Breast Cancer Management

How treatment is planned

• The main treatments for breast cancer are• Surgery • Radiotherapy • Hormone therapy • Chemotherapy • Biological treatments (such as Herceptin)

Factors to be considered are• Whether patient have menopause • The type of breast cancer • The size of breast tumor • The stage of breast cancer • The grade of cancer cells • The results of tests on breast cancer cells • general health

Surgical therapies

• Breast-conserving surgery– Lumpectomy: Surgery to remove a tumor (lump)

and a small amount of normal tissue around it– Partial mastectomy: Surgery to remove the part

of the breast that has cancer and some normal tissue around it. This procedure is also called a segmental mastectomy.

Breast conserving surgery

Breast-conserving surgery. Dotted lines show the area

containing the tumor that is removed and some of the

lymph nodes

Surgical therapy

• Modified radical mastectomy: Surgery to remove the whole breast that has cancer, allowing removal of level one and level two lymph nodes but not the apical axillary lymph nodes and preserves chest wall muscles

Modified radical mastectomy

Modified radical mastectomy. The dotted line shows where the entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed

Surgical therapy

• Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision

Total (simple) mastectomy

Total (simple) mastectomy. The dotted line shows where the entire breast is removed. Some lymph nodes under the arm may also be removed

Surgical therapy

• Radical mastectomy: Surgery to remove the breast that has cancer, chest wall muscles under the breast, and all of the lymph nodes under the arm. This procedure is sometimes called a Halsted radical mastectomy

Breast reconstruction

• If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at a future time. The reconstructed breast may be made with the patient’s own (nonbreast) tissue like TRAM flap or by using implants filled with saline or silicone gel

Adjuvant therapy

• Adjuvant therapy (treatment given after surgery to increase the chances of a cure) may include the following:

• Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.

• Systemic chemotherapy with or without hormone therapy.

• Hormone therapy.

Radiation therapy

• is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Radiation therapy

– External radiation therapy uses a machine outside the body to send radiation toward the cancer.

• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

Chemotherapy

• Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

• Before surgery to shrink a tumor down (neoadjuvant therapy)

• After surgery to reduce the chance of it spreading or coming back (adjuvant therapy)

• As treatment for breast cancer that has spread or come back

Treatment after surgery

• The lymph nodes contained breast cancer cells

• large primary cancer in the breast • breast cancer cells were high grade (grade 3) • cancer cells did not test positive for hormone

receptors and so are not likely to respond well to hormone therapy

The drugs used to treat breast cancer

• Cyclophosphamide • Epirubicin • 5-Fluorouracil or 5 FU • Methotrexate • Mitomycin • Mitozantrone (mitoxantrone) • Doxorubicin (Adriamycin) • Docetaxel (Texture)

Chemotherapy

• NICE(National Institute for Health and Clinical Excellence) guidance recommends that adjuvant chemotherapy for breast cancer should consist of 4 to 8 cycles of a combination of drugs, including an anthracycline (epirubicin or doxorubicin).

Chemotherapy

• Some of the most common combinations used for breast cancer are

• CMF - cyclophosphamide, methotrexate and 5-FU • FEC - epirubicin, cyclophosphamide and 5-FU • E-CMF - epirubicin, followed by CMF • AC - doxorubicin (adriamycin) and cyclophosphamide • MMM - methotrexate, mitozantrone and mitomycin • MM - methotrexate and mitozantrone

Hormone therapy

• The female hormones oestrogen and progesterone are naturally produced by the ovaries before menopause. After the menopause, oestrogen is made in much smaller amounts by the adrenal glands. These hormones affect the growth of some breast cancer cells.

Hormone therapy

• drugs or treatments that block the effects of hormones, or lower the levels of oestrogen and progesterone, can be used as a treatment for some types of breast cancer.

Hormone therapy

• Before breast surgery • After breast surgery • That has spread or come back after it was first

treated

 hormone therapy for breast cancer

• Hormone therapy isn't always a suitable treatment for breast cancer.

• cancer cells can be tested for estrogen receptors (ER) or progesterone receptors (PR)

Hormone therapy after surgery

• Hormone treatment has been proved to reduce the risk of breast cancer coming back

• Hormone therapy seems to work best for women who have oestrogen receptor positive cancers.

