Breast Cancer Treatment-lumpectomy | Metastatic breast cancer treatment

Breast-cancer-treatment

Breast cancer treatment: Treatment decisions are made put together by the patient and also the physician after consideration of the stage and biological characteristics of cancer, the patient’s age, menopausal status, and preferences, and the risks and benefits associated with each choice.

Ductal carcinoma in situ

Since there is currently no certain way to determine the progressive potential of a DCIS lesion, surgery and sometimes radiation and/or hormonal therapy are the usual course of action following a diagnosis of DCIS.

However, there is likely a group of patients that could safely forgo surgical treatment for DCIS. Several clinical trials are currently underway that are comparing the standard treatment to active monitoring (with optional hormonal therapy) in women with “low-risk” DCIS.

Ongoing research also seeks to identify molecular markers of DCIS that could predict recurrence or progression to invasive cancer.

Invasive breast cancer

Metastatic Breast Cancer Treatment

The treatment patterns among US women with invasive breast cancer in 2016 by stage at diagnosis. Most women with early-stage breast cancer will have some type of surgery, which is often combined with other treatments such as radiation therapy, chemotherapy, hormone therapy, and/or targeted therapy to reduce the risk of recurrence.

Patients with metastatic disease are primarily treated with systemic therapies, which can include chemotherapy, targeted therapy, hormonal therapy, and more recently immunotherapy.

Surgery

  • The primary goals of breast cancer surgery are to remove cancer and determine its stage. Surgical treatment involves mastectomy (surgical removal of the entire breast) OR breast-conserving surgery(BCS).
  • With BCS (also known as partial mastectomy or lumpectomy), only cancerous tissue, plus a rim of normal tissue (tumor margin), is removed. BCS is generally not an option in those with high tumor-to-breast ratio, multiple tumors within the same breast, or inflammatory or locally advanced cancers.
  • In most cases, BCS is followed by radiation to the breast. Mastectomy can also be followed by radiation. Despite equivalent survival when combined with radiation, BCS-eligible patients are increasingly electing mastectomy for a variety of reasons, including reluctance to undergo radiation therapy, fear of recurrence, and desire for symmetry.
  • Some women who are diagnosed with breast cancer in one breast also choose to have the unaffected breast removed, which is known as bilateral mastectomy or contralateral prophylactic mastectomy (CPM). Younger patients (<40 years of age) and those with larger and/or more aggressive tumors are more likely to be treated with mastectomy or CPM.
  • Although CPM nearly eliminates the risk of developing new breast cancer, it does not improve long-term breast cancer survival for the majority of women and nearly doubles the risk of surgical complications.
  • In the US, the percentage of surgically treated women with the early-stage disease in one breast who undergo CPM has increased rapidly, from 10% in 2004 to 33% in 2012 among women ages 20-44 and from 4% to 10% among those 45 years of age and older.
  • Women who undergo mastectomy may have breast reconstruction, either with a saline or silicone implant, tissue from another part of the body, or a combination of the two.
  • A woman considering breast reconstruction should discuss this option with her breast surgeon prior to the mastectomy in order to coordinate the treatment plan with a plastic surgeon.
  • Both BCS and mastectomy are usually accompanied by the removal of one or a few regional lymph nodes from the armpit (axilla) to determine if the disease has spread beyond the breast.
  • This procedure identifies the lymph node(s) to which cancer is most likely to spread and is called sentinel lymph node biopsy (SLNB).
  • The presence of cancer cells in the lymph nodes increases the risk of recurrence, and so results from the SLNB can help determine whether further treatment is needed.
  • Some breast cancer patients need to undergo more extensive lymph node surgery, called an axillary lymph node dissection (ALND). Surgery involving the axillary lymph nodes can lead to lymphedema, a serious swelling of the arm caused by retention of lymph fluid.
  • It affects about 20% of women who undergo ALND and 6% of patients who receive SLNB. Axillary radiation and excess body weight are also associated with an increased risk of lymphedema. The onset of symptoms usually occurs within 3 years of surgery but has been reported to occur even 20 or more years later.
  • Early diagnosis and treatment are critical to reducing the risk of progression to more severe lymphedema.
  • For more information about breast cancer survivorship, see Cancer Treatment and Survivorship Facts & Figures, available online at cancer.org/statistics.
  • Radiation therapy is often used after surgery to destroy cancer cells remaining in the breast, chest wall, or underarm area and reduce the risk of recurrence. BCS is almost always followed by radiation therapy to the breast because it has been shown to reduce the risk of cancer recurrence by about 50% at 10 years and the risk of breast cancer death by almost 20% at 15 years.
  • However, studies have shown that radiation does not improve survival for breast cancer patients 70 years of age and older with small, lymph node-negative, HR+ cancers who take hormonal therapy, although it does reduce the risk of local recurrence.
  • Older patients with HR+ tumors who opt to omit radiation must be aware of the heightened importance of adhering to their prescribed hormonal therapy regimen.
  • Some mastectomy-treated patients also benefit from radiation if their tumor is larger than 5 centimeters, growing into nearby tissues, or if cancer is found in the lymph nodes.
  • Radiation can also be used to treat the symptoms of advanced breast cancer, especially when it has spread to the central nervous system or bones. Radiation therapy may be administered as external beam radiation, internal radiation therapy (brachytherapy), or a combination of both.
  • The method depends on the type, stage, and location of the tumor, as well as patient characteristics and doctor and patient preferences.
  • External beam radiation is the standard type of radiation, whereby radiation from a machine outside the body is focused on the area affected by cancer. Brachytherapy uses a radioactive source placed in catheters or other devices that are put into the cavity left after BCS and is sometimes an option for patients with early-stage breast cancers.
  • Accumulating evidence suggests that radiation therapy given at higher doses over fewer days (known as accelerated partial breast irradiation) may be as effective as conventional therapy.
  • Intra-operative radiation therapy, in which a single fraction of radiation is given into the cavity left by tumor removal during BCS, is also sometimes an option.

