, and it helps in matching the natural appearance of both breasts.
Glossary of definitions used in this section:
- Standard of care – Refers to the best treatments known for early breast cancer and locally advanced breast cancer
- Clinical trial – Refers to a study or research process that tests a new medicine/new method of treatment which is not used in mass effect
- Treatment plan – This contains a clinical summary of your breast cancer diagnosis, and a layout/schedule for the treatment that your attending oncologists have planned. A treatment plan is meant to provide basic information about your medical history/ongoing treatment history to any doctor who might want to review, or get involved in your treatment journey at a later stage.
- Multidisciplinary panel – In cancer treatment, doctors from multiple oncology disciplines such as surgical, radiation and medical oncology work together to develop the right treatment plan. Such a team, is called a multidisciplinary panel. Sometimes, at treatment delivery centers, these teams can extend to include a variety of healthcare professionals, such as assistant physicians, nurses, pharmacists, counselors, nutritionists, and even social workers. For patients who are senior citizens (aged 65 and above), a geriatric oncologist may also be involved.
Drugs Used To Treat Breast Cancer
What are the most commonly used medicines in the treatment of breast cancer?
The most commonly used drugs (either as oral prescriptions or as intravenous chemotherapy) in the systemic, adjuvant and neoadjuvant treatment of breast cancer include:
- Docetaxel (Trade name: Taxotere)
- Paclitaxel (Trade name: Taxol)
- Trastuzumab (Trade name: Herceptin)
- Pertuzumab (Trade name: Perjeta)
- Lapatinib (Trade names: Tykerb, Tyverb)
Docetaxel is a cytotoxic chemotherapy drug and an anti-microtubule agent, used in the treatment of early, locally advanced and metastatic breast cancer. [See more]
Paclitaxel is one of the most popular chemotherapy drugs used in the treatment of early, locally advanced and metastatic breast cancer. [See more]
Trastuzumab is a MaB (monoclonal antibody) that is approved for the treatment of HER2-positive breast cancer in early, locally advanced and metastatic stages. [See more]
Pertuzumab is an anti-HER2 antibody, which is approved for the treatment of HER2-positive breast cancer. It is used in combination with both Trastuzumab and other taxanes. [See more]
Lapatinib (Tyverb, Tykerb)
Lapatinib is a single transduction inhibitor, approved for use in the treatment of advanced or metastatic breast cancer, wherein the tumour has a HER2 expression. It is used in combination with standard chemotherapy. [See more]
Other drugs approved for, and in use for the treatment of breast cancer in different stages
The following is a complete list of all approved drugs that are used in the treatment of breast cancer.
- Abraxane (Paclitaxel Albumin-stabilized Nanoparticle Formulation)
- Ado-Trastuzumab Emtansine
- Afinitor (Everolimus)
- AnastrozoleAredia (Pamidronate Disodium)
- Arimidex (Anastrozole)
- Aromasin (Exemestane)
- Doxorubicin Hydrochloride
- Ellence (Epirubicin Hydrochloride)
- Epirubicin Hydrochloride
- Eribulin Mesylate
- 5-FU (Fluorouracil Injection)
- Fareston (Toremifene)
- Faslodex (Fulvestrant)
- Femara (Letrozole)
- Fluorouracil Injection
- Gemcitabine Hydrochloride
- Gemcitabine Hydrochloride
- Goserelin Acetate
- Eribulin Mesylate
- Ado-Trastuzumab Emtansine
- Lapatinib Ditosylate
- Lynparza (Olaparib)
- Megestrol Acetate
- Neratinib Maleate
- Nerlynx (Neratinib Maleate)
- Paclitaxel Albumin-stabilized Nanoparticle Formulation
- Pamidronate Disodium
- Perjeta (Pertuzumab)
- Tamoxifen Citrate
- Taxol (Paclitaxel)
- Taxotere (Docetaxel)
- Trexall (Methotrexate)
- Tykerb (Lapatinib Ditosylate)
- Verzenio (Abemaciclib)
- Vinblastine Sulfate
- Xeloda (Capecitabine)
- Zoladex (Goserelin Acetate)