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How is Breast Cancer Treated?

The treatment choices for each woman depend on the size and location of the tumor in her breast, the results of lab tests (such as hormone receptor tests), and the stage or extent of the disease. A doctor also considers the woman's age, general health, the size of her breasts, and whether or not she is in menopause when making recommendations about a treatment plan for her. A woman considers these recommendations based on a range of personal factors as well. 

TNM Staging of Breast Cancer

  • Size of tumor (T)
  • Spread of cancer to the axillary lymph nodes. If yes, then how many nodes are involved (N)
  • Spread of cancer to other lymph nodes in the neck or the chest
  • Metastasis or spread of cancer to other parts of the body (M)

Many women want to learn all they can about their disease and their treatment choices so that they can take an active part in decisions about their care. They are likely to have many questions and concerns about their treatment options. Most patients also want to know how they will look after treatment and whether they will have to change their normal activities. The doctor is the best person to answer such questions as what treatment choices are, how successful it is expected to be, what the risks and side effects may be, and how much it is likely to cost. Many times treatments are given in a sequential fashion. 

Types of Breast Cancer Treatment

Treatments for breast cancer are either local or systemic. Local treatments remove, destroy, or control the cancer cells in one certain area. Surgery and radiation therapy are local treatments. Systemic treatments are used to destroy or control cancer cells throughout the entire body. Chemotherapy and hormonal therapy are systemic treatments. A patient may have one treatment or a combination of different treatments. 

Different types of treatments have different goals. Below is a list of various treatments and how they may be used. 

SURGERY

Lumpectomy:  Surgeons remove only the tumor and a bit of the normal surrounding tissue.  This is ideal for patients who have small tumors and/or early-stage breast cancer.  With this option you will be able to maintain the appearance of your breast.   You may experience some pain and numbness after the procedure.  Radiation almost always follows a lumpectomy to ensure that cancer cells don't return.  

Sentinel Lymph Node Biopsy:  This type of biopsy is done to determine if breast cancer has spread into your lymphatic system.  The sentinel lymph node is the first lymph node where a tumor will drain and it will be removed during this biopsy.  Sentinel lymph node biopsy is also used in detecting melanoma.  

If the biopsy shows that this lymph node is cancer free that means the cancer hasn't spread and surgeons won't have to remove additional lymph nodes.  But if cancer is found in the sentinel lymph node then surgeons will need to remove other lymph nodes to see how far the cancer has spread.  

Axillary Node Dissection:  Axillary nodes are the lymph nodes found under the arm.  Surgeons may have to remove these axillary nodes if cancer is present in the sentinel lymph node, which is the first lymph node where a tumor will drain.  

A traditional axillary node dissection involves removing up to approximately 30 lymph nodes.  This is done through an incision in the arm and can accompany a mastectomy or lumpectomy.  

Mastectomy:

  • Mastectomy without reconstruction:  Surgeons will remove all of the glandular tissue and skin of the breast when you have a mastectomy.  Some women decide not to have breast reconstruction surgery along with their mastectomy.  Prosthetics are available to women who want to recreate the look of their breasts in clothing and can be worn in special-fitting bras. 
  • Modified Mastectomy:
  • Radical Mastectomy:  A radical mastectomy is the removal of all the breast tissue, skin, muscles and lymph nodes.  In the past this was the standard surgical care for breast cancer patients.  It is rarely performed today because radical mastectomies aren't more effective than other forms of surgery.  This type of mastectomy is used on women who have locally-advanced cancer that has invaded the muscle or chest wall.  
  • Nipple-sparing mastectomy with reconstruction:  As with any mastectomy, surgeons will remove all the glandular tissue in your breast.  With traditional mastectomies skin is taken from the patient's abdomen to reconstruct the breast.  During a nipple-sparing mastectomy we are able to preserve all of the patient's skin, nipple and areola after making sure they are cancer free.  Surgery to reconstruct the look of your breast is done at the same time.  
  • Areola-sparing mastectomy with reconstruction: All of your glandular tissue in the breast will be removed with this surgery.  Surgeons will be able to preserve the areola but remove the nipple while reconstructing the breast.  This can be done at the same time as your mastectomy surgery.  Skin-sparing and areola-sparing surgeries have become more popular in recent years and they have become a good option for many patients.  Women who have small stage I or II breast tumors are the best candidates for this surgery.  An areola-sparing mastectomy is done under general anesthesia and you will need a few weeks to recover.  
  • Prophylactic mastectomy:  A prophylactic mastectomy is done electively without the presence of breast cancer.  It is best done as a nipple-sparing or areola-sparing mastectomy.  Surgeons remove all of the glandular breast tissue and can reconstruct the breast at the same time.  

Patients who opt for this preventative mastectomy are at a higher risk for developing breast cancer. This means they either have a strong family history or test positively for the BRCA gene mutation.  If you test positive for the BRCA1 or BRCA2 gene mutation you have a 35 to 85 percent chance of developing breast cancer.  Some patients who have breast cancer in only one breast also opt to have a prophylactic mastectomy in the other breast.  

RADIATION THERAPY: 

The goal of radiation therapy is to kill cancer cells using x-rays and other types of radiation. This treatment can be used to shrink a tumor before surgery, to kill cancer cells that may remain in the breast or chest area after surgery, or to treat tumors in other areas of the body. Radiation therapy is usually given daily, Monday through Friday, for several weeks. Accelerated techniques are also used. 

CHEMOTHERAPY:

Chemotherapy is used to kill cancer cells with medicines that can go throughout the body. It may be used to shrink a tumor before surgery, to kill cancer cells that may remain in the body after local treatments, or to treat tumors that have already developed in other areas of the body. Chemotherapy is usually given in cycles, with treatments given every two to four weeks over several months. Treatment of breast cancer that has spread will usually involve hormone therapy and/or chemotherapy with or without trastuzumab (Herceptin), depending on whether or not the cancer cells over express the HER-2 protein. 

HORMONAL THERAPY: 

Hormonal therapy is used to stop the growth of cancer cells that rely on hormones. Hormonal therapy may be used to decrease the chances of cancer returning or a new cancer developing after surgery. It can also be used to treat cancer that has spread. Hormonal therapy may include the use of any of the following agents: anastrozole (Arimidex®), fulvestrant (Faslodex®), letrozole (Femara®), exemestane (Aromasin®), and tamoxifen (Nolvadex®). These maybe given as a daily pill or as an injection with treatment continuing for several years or as long as it appears to be working, if it is being given for active disease.

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