Chemotherapy for breast cancer

  • The benefit of chemotherapy is dependent on multiple factors, including the size of the tumor and the number of lymph nodes involved, as well as HR and HER2 status.
  • Triple-negative and HER2+ breast cancers tend to be more sensitive to chemotherapy than HR+ tumors.
  • There are also gene expression panels (such as Oncotype DX, PAM 50, and MammaPrint) that can help assess the risk of distant recurrence and potentially identify those who would more likely benefit from adjuvant chemotherapy.
  • The Oncotype Dx 21-Gene Recurrence Score is used most widely in the United States, but it is only applicable for patients with early-stage HR+/HER2- breast cancer. A high recurrence score identifies women who will benefit from adjuvant chemotherapy (in addition to hormonal therapy), whereas a low score identifies women who could safely avoid it.
  • Evidence is less clear for patients with intermediate-risk scores, although recent clinical trial results based on 9 years of follow-up suggest that most patients over age 50 with intermediate scores are unlikely to benefit from the addition of chemotherapy.
  • Although most women who are treated with chemotherapy receive it after surgery, a recent study documents an increase in the use of neoadjuvant chemotherapy, particularly among patients with HER2+ and triple-negative breast cancers.
  • A summary analysis of clinical trials recently concluded that neoadjuvant chemotherapy is as effective as the same therapy given after surgery in terms of survival and distant recurrence. However, breast and axillary surgery remain necessary after neoadjuvant chemotherapy, even when the preoperative treatment appears to have completely cleared all clinical evidence of cancer.
  • Recent clinical trials have focused on identifying therapies that can improve outcomes among neoadjuvant treated breast cancer patients who have residual disease detected during surgery.

Hormonal (endocrine) therapy

  1. Estrogen, a hormone produced by the ovaries in addition to other tissues, promotes the growth of HR+ breast cancers.
  2. About 83% of breast cancers are HR+ and can be treated with hormonal therapy to block the effects of estrogen on the growth of breast cancer cells.
  3. These drugs are different than menopausal hormone therapies, which actually increase hormone levels.
  4. For premenopausal women, tamoxifen for up to 10 years is standard treatment; however, the combination of ovarian suppression and either tamoxifen or an aromatase inhibitor is recommended for those women with a high risk of recurrence.
  5. For postmenopausal women, aromatase inhibitors (i.e., letrozole, anastrozole, and exemestane) are the preferred hormonal treatment.
  6. The decision to treat with an aromatase inhibitor beyond 5 years is individualized based on patient factors and the expected benefit from the reduction in risk of subsequent breast cancers.
  7. Studies have found that adherence to hormonal therapies remains suboptimal, particularly among black women, and maybe in part due to out-of-pocket costs.