• One advantage of hormone treatments is very safe to take and although side effects they are rarely serious.

Types of hormone therapy

• There are several types of hormone drugs used for primary breast cancer including

• Tamoxifen • Aromatase inhibitors (eg Arimidex) • Pituitary downregulators (eg Zoladex

Tamoxifen

• is often given to patients with early stages of breast cancer

• metastatic breast cancer• act on cells all over the body and may

increase the chance of developing endometrial cancer.

• blocks the uptake of estrogen by breast tissue

Tamoxifen

• Tamoxifen has made a major contribution to the treatment of breast cancer. Research by the Early Breast Cancer Triallist Collaboration Group (EBCTCG) has shown that taking tamoxifen greatly improves survival rates for women with oestrogen receptor positive breast cancer

• by 25% reduction in recurrence and 7% in mortality

Aromatase inhibitors

• Hormone-dependent breast cancer needs• Aromatase inhibitors decrease the body's

estrogen by blocking an enzyme called aromatase from turning androgen into estrogen

Aromatase inhibitors

• For the treatment of early stage breast cancer, certain aromatase inhibitors may be used as adjuvant therapy instead of tamoxifen or after 2 or more years of tamoxifen.

• For the treatment of metastatic breast cancer, aromatase inhibitors are being tested in clinical trials to compare them to hormone therapy with tamoxifen.

Switching off the ovaries

• Women who haven't had their menopause before being diagnosed with breast cancer are still producing estrogen. treatment to stop oestrogen production. They call this ovarian ablation. There are various ways of doing it.

Switching off the ovaries• Chemotherapy • Surgery to remove ovaries• 'LHRH analogue' or 'pituitary down regulator• LHRH stands for 'luteinising hormone releasing

hormone'.) It blocks a hormone in the brain that stimulates your ovaries to make and release oestrogen.

• The commonest of these drugs is goserelin (Zoladex)

Biological therapy

• Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory These antibodies can identify substances on cancer cells The antibodies attach to the substances and kill the cancer cells

Biological therapy

• Trastuzumab (Herceptin) is a monoclonal antibody that blocks the effects of the growth factor protein human epidermal growth factor type 2 receptors HER2, which transmits growth signals to breast cancer cells. About one-fourth of patients with breast cancer have tumors that may be treated with trastuzumab combined with chemotherapy.

Biological therapy

• NICE recommended Herceptin as a treatment option for women with HER2 positive early breast cancer in August 2006. Women who are suitable for treatment with Herceptin have it through a drip every 3 weeks for a year

Biological therapy

• guidance says you can have Herceptin for early breast cancer if

• cancer cells test positive for HER2 • You have completed surgery and

chemotherapy (and sometimes radiotherapy)

Sentinel lymph node biopsy followed by surgery

• The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor

• It is the first lymph node the cancer is likely to spread to from the tumor.

Sentinel lymph node

• A radioactive substance and/or blue dye is injected near the tumor

• The substance or dye flows through the lymph ducts to the lymph nodes.

• The first lymph node to receive the substance or dye is removed.

Sentinel lymph node

• A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. After the sentinel lymph node biopsy, the surgeon removes the tumor (breast-conserving surgery or mastectomy).

Sentinel lymph nodes

Treatment according the stages

Ductal Carcinoma In Situ (DCIS)

• Treatment of ductal carcinoma in situ (DCIS) may include the following:

• Breast-conserving surgery and radiation therapy with or without tamoxifen.

• Total mastectomy with or without tamoxifen. • Breast-conserving surgery without radiation

therapy.

Lobular Carcinoma In Situ (LCIS)

• Biopsy to diagnose the LCIS followed by regular examinations and regular mammograms to find any changes as early as possible. This is referred to as observation.

• Treatment of lobular carcinoma in situ (LCIS) may include the following:

• Tamoxifen to reduce the risk of developing breast cancer.

• Bilateral prophylactic mastectomy. This treatment choice is sometimes used in women who have a high risk of getting breast cancer.

Stage I, Stage II, Stage IIIA, and

Operable Stage IIIC Breast Cancer

• Treatment of stage I, stage II, stage IIIA , and operable stage IIIC breast cancer may include the following:

• Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.

• Modified radical mastectomy with or without breast reconstruction surgery.

