Treatment of breast cancer
There are different types of breast cancer. For example, some tumors are small but grow rapidly whereas some are big in size but grow at a very slower pace. This is why the treatment for breast cancer needs to be customized as per the patient’s profile. Some of the common parameters that need to be taken into account before deciding the type of treatment include:
- The location of the cancer in the breast
- The size of the tumor
- Whether it has spread to other sites of the body
- The type of the cancer
- The stage/grade of the cancer
- Menopausal status of the woman
- The age of the patient
- The presence of any genetic mutations
- The presence of hormonal receptors or proteins on the cancer cells
- The general health & fitness of the patient
For example, early-stage invasive breast cancer may require surgery whereas systemic treatment with chemotherapy or hormonal therapy might be the preferred option for large cancer or those growing at a rapid rate.
The treatment options for breast cancer might involve one or more of the following:
- Chemotherapy
- Radiation therapy
- Hormonal therapy
- Targeted therapy
- Immunotherapy
- Surgery
1. Chemotherapy
It involves the use of medications/drugs to shrink or kill the cancerous cells. These medications can be given either in the form of pills or as injections (through intravenous mode) or both. Usually, chemotherapy involves intravenous administration of the drugs either through a central line (long tube attached to the large vein in the chest) or a cannula (thin short tube attached to the vein in the arm).
When is chemotherapy recommended?
Chemotherapy is found to be most effective when these drugs are used in combinations. It can be given before surgery (neoadjuvant) or after surgery (adjuvant).
Chemotherapy before surgery aims to shrink the tumour down & lower the chances of recurrence of the cancer. Chemotherapy after surgery might be recommended if:
- There is a presence of cancer cells in the lymph nodes under your arm
- There is a large tumour in your breast
- The cancer cells were of a high grade (grade 3 or more)
- Hormone therapy fails to work (due to absence of hormone receptors on the cancer cells)
How many cycles?
A chemotherapy schedule involves use of a combination of drugs in a specified number of cycles set over a specific time by your doctor. The regimen can be once a week, 2 weeks, 3 weeks or 4 weeks. In most cases, you can have chemotherapy cycles in a day & come back home. In some cases, you may need to stay in the hospital overnight or for a few days.
Are there any side-effects?
Some of the common side-effects of chemotherapy include:
- Fever
- Loss of appetite
- Weight loss
- Extreme fatigue
- Risk of infections
- Bleeding/bruising easily
- Diarrhoea or constipation
- Hair loss
Note: Consult your doctor if you have any signs of an infection following the treatment.
Types of drugs
Some of the common examples of chemotherapy drugs include
- Cyclophosphamide
- Vinblastine
- Vinorelbine
- Fluorouracil
- Capecitabine
- Gemcitabine
2. Radiation therapy
This therapy uses radiation (high-energy rays (similar to X-rays) to kill the cancer cells. This therapy can also be used along with other treatment modalities such as chemotherapy and surgery. The radiotherapy team will work out the radiotherapy which includes the dose of the radiation, where you need it & also the dose of the surrounding tissue.
Types of radiation therapy
- External-beam radiation therapy (radiation given from a machine outside the body)
- Intraoperative radiation therapy (radiation given using a probe in the operating room)
- Brachytherapy (radiation given by placing radioactive sources into the tumor)
External-beam therapy is the most common one which is used for whole breast & partial breast radiation therapy.
What happens during radiotherapy?
The radiographers will tell you to lie on a special board called a breast board. If you have had a shell (mould) made, it will be fixed over your breast & you might need to raise your arms over your head. After this, the experts will line up the machine using the marks on your body or shell to place you in the right position.
As you lie still on your back, multiple images will be taken before your treatment to make sure you are in the right position. Your radiographer might ask you to hold your breath for few seconds (at times) during the treatment.
How many cycles?
A radiotherapy schedule involves a specified number of cycles set over a specific time by your doctor for example 5 days a week for 3 to 6 weeks. The daily treatment of radiotherapy is known as a fraction.