Targeted therapy for Breast Cancer

Triple-negative Breast Cancer Treatment

  • Multiple medications are available for the treatment of the HER2+ subtype, which accounts for about 15% of all female breast cancers in the US Trastuzumab, the first approved drug, is a monoclonal antibody that directly targets the HER2 protein.
  • Several newer drugs have been developed that target the HER2 protein and can be used in combination with trastuzumab or if trastuzumab is no longer working.
  • All invasive breast cancers should be tested for HER2 to identify women who would benefit from this therapy.
  • Additional targeted therapy drugs, such as CDK4/6, PARP, and PIK3 inhibitors, are available for the treatment of select patients with advanced disease.

Immunotherapy for breast cancer

Triple-negative Breast Cancer Treatment

  • Immunotherapy drugs are an emerging area of breast cancer treatment.
  • These drugs stimulate a person’s own immune system to recognize and destroy cancer cells more effectively.
  • Checkpoint inhibitors are one type of immunotherapy drug that has been identified to treat some breast cancers, particularly the triple-negative subtype.
  • Drugs that target these checkpoints help to restore the immune response against breast cancer cells.
  • Atezolizumab targets the PD-L1 “checkpoint” and can be used along with the chemotherapy drug nab-paclitaxel in patients with advanced triple-negative breast cancer whose tumor makes the PD-L1 protein.215 Research on other immunotherapy drugs for metastatic breast cancer treatment is ongoing.

Mammograms after breast-conserving surgery

The goad of breast cancer surgery is to remove the entire tumor from the breast. In short, some lymph nodes from the underarm area (axillary lymph nodes) may also be removed to check or find for cancer cells.

Besides surgery of breast cancer, treatment may also include radiation therapy, chemotherapy, hormone therapy and/or targeted therapy. This treatment help kill any cancer that might still be in the body.

Types of breast cancer surgery

There are two types of breast cancer surgery: Lumpectomy (breast-conserving surgery) and mastectomy. Here, survival with lumpectomy plus radiation therapy is the same as with mastectomy.

Lumpectomy

With a lumpectomy therapy, the surgeon removes that particular tumor and a small amount of normal tissue around it. Then the rest of the breast remains intact. Most often, the general shape of the breast and nipple area is retained.

A lumpectomy is also sometimes called breast-conserving surgery or therapy, partial mastectomy or wide excision. Radiation therapy is usually given after a lumpectomy to get rid of any cancer cells that may be left in or around the breast.

Mastectomy

Mastectomy is totally different from a lumpectomy. With a mastectomy, the whole breast is removed from the chest.

Nowadays, in some breast cancer cases, radiation therapy may be given after mastectomy.

Total (simple) mastectomy

The surgeon removes the whole breast from the chest and the lining of the chest muscle, but no other tissue.

Modified radical mastectomy

Here, the surgeon does the same as simple mastectomy but the surgeon removes the whole breast as well as the lining of the chest muscle and some of the axillary lymph nodes.

Skin-sparing mastectomy and nipple-sparing mastectomy

If you're having breast reconstruction at the same time as a mastectomy, the surgeon could also be able to use a skin-sparing or a nipple-sparing technique.

A skin-sparing mastectomy saves as much of the skin of the breast or chest as possible. The plastic surgeon can use this skin to assist form the reconstructed breast. A nipple-sparing mastectomy is a skin-sparing mastectomy that also keeps the sexy and beautiful nipple and areola (the darkly shaded circle of skin around the nipple) intact.

Also, the choice of surgery doesn't have an effect on whether you will need chemotherapy, hormone therapy and/or targeted therapy. Drug therapies are given based on the characteristics of the tumor, it means it totally depends on the tumor, not the type of surgery you have.
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