Education: Breast Cancer Treatments

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At Austin Breast Center we believe in empowering our patients with educational resources. The information you can read on our site is similar to the information that each patient is given in their new patient binder. Our staff explains the contents thoroughly, but recognizes that you may choose to do research on your own to educate yourself. Our surgeons design your treatment plan according to your cancer, and will find the option that is designed to provide you with the best outcome. On this page you will find common terms and types of treatments, but please feel free to ask our team if you have any questions, and be sure to visit our patient resource page to learn about services that will help you during treatment.

Common Breast Cancer Treatments:

Lumpectomy-

Many patients who are diagnosed with breast cancer choose a treatment that will save their breast. This surgery is called a lumpectomy, or partial mastectomy. The goal of the surgery is to remove the breast cancer, as well as a rim of healthy tissue. Lumpectomies can be performed as an outpatient procedure in an ambulatory surgery center or hospital. The surgery can be performed using a local anesthetic with intravenous sedation, a general anesthetic, or a regional anesthetic, depending on patient preference and the recommendations of the surgeon and anesthesiologist.

The goal of the lumpectomy is to remove the cancer, as well as normal tissue around the edge of the lumpectomy specimen, known as a clear margin. If there is cancer involving the edge, or margin, of the specimen on the final pathology report, repeat surgery to remove additional tissue may be required so that clear margins are obtained. In nearly all patients who choose breast conservation therapy, radiation therapy will follow the lumpectomy. In most cases, radiation therapy will be delivered after the surgery.

The long-term survival rates for early-stage breast cancer are the same for patients who choose breast conservation therapy and those who choose mastectomy. The risk of cancer recurring in the treated breast following a lumpectomy is not significantly higher than the risk of recurrence following mastectomy. 

Mastectomy- 

A mastectomy is an operation that removes the entire breast tissue. Mastectomy, which was the original surgery offered for breast cancer, is an effective way to obtain local control of many breast cancers, but it comes at the cost of losing the breast.

There are several different types of mastectomies:

  • Radical mastectomyA radical mastectomy is a historical surgery rarely performed today. The procedure removed the breast tissue, including the nipple, along with the chest muscles (pectoralis) and most of the lymph nodes underneath the arm. It was used prior to the development of modern chemotherapy and radiation therapy. Radical mastectomy has little place in modern medicine.
  • Modified radical mastectomy—A modified radical mastectomy removes the nipple, the breast tissue, and lymph nodes from the underarm. The chest wall muscle (pectoralis) is not removed. Lymph nodes in the lower portion of the underarm (axilla) are removed. During the procedure, the surgeon will avoid injuring two specific nerves that help control muscles in the shoulder and back region.
  • Total (or simple) mastectomy—A total mastectomy, also known as simple mastectomy, removes the nipple and breast tissue but does not attempt to remove  lymph nodes under the arm. Some excess breast skin is removed during a total or simple mastectomy so that a flat, straight-line incision results. A total or simple mastectomy is frequently combined with a sentinel lymph node biopsy.
  • Skin-sparing mastectomy—A skin-sparing mastectomy, like a total or simple mastectomy, removes the breast tissue and nipple. But in a skin-sparing mastectomy, the surgeon saves as much of the overlying breast skin as possible. The preserved skin is used to house a breast implant or other form of reconstructive tissue. A skin-sparing mastectomy is almost always followed by an immediate breast reconstruction, which is performed by a plastic surgeon. The cosmetic result of the reconstruction is usually superior with this approach as the normal breast skin is left intact.
  • Nipple sparing mastectomy—A nipple-sparing mastectomy saves a woman’s nipple, as well as her breast skin, although the underlying breast tissue is removed. While patients who have a nipple-sparing mastectomy must meet very strict criteria, it is a good option for some women. The nipple-sparing mastectomy is followed by immediate breast reconstruction.

Long-term survival in early-stage breast cancer patients is the same for patients who choose mastectomy and patients who choose lumpectomy combined with radiation therapy.

Which patients require a mastectomy?

  • Those who are not candidates for radiation therapy
  • Those who have multiple sites of cancer in different locations in their breast
  • Those who have widespread ductal carcinoma in situ, or DCIS (noninvasive breast cancer)
  • Those who have a very large cancer relative to the size of their breast (especially if attempts to shrink the cancer with chemotherapy have failed)
  • Those who have certain types of locally advanced breast cancer (for example, inflammatory breast cancer)
  • Those who have a genetic change that predisposes them to breast cancer
  • Those who have had breast cancer therapy previously (especially with prior radiation) and have a recurrent cancer or new cancer in that same breast

Axillary Node Dissection/Sentinel Lymph Node Biopsy

One of the pieces of information needed by your doctor, so that she can “stage” a breast cancer, is whether or not the cancer has spread to the lymph nodes, or glands, underneath the arm.Those lymph nodes are a component of your body’s lymphatic system, which helps your body fight infection as well as removing toxins and debris. The lymphatic channels are the system’s “streams” and “rivers” that drain into the lymph nodes, or its “lake.” Cancer cells from a breast cancer can break off and travel through the lymphatic channels into lymph nodes.


