Treatment
Treatment broadly consists of two parts:
Locoregional treatment, which pairs surgery with radiotherapy to treat cancer cells in the breast and armpit lymph nodes
Mastectomy and Lumpectomy
The two surgical techniques used to treat breast cancer are mastectomy and lumpectomy:
A mastectomy entails the removal of the whole breast, including the nipple.
A lumpectomy entails the removal of a tumour along with a margin of normal breast tissue. This leaves the rest of the breast untouched. After a lumpectomy, radiotherapy is given to the breast for 6 weeks. This treatment is safe and has a low recurrence rate. Breast cancer patients who are suitable for lumpectomy and radiotherapy have:
- Tumours situated away from the nipple
- Tumours less than 2-3 cm in diameter
- Breasts of a suitable size
Breast cancer patients are not suitable for a lumpectomy if they:
- Are under the age of 30 due to a high recurrence rate
- Are pregnant
- Have connective tissue disease
- Have 2 or more tumours within the same breast
Armpit Surgery
Armpit surgery is required to remove the axillary lymph nodes for diagnostic and therapeutic purposes. Knowing whether cancer has entered the axillary lymph nodes is important in determining the stage of breast cancer. Removal of the axillary lymph nodes also prevents the recurrence of cancer in this area. Some breast cancer patients may experience temporary shoulder stiffness and arm swelling after this procedure.
Sentinel Lymph Node Biopsy (SLN Biopsy)
1 or 2 lymph nodes act as a gateway to the axilla and will be the first to be affected should cancer enter this area of the body. By identifying and biopsying these sentinel lymph nodes, it can be determined whether the rest of the axillary lymph nodes are affected by cancer.
SLN biopsy is a viable treatment option for patients with:
- Small tumours
- Non-palpable nodes in the axilla
SLN biopsy is not recommended for:
- Patients with large tumours and palpable nodes, who should undergo an axillary dissection
- Patients with non-invasive tumours, for whom no axillary surgery is required
Post-Mastectomy Breast Reconstruction
Following a mastectomy, breast reconstruction can be carried out using a variety of techniques. The following considerations may be important to note:
- Timing of Reconstruction
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Cost and Complications
The breast can be reconstructed using an artificial implant (usually made of silicon) or a skin-muscle flap from the patient's own body. An artificial implant is quicker and cheaper to undertake but some women may be averse to the presence of a foreign object in their body.
Extracting a skin-muscle flap from the patient is a natural method for breast reconstruction but is longer and costlier to undertake. This method may also lead to complications surrounding the area where the skin-muscle is taken.
- Cancer Recurrence
An artificial implant or a reconstructed breast has not been found to interfere with the detection of cancer recurrence or to increase the risk of cancer recurrence.
Radiotherapy
Radiotherapy utilises radiation to treat breast cancer. Radiotherapy is recommended for the local treatment of breasts following a lumpectomy. It is given over 6 weeks during daily outpatient treatment sessions. Side effects are usually tolerable and mainly confined to the treatment area. Radiotherapy is also recommended for women after mastectomy whose risk of local recurrence is high and whose lymph nodes and tumours are more than 4cm wide.
Systemic treatment utilises chemotherapy or hormonal drugs such as Tamoxifen to eliminate clumps of cancer cells that may be circulating in a woman's body. The type of treatment varies depending on need and appropriate treatment to be adopted.
Risk Assessment
Based on microscopic analysis of biopsies or breast cancer cells, women may be divided into low or high risk groups. Women in the low-risk group may be treated with Tamoxifen while women in the high-risk group are offered systemic treatment. There are 3 main forms of systemic treatment:
A. Cytotoxic Chemotherapy
This involves the administration of toxic drugs which are harmful to both cancer cells and healthy cells. Given their toxicity, the drugs are administered at controlled dosages over a period of time to limit their toxicity while eliminating cancer cells.
There are 3 main regimes, each consisting of a combination of cytotoxic drugs. Depending on the condition and needs of the patient, the most suitable regime is selected and administered at 3 weekly intervals over 4 to 6 months.
The following list of short-term side effects resulting from chemotherapy may be severe but are usually tolerable and temporary.
- Low total white cell count (Less than 2000/mm3)
- Fever
- Infection
- Nausea
- Diarrhoea
- Hair loss
- Low platelet count (Less than 50,000/mm3)
- Blood clots in veins
- Cystitis
- Weight gain (More than 10%)
Although these are significant side effects associated with cytotoxic chemotherapy, the mortality rate resulting from chemotherapy is low. Nevertheless, in very sick patients, death may result from overwhelming infection or the formation of blood clots in veins.
3 major long-term side effects associated with chemotherapy have been identified:
- Premature menopause – A woman in her forties has a 50 per cent chance of experiencing premature menopause if she undergoes chemotherapy. The effects of menopause are more severe in younger women, varying from hot flushes, palpitations, and dry skin to more debilitating conditions such as osteoporosis and increased risk of cardiovascular disease.
- Cardiac toxicity – Adriamycin (or Doxorubicin) is a common drug component of chemotherapy that can cause heart failure. However, the probability of experiencing this side effect is low and can be decreased by:
1. Assessing cardiac function
2. Limiting the dose administered
3. Calibrating the method of drug administration
- Risk of a second cancer – Rare instances of chemotherapy-induced leukaemia have been recorded.
B. Hormonal Manipulation
This entails altering or stopping the secretion of oestrogen in the patient's body as a means of treating breast cancer through the use of Tamoxifen. It is taken orally once a day and causes few side effects. It is effective for:
- Women at high risk of breast cancer and is taken as a preventive drug.
- Women whose breast cancer is oestrogen receptor positive (ER+) and is at low risk of recurrence. Tamoxifen is given as the sole systemic drug.
- Women whose breast cancer is ER+ and is at high risk of recurrence. Tamoxipfen is combined with chemotherapy or other measures of hormonal manipulation.
C. Ovarian Ablation
This refers to methods to stop the secretion of oestrogen in a woman's body in order to reduce the stimulation of cancer cells and hence reduce the chance of cancer recurrence. This method applies only to pre-menopausal women and leads to premature menopause. Ovarian ablation can be achieved by surgical or non-surgical methods:
- Surgical Oophorectomy - Surgery is undertaken to permanently remove the ovaries. This method is now seldom used.
- Radiation Castration - Radiotherapy is given to patients over a 2 week period to permanently disable the ovaries from secreting oestrogen. This is a quick and relatively painless method.
- Ovarian Suppression - The secretion of oestrogen is controlled by the pituitary gland. Drugs can be prescribed to temporarily suppress oestrogen secretion. Ovarian function usually recovers once the drug is stopped. This is a relatively expensive method.