BREAST CANCER INDIA

Correct information is .. half the war won already

TREATMENT PLANNING FOR BREAST CANCER


Basics of treamtent planning

The mainstay is to tackle the tumour which is present in the breast. That would mean 'local' treatment. 'Cancer in my breast has been addressed locally, by surgery. But what about some cells, which might have escaped into circulation. Will it seed somewhere else, and cause tumour to grow there. Besides, what is the chance that the cancer wont come back at the site where it was operated?' This is exactly the question which we answer while treatment planning.
Briefly, the treatment of a non metastatic breast cancer can be divided into the following:

  • Locoregional treatment

  • Systemic treatment



LOCOREGIONAL TREATMENT

The locoregional treatment consists of measures to remove the tumour i.e. Surgery, and measures to prevent recurrence of the tumour i.e. Radiotherapy.

  • SURGERY: This is the mainstay of the treatment. Surgery may be a Breast Conserving Surgery which involves a wide excision of the tumour called variously as 'wide excision' or 'lumpectomy' or 'quadrantectomy' along with dissection of the draining of the nodes in the axilla; or it may be a mastectomy, which means removal of the entire breast along with axillary lymph nodes. To note, for a breast conservation surgery, adjuvant radiotherapy is a must.

  • RADIOTHERAPY: If a breast conservation surgery is done, then radiotherapy is compulsory. If a mastectomy is done, then depending on the stage of the disease, radiotherapy may or may not be advised.



SYSTEMIC TREATMENT

Systemic treatment includes measures to reduce the chances of a 'recurrence' of the disease after surgery, and in some cases, to downstage a locally advanced cancer so as to make it operable, or make it possible to conserve the breast. Systemic treatment includes chemotherapy, hormonal therapy and targeted therapy.

  • CHEMOTHERAPY: Chemotherapy consists of drugs which act against cancer, and which are injected into the body, either by a peripheral intra venous line, or by one of the vascular access system called as 'PORT'. (These are discussed spearately)

  • HORMONAL THERAPY: Breast cancers are intimately related to the hormone called 'estrogen' present in females. If 'receptors' for estrogen or pregesterone are present in the tumour (detected by immunohistochemistry, during a pathology examination following a core biopsy or surgery), then hormonal therapy is given. This consists of a tablet, which has to be taken daily (or twice daily) for a period of 5 to 7 years, and has a good result in redunig chances of cancer coming back again, both locally as well as in distant organs.

  • TARGETED THERAPY AND SMALL MOLECULES: Again, on the basis of particular receptor called 'HER2neu' a 'targeted' therapy is available. Newer technologies have made it possible to target very tiny receptors, which help in growth of a tumour by inducing vascularity (called as 'anti angiogenic therapy'). See the respective section on the left for details.



So how is the treatment planned?

As discussed in the section on staging of breast cancers, the first step towards treatment planning is staging of the cancer. If you have not read the section on staging of breast cancer, please do it so, as it will facilitate a proper understanding of treatment planning. Let us simplify the staging and consider each treatment subsequently



OPERABLE BREAST CANCER (OBC):

This is the earliest stage of breast cancer, where the tumour is smaller than 5 cm, is localized to breast, and there may be some mobile axillary nodes. In staging, this will include combinations of T1 or T2 with N0 or N1. The standard treatment here is in the following order:

  • Breast Conservation Surgery (if feasible and if no contra indications) or Mastectomy

  • Adjuvant Chemotherapy (if indicated)

  • Adjuvant Radiation Therapy (compulsory if BCT, may or may not be needed if mastectomy is done

  • Adjuvant Hormonal Therapy (depending on hormonal receptor status)

  • Targeted therapy is not usually recommended in this stage, though some trials have show benefit of adding targeted therapy even in this stage.



LARGE OPERABLE BREAST CANCER (LOBC)

In this stage, the tumour is more than 5 cm, but is mobile. Nodes maybe enlarged, but not matted or fixed. So staging will include T3 with N0 or N1. In this, the treamtent is in the following order:

  • Surgery: If breast conservation is desirable, then if possible, Breast Conservation Surgery (BCS) may be done. But more often, BCS may not be feasible due to large size of the tumour and an initial downsizing of tumour maybe needed by giving a 'neoadjuvant' chemotherapy (usually 4 cycles). Alternatively, a Mastectomy may be done.

  • Adjuvant Chemotherapy If a few cycles of chemotherapy have been given prior to surgery, then only the remaining cycles (usually a total of 6 depending on chemo agent)have to be given.

  • Adjuvant Radiation Therapy

  • Adjuvant Hormonal Therapy (depending on receptor status)

  • Adjuvant Herceptin (if HER2neu is 3+)



L0CALLY ADVANCED BREAST CANCER (LABC):

Here, the disease is advanced 'locally', though not spread elsewhere on routine work up. 'Locally Advanced' implies involvement of the skin over the tumour, puckering of skin to produce an 'orange peel' appearance, fixity to underlying wall, 'matted' nodes in the axilla which are not freely mobile. In staging, this includes T4 and / or N2. All these signs imply a disease which has gone beyond the confines of routine curative treatment. There is a very high chance of latent 'metastatic' disease in such cases. After a thorough work up for metastases, and after confirming that there are no distant metastases, it is prudent to give 4 cycles of 'Neo adjuvant' chemotherapy first. The plan is as follows:

  • Neoadjuvant Chemotherapy: Chemotherapy is given first, with reassessment after first 2 cycles, to see if chemotherapy is working or not. After chemotherapy, majority of women will have a downsizing and some will have downgrading of tumour, following which surgery is done.

  • Surgery: This can be a BCS or Mastectomy .

  • Adjuvant Chemotherapy: The remaining cycles of chemotherapy are completed.

  • Adjuvant Radiation Therapy

  • Adjuvant Hormonal Therapy

  • Adjuvant Targeted Therapy



METASTATIC BREAST CANCER (MBC)

In this stage, the patient presents with a cancer which has already spread to another organ/organs. This includes M1 in staging. This represents stage 4 disease, and survival obviously is the lowest in this stage. The treatment protocols will vary depending on the site of seconday disease. The flow here would be like following:

  • Palliative Mastectomy: Surgeons still debate as to whether a mastectomy would help or not at this stage, and there is no common consensus. However, many (including myself) would agree that mastectomy would definitely help, atleast for the well being of the patient, who feels somewhat 'secure' that atleast the primary cancer is out. Besides, once the primary is tackled, the metastatic lesions could be targeted aggressively.

  • Palliative Chemotherapy: Palliative chemotherapy has a role in treatment of visceral metastases.

  • Hormonal Therapy: Hormonal therapy is indicated in patients who are hormonal receptor positive, irrespective of the site of metastases.

  • Targeted Therapy

Since metastatic breast cancer is a topic that deserves a detailed attention, a section has been given for the same where the details will be discussed.