Axillary Node Dissection

Surgeons have used a procedure called an axillary lymph node dissection to determine if the cancer had spread to the lymph nodes. In this procedure, a surgeon removes the lymph node tissue within a triangle that is bordered by the axillary vein (the vein that drains the blood from the arm to the heart), the chest wall, and the large muscle going to the back, called the latissimus dorsi, sparing the nerves that cause muscle movement.

An axillary lymph node dissection typically removes 10 to 20 lymph nodes (or more) for evaluation. It provides very accurate staging and treatment for breast cancer; however, it may also cause long-term pain and swelling of the arm and/or breast, known as lymphedema. Because of this possible side effect, a more limited removal of lymph nodes known as sentinel lymph node biopsy was developed and adopted in the 1990s (see below). Some situations still require axillary node dissection, such as when multiple abnormal nodes can be felt or when nodes have not gone away following treatment administered before surgery, or in cases of inflammatory or recurrent breast cancer.


Sentinel Lymph Node Biopsy

The efforts of breast surgeons and the positive results of clinical trials led to the development and adoption of another procedure, known as sentinel lymph node biopsy.

The sentinel lymph node (or nodes) is/ are the first lymph node(s) to which a breast cancer will travel as it spreads. Therefore, the principle of sentinel lymph node biopsy is that if there is no cancer in the sentinel lymph node(s), then there should be no cancer in other lymph nodes “downstream” from the sentinel lymph node.

During the procedure, a surgeon will first use one of the following techniques to locate the sentinel lymph nodes:

  • Place radioactive material into the breast through an injection into the breast. The radioactive material will then collect into the sentinel lymph node, which may be located by use of a Geiger counter.
  • Inject a blue dye into the breast. The blue dye will collect into the sentinel lymph nodes, which can be identified. The blue dye can cause a blue discoloration at the site of injection which will usually fade and cause a discoloration of the urine for the first day.
  • Use both a radioactive dye and a blue dye to find the sentinel lymph nodes.

Then the surgeon will remove the sentinel lymph nodes through an incision underneath the arm. Once they are removed, the nodes are sent to a pathologist who will look at them underneath a microscope to see if they contain cancer. Determining whether the axillary lymph nodes contain cancer will help your doctor determine what additional breast cancer therapy, such as chemotherapy and radiation therapy, is needed to treat the breast cancer.

Radiation Therapy-

Radiation therapy, or radiotherapy, is used to treat breast cancer by killing cancer cells in an area that has been specifically targeted. (Adjacent normal cells are better able to repair the damage caused by radiation than are cancer cells.)

When Is Radiation Therapy Used?

Radiation is primarily used in the following settings:

  • After partial mastectomy (lumpectomy)
  • After mastectomy (whole breast removal), if the cancer invades into the chest wall or through the skin
  • After mastectomy and axillary staging if more than 4 nodes were positive.  If 1 to 3 nodes were positive after mastectomy, radiotherapy may be recommended

Why Is Radiation Therapy Used?

Multiple studies have shown that women who received radiation had a significant reduction of local or distant recurrence when compared to those who did not undergo radiation. They also found a significant reduction in the risk of death by breast cancer in those treated with radiotherapy. Thus, the patients who had radiotherapy when radiotherapy was indicated did better than those who did not receive radiotherapy. This is why radiation is included as part of the therapy for breast cancer.

How Is Radiation Therapy Administered?

Radiotherapy can be administered in two ways:

  • Whole-breast radiation therapy
  • Partial-breast radiation therapy

There are lifetime limits to the amount of radiation that can be given to a specific area of the body and this limit will determine the dosage of the radiation therapy. The physician who delivers radiation therapy (the radiation oncologist) will work with the breast surgeon and patient to determine the most suitable treatment.

Whole-Breast Radiation Therapy

Whole-breast radiation therapy treats all remaining breast tissue after a partial mastectomy (or lumpectomy). This therapy is delivered in daily doses over 4 to 6 weeks, typically Monday through Friday. In each session the patient lies in a machine that delivers the radiation, which is targeted on the breast tissue.

What to Expect If Whole Breast Radiotherapy Is Prescribed

  1. During treatment planning, which is sometimes done the same day that you are evaluated by the radiation oncologist, the target will be determined, imaging will be used to map the area to be targeted, and dosage and schedule will be decided).
  2. A virtual or clinical simulation of treatment may then be performed to ensure that the area intended for treatment is indeed the area that will be treated.
  3. Treatment will last 15 to 30 minutes of each day for approximately 25-30 days of therapy.
  4. Fatigue and mild breast dermatitis may be experienced, although most patients return back to baseline within a month of finishing therapy.
  5. The treated area could become red, warm, or itchy. There could be mild discomfort in the area, similar to sunburn.
  6. Skin may swell and darken, which may persist for a while.