Who should take it?
It is recommended:
- When the cancerous mass is huge enough that it can’t be removed with surgery
- To treat metastatic breast cancer (cancer that has spread to other parts of body such as bones or brain)
- After breast-conserving surgery (BCS) to lower the risk of cancer recurrence in the same breast or nearby lymph nodes
- After mastectomy (breast removal surgery), if cancer is found in nearby lymph nodes or is larger than 5 cm in size or has spread to nearby skin or muscle
What are the side-effects?
Radiation therapy can cause side effects such as
- Fatigue
- Swelling of the breast
- Redness and/or skin discoloration
- Pain or burning in the skin (at the site of radiation)
- Pneumonitis (Very rare)
3. Hormonal therapy
This treatment approach works by either lowering or blocking the production of the hormones needed for the growth of the cancer cells. This therapy is often used as an adjuvant therapy post surgery to help lower the risk of recurrence. Most types of hormone therapy either lower estrogen levels or stop estrogen from acting on the breasts thereby aiding in the treatment.
Who should take it?
Hormone therapy is only likely to work if the breast cancer cells have estrogen receptors (ER). It is seen that around 70% of breast cancers have estrogen receptors. These types of breast cancers are known as estrogen receptor positive cancer or ER positive cancer.
The type of hormone therapy used depends on the status of menopause, chances of cancer recurrence & side-effects of the drug.
How to take it?
The drugs used for hormone therapy are available in the form of tablets or injections. The drugs such as tamoxifen or aromatase inhibitors are usually advised for a period of 5 years (or more depending on the need), whereas fulvestrant is given in the form of an injection once every month.
Types of drugs
Examples of these class of drugs include
- Tamoxifen acts as selective estrogen receptor modulator (SERM) that blocks estrogen receptors
- Fulvestrant acts like an anti-estrogen which blocks and damages estrogen receptors
- Letrozole acts as aromatase inhibitors which lowers the level of estrogen by blocking the production of the hormone estrogen
- Megestrol acts as progesterone-like drug which lowers progesterone level in the body
What are the side-effects?
The side-effects of hormonal therapy might vary based on the drugs used, however some of the common side-effects include:
- Hot flushes and sweating
- Irregular periods
- Low sex drive
- Vaginal dryness or discharge
- Feeling sick
- Joint pain
- Mood changes
- Tiredness
4. Targeted therapy
Targeted therapy is a treatment in which the drugs are targeted to cancer’s specific genes, proteins, or environment that contributes to cancer growth and survival. Unlike chemotherapy, this treatment works in a focused manner & limits the damage to the healthy cells. As tumors might have different targets, your doctor might need to run a few tests to identify the target before initiating the treatment.
Hormonal therapies were the first approved targeted therapy for breast cancer. Recently, HER2 (human epidermal growth factor receptor 2) targeted therapies were approved for HER2-positive breast cancer. HER2 is a gene that can play a role in the development of breast cancer.
Who/when to take it?
Targeted therapy is usually recommended
- Before surgery (to shrink a cancer)
- After surgery (to reduce the risk of recurrence)
- For secondary breast cancer (if cancer has spread to other parts of the body)
- If cancer recurs
Examples of drugs
Some of the common examples include:
- Trastuzumab approved for non-metastatic HER2-positive breast cancer
- Pertuzumab approved for HER2-positive breast cancer in combination with Trastuzumab & chemotherapy
- Pertuzumab, trastuzumab, and hyaluronidase–zzxf approved for people with early-stage HER2-positive breast cancer
- Neratinib approved for higher-risk HER2-positive, early-stage breast cancer
- Alpelisib used hormone receptor-positive, HER2-negative metastatic breast cancer along with fulvestrant
What are the side-effects?
The side effects of targeted therapy for breast cancer is dependent on the type of drug, the dose of the drug, overall health & other drugs used for the therapy (along with it). Some of the common side-effects seen include:
- Feeling sick
- Breathlessness
- Allergic reactions
- Fatigue & tiredness
- Diarrhea or constipation
- Body pain
- Hot flushes
- Muscle spasms
- Soreness
- Loss of appetite
5. Immunotherapy
As the name suggests, immunotherapy works by helping the immune system work to fight cancer cells. This therapy uses substances either made naturally by the body or chemically (in the form of drugs) to:
- Stop or slow down the growth of cancer cells
- Prevent the spread of cancer other parts of the body
- Aid the body to kill cancer cells
Examples of drugs
Some of the approved immunotherapy drugs to treat breast cancer are:
How does it work?
One of the immune cells produced by our body is T cells. These cells fight infection by analyzing and identifying the proteins present on a cell’s surface. If the surface proteins signal that the cell is normal & healthy, then T cells leave it alone. However, if the surface proteins indicate that a cell is cancerous or abnormal, then T cells attack the cell. These specialized proteins that keep healthy cells and tissues safe are called immune checkpoints. Immunotherapy drugs are targeted to these proteins to help identify cancerous cells & attack them.
What are the side-effects?
Immunotherapy medicines are very new and have not been studied as long as other cancer treatments such as surgery, chemotherapy, radiation therapy, and hormonal therapy. However, research has revealed that there is a risk that medicines targeted to specific proteins may help to attack the healthy cells. This in turn can lead to various effects on the major organs of the body such as the lungs, liver, pancreas, kidneys and the intestines.
6. Surgery
Mastectomy
It involves surgical removal of the entire breast (and not just the lump as in the case of lumpectomy). Depending upon the type and the stage of breast cancer, your doctor might decide whether you need to undergo mastectomy or lumpectomy. Your doctor is most likely to recommend mastectomy if you have:
- a large lump (tumour), particularly in a small breast
- a tumour in the middle of your breast
- more than one area of cancer in your breast
- large areas of DCIS in your breast
- had radiotherapy to the breast before
The type of surgery depends on how big the cancer is, where it is in the breast and whether you have a breast reconstruction. The scar from a simple mastectomy extends across the skin of the chest and into the armpit. Breast reconstruction surgery can be performed at the same time after mastectomy or later as per the convenience.
You may also go for prophylactic mastectomy which is preventive removal of the breast to lower the risk of breast cancer in high-risk people.
Breast-conserving therapy
Also known as lumpectomy, this technique involves the excision of the tumor and some of the normal tissue that surrounds the cancer cells. Technically, a lumpectomy is a partial mastectomy, because part of the breast tissue is removed.
Before the surgery, your surgeon or a nurse may draw markings on your breast that show where the incision will be made. It is followed by radiation of the entire breast area. The lumpectomy surgery itself should take about 15-40 minutes.
You may be advised to rest at home followed by instructions to take medications, care for the incision area/stitches, exercise the arm & report any signs of infection at the earliest to the doctor. Moreover, it should be followed by a follow-up as it helps in a prompt detection of local recurrence of the cancer (if any) post the therapy.
Breast reconstruction therapy
It is mostly considered by women who have a mastectomy or lumpectomy. It is a surgical procedure in which a plastic surgeon helps to recreate a breast . There are two main techniques for reconstructing your breast:
Implant reconstruction which involves inserting an implant (which is a saline-filled or silicone gel-filled forms to reshape the breast)
Autologous or "flap" reconstruction which involves use of tissue transplanted from another part of the body (such as your belly, thigh, or back)
Breast prostheses come in many shapes, sizes, and materials: silicone gel, foam, or fiberfill interior. There are two types: a lightweight model (polyfill or foam) and a silicone prosthesis (look more realistic & feel natural).
Here’s more on cancer treatment options by a medical oncologist.
The prognosis of breast cancer depends on:
1. Stage of cancer (lymph node status and tumor size)
2. Expression of certain proteins [estrogen receptor and progesterone receptor, human epidermal growth factor receptor 2 (ER and PR, HER2)]
3. If the woman is still menstruating or has had menopause
Regular examination and screening through mammography can help in early detection of breast cancer.
