There are two broad aspects considered during the treatment of breast cancer. Surgery and radiotherapy are locally acting modalities of treatment while chemotherapy, targeted therapy, hormone therapy are systemic modalities of treatment which act on the entire body. In breast cancer which is localised (not spread to distant organs); surgery forms the mainstay of the treatment. Extent of surgery depends on size of the tumour, ratio of tumour size to breast size, location of the tumour within the breast, extent of skin / nipple involvement, condition of the surrounding breast tissue on mammogram and most importantly choice of the patient. The use of other modalities depends on the stage, type of surgery and sensitivity of tumour cells. Radiotherapy is a must if the rest of the breast is conserved during surgery.
- Surgery: Surgery for breast cancer can comprise of total or partial removal of the breast tissue. Mastectomy means total removal of breast tissue. Breast conservation means partial removal of the breast tissue in which the tumour is removed along with a margin of normal tissue. Depending on its extent, it may be called as lumpectomy, quadrantectomy or partial mastectomy and may or may not be associated with reconstruction to improve cosmesis. Localised surgery that is breast conservation surgery has to be followed by radiotherapy to prevent recurrence in rest of the breast. The choice of surgery depends on the size of the tumour, its ratio to the size of the breast, overlying skin / nipple changes, location of the tumour, condition of the rest of the breast on mammogram, choice of the patient etc. Both mastectomy as well as breast conservation are associated with some surgery in the armpit to address the lymph nodes, the extent of which depends on the extent of spread of disease to the lymph nodes.
- Radiotherapy involves subjecting the tumour-bearing region either in part or whole to ionising radiation using a variety of delivering systems.
- Chemotherapy using cytotoxic drugs is capable of arresting rapid growth of cancer cells.
The need for radiation depends on type of surgery done and the stage of the disease. Radiation is used in different situations like:
- After breast conserving surgery to prevent recurrence of cancer in the rest of the breast
- After mastectomy, if the lump is larger than 5 cm, locally advanced stage at presentation or when cancer has spread to the lymph nodes
- If cancer has spread to bones, brain and other parts of the body – for symptomatic / palliative treatment
Side effects of radiation
- Heaviness in the breast
- Skin changes in the treated area can range from mild redness to blistering and peeling.
- Delayed effects like reduction in size of breast
- Radiation to the underarm may cause swelling of the arm (lymphedema) and numbness, pain and weakness (brachial plexopathy) due to nerve damage, however radiation to the armpit has very few indications and is not given as a routine to all patients.
Types of radiation
- External radiotherapy, where radiation is delivered from the skin surface.
- Brachytherapy, where a device containing radioactive seeds / pellets / wires is placed in the area harboruing the tumour tissue prior to surgery (tumour bed) for a short period during or for few days after the surgery. It can be used in very early stages of the disease or in elderly patients.
This is a treatment where cancer cell killing drugs are given intravenously or orally to reach cancer cells in most parts of the body. They also have some side effects on rapidly dividing / multiplying cells in the body like bone marrow, hair, nails, lining of oral cavity / intestines, ovaries in young women etc.
They are given in cycles to enable the body to recover from the side effects of the drugs and majority of the side effects are reversible.
Side effects of chemotherapy
- Hair loss and nail changes
- Mouth sores
- Loss of or increased appetite
- Nausea, vomiting, diarrhoea
- Affects blood forming cells of the bone marrow leading to increased chances of infection, easy bruising or bleeding
- Numbness, pain, weakness, increased sensitivity to heat and cold and burning sensation in the hands and feet
- Menstrual changes and fertility issues in young women
Types of chemotherapy
- After the surgery (adjuvant chemotherapy), drugs are given to destroy any cancer cells that are left behind or spread but not detectable. It reduces the chances of recurrence or spread of the cancer to other areas of the body.
- Before the surgery (neoadjuvant chemotherapy) drugs are given to shrink a large or locally advanced tumour to improve the results of the surgery.
- For advanced breast cancer, chemotherapy is used to treat spread of cancer cells to the underarm and other parts of the body. The duration of treatment depends on whether the tumour shrinks, how much it shrinks and how well it is tolerated.
Hormone therapy for breast cancer
Some cancer cells have ER (estrogen) and PR (progestrone) receptors which attach to these hormones and their growth is stimulated by these hormones. Drugs are used to stop the hormones from attaching to the receptors on the cancer cells.
It is most often used as an adjuvant therapy after surgery in receptor positive cases to prevent cancer cells from growing back and is used for at least five years. It is also used to treat recurrence and spread of cancer.
Some drugs are designed to check the growth and spread of cancer cells which are specifically sensitive to the same. Targeted therapy works better even when chemotherapeutic drugs do not and also have less side effects.
Treatment for recurrence
Although surgery is very unlikely to cure breast cancer that has spread to other parts of the body, it can still be helpful in some situations, either as a way to slow the spread of the cancer, or to help prevent or relieve symptoms from it. For example, surgery might be used:
- When the breast tumour is causing an open wound in the breast (or chest)
- To treat a small number of areas of cancer spread (metastases) in a certain part of the body, such as the brain
- When an area of cancer spread is pressing on the spinal cord
- To provide relief of pain or other symptoms
Radiation, chemotherapy, hormone therapy or targeted therapy or some combinations of these may be given.