This type of therapy can be accelerated, or shortened, using accelerated whole breast radiation therapy. (In this instance, the total dose is about 42.5 Gy.)

What to Expect If Accelerated Whole Breast Radiotherapy Is Prescribed

  1. During treatment planning, which is sometimes done the same day that you are evaluated by the radiation oncologist, the target will be determined, imaging will be used to map the area to be targeted, and dosage and schedule will be decided.
  2. A virtual or clinical simulation of treatment may then be performed to ensure that the area intended for treatment is indeed the area that will be treated.
  3. Treatment will last 15 to 30 minutes each day for approximately 16 days of therapy.
  4. Fatigue and mild breast dermatitis may be experienced, although most patients return back to baseline within a month of finishing therapy.
  5. The treated area could become red, warm, or itchy. There could be mild discomfort in the area, similar to sunburn.
  6. Skin may swell and darken, which may persist for a while.

Partial Breast Radiation Therapy

Partial breast irradiation therapy treats only the breast tissue where the breast cancer was located; therefore, a smaller amount of normal tissue will be irradiated with this type of radiation therapy.  In addition, fewer days of therapy are required to reach the desired overall dosage.

Although it is attractive to have a shorter course of radiotherapy, not everyone is a candidate. Most candidates are patients with favorable tumors.

What to Expect If Partial Breast Radiotherapy Is Prescribed

  1. During treatment planning, which is sometimes done the same day that you are evaluated by the radiation oncologist, the target will be determined, imaging will be used to map the area to be targeted, and dosage and schedule will be decided.
  2. A virtual or clinical simulation of treatment may then be performed to ensure that the area intended for treatment is indeed the area that will be treated.
  3. Treatment will last 15 to 30 minutes of each day, twice a day for approximately 5 days of therapy.
  4. Fatigue and mild breast dermatitis may be experienced, although most patients return back to baseline within a month of finishing therapy.
  5. The treated area could become red, warm, or itchy. There could be mild discomfort in the area, mostly like sunburn.
  6. Skin may swell and darken, which may persists for a while.

What to Expect If Accelerated Partial Breast Radiotherapy Is Prescribed

While the previously described treatments are administered using an external beam to the area, the following forms of accelerated partial breast irradiation, in which treatment duration is shorter, are administered internally:

Intracavitary brachytherapy—The radiation source is placed inside the area requiring therapy and may be done at the time of surgery or after. A balloon catheter is placed into the cavity left after the partial breast resection and is filled with radioactive material. It can deliver high doses of radiation to the tumor, while reducing the dose to the tissue around. It may be associated to increased breast induration or fibrosis post therapy, increased breast pain, or increased fat necrosis. 

Systemic Therapy

Surgery and radiation treat breast cancer in the breast and axilla. Systemic therapy treats breast cancer cells that cannot be treated by surgery or radiation, as well as treating breast cancer in the breast and axilla. The goal of systemic therapy, which gives medication via the bloodstream, is to treat the whole body.

Systemic therapy is most often given in the “adjuvant” setting (in other words, after surgery has been performed) to decrease the risk of the cancer returning. Your doctor will decide whether you need adjuvant systemic therapy and the type of therapy needed based on the size of the tumor, whether or not it has spread to lymph nodes, the tumor marker profile of your cancer (your cancer’s biology), and possibly genomic testing of your tumor (your cancer’s DNA).

Systemic therapy can also be given “neoadjuvantly,” meaning before surgery. Neoadjuvant therapy is recommended if a cancer is too large to be removed by surgery, in hopes of shrinking the cancer so that it can be surgically removed or, in some cases, to enable a lumpectomy to be performed instead of a mastectomy.

Systemic therapy is also given to patients whose cancer has recurred or spread to other organs. Once a breast cancer has metastasized outside of the breast and axilla, surgery plays a very small role in treatment and systemic therapy is used to kill or control the growth of the cancer.

Three different types of systemic therapies are used to treat breast cancer:

  • Chemotherapy-Chemotherapy is usually prescribed by a medical oncologist. It is most often given intravenously through a port-a-catheter, but some chemotherapy drugs come in pill form. Usually chemotherapy is given in cycles with time to recover between treatments. The type of chemotherapy drug your medical oncologist prescribes determines how long each cycle is. Some drugs are given only once every 2 to 3 weeks, while others are given daily for a week to 2 weeks.
  • Hormone therapy- medications that slow or stops the growth of hormone-sensitive cancer cells by prohibiting the body to produce hormones or by interfering with effects of hormones on breast cancer cells. Tumors that are hormone insensitive do not have hormone receptors and do not respond to hormone therapy.
  • Targeted therapy-drugs that target only cancer cells, while not attacking healthy cells.