Treatment
The majority of women present with early breast cancer and have surgery followed by adjuvant treatment. Some women have very early cancer that is not invasive. This condition is called Ductal Carcinoma-in-Situ (DCIS) or Lobular Carcinoma-in-Situ (LCIS). These are very early types of cancer that have not spread – they can often be completely cured by surgery. The treatment and outcome of breast cancer depends on stage of disease. In this guidance breast cancer treatment is described under the following headings:
- Treatment of early breast cancer
- Treatment of locally advanced breast cancer
- Neoadjuvant chemotherapy
- Treatment of metastatic breast cancer
- Names of some hormone therapies used in metastatic or locally advanced breast cancer
- Spinal cord compression
Treatment of early breast cancer
For women with early breast cancer the first stage of treatment will involve surgery to remove the breast lump and usually some or all of the lymph nodes from the armpit on the same side. To get clearance of the cancer the tumour and a rim of normal breast tissue will be removed. Whether the whole breast or just part is removed will depend on the size of the tumour in proportion to the size of the breast. The operations used to check lymph node involvement are called lymph node sampling or ‘sentinel’ lymph node sampling. If axillary lymph nodes contain tumour cells or the tumour is large all lymph nodes from the axilla will be removed in a bigger operation called an axillary lymph node clearance.
Surgery will usually be followed by radiotherapy and hormone therapy with or without chemotherapy; this treatment after surgery is called ‘adjuvant’ therapy and is aimed at reducing the risk of breast cancer cells growing again at the site of surgery (local recurrence) or elsewhere in the body (metastatic cancer).
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Treatment of locally advanced breast cancer
Locally advanced breast cancer is a term used to describe a breast cancer that has not metastasised but has a poor survival outcome because the breast cancer is:
- very large; or
- has invaded surrounding structures such as the chest wall muscle or skin – involvement of the skin can lead to breakdown of the skin (ulceration) over the tumour. This may be described in the medical evidence as a ‘fungating’ tumour; or
- is associated with large lymph node metastases in the arm pit.
Neoadjuvant chemotherapy
This type of chemotherapy is used over several months in locally advanced breast cancer to ‘downstage’ disease. Progress will generally be monitored with either CT or MRI scans although rarely PET scanning will be used to see if a tumour is shrinking. When treatment works, the tumour shrinks enough to be removed by surgery. Surgery will generally involve partial or complete removal of the breast and an axillary node clearance. Surgery in these cases may be followed by adjuvant chemotherapy and radiotherapy as in early breast cancer. These women are expected to make a complete recovery for a time following treatment (if initial chemotherapy is successful) but they are at high risk for recurrent disease.
If the tumour fails to respond to neoadjuvant chemotherapy, other treatments such as hormone treatment can be tried but the approach will be essentially palliative.
Treatment of metastatic breast cancer
Once breast cancer has spread, it is not curable but can still be treated and controlled. Breast cancer commonly spreads to the brain, liver, lungs and bones. Women may be alive and well for some time with metastatic disease particularly isolated bony metastases. If metastases are multiple or present in any soft tissue such as brain or liver this leads to a much shorter survival.
Types of treatment used may include:
- Palliative care - click on the link for details
- Chemotherapy – to reduce symptoms and improve quality of life
- Radiotherapy – to reduce pain usually from metastases – especially bone metastases
- Hormone therapy – there are many hormone treatments used in late or recurrent breast cancer.
- Surgery – is usually avoided but mastectomy to remove a fungating tumour may be necessary.
Examples of specific treatments given for metastatic disease include:
- Brain metastases – steroid tablets and radiotherapy to the head
- Liver metastases – chemotherapy
- Lung metastases – chemotherapy
- Bony metastases – radiotherapy and tablet treatments such as Biphosphonates and or orthopaedic surgery to stabilise the bone. Also see spinal cord compression.
Names of some hormone therapies used in metastatic or locally advanced breast cancer
- Anti-oestrogens including tamoxifen and toremifene – see above
- Aromatase inhibitors including anastrozole (Arimidex) Exemestane (Aromasin), Letrozole (Femara) – see above
- LHRH analogue including Goserelin (Zoladex) - this prevents the production of oestrogen, its side effects are menopausal symptoms, weight gain and tiredness. It is given as an injection every 1 to 3 months.
- Progesterones including Medroxyprogesterone acetate (Provera) and Megestrol acetate (Megace), these are synthetic versions of the natural female hormone progesterone. These drugs are tablets that need to be taken daily. Side effects include hunger, weight gain and occasionally anxiety and mood swings.
Spinal cord compression
Breast cancer cells can metastasise to bone. If a lot of breast cancer cells grow in the spinal column the vertebrae can collapse (fracture); this is painful in itself, but it can also squash and damage the spinal cord. The lower part of the spinal cord carries nerve impulses to the muscles of the legs to enable walking and nerve impulses of sensation from the legs, bladder and bowel. These sensory nerve impulses are essential to enable balance for normal walking and opening of the bladder and bowels. When this area of the spinal cord is crushed symptoms can range from numbness and tingling of the lower limbs with loss of sensation when passing urine, to the inability to pass urine or open the bowels and loss of sensation in the legs with paralysis. When the spine is affected in this way it can sometimes be stabilised by surgery. Radiotherapy will also be given. Any loss of sensation or functional ability is unlikely to be recovered unless treatment is instituted within 24 hours of onset of symptoms.
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Amended May 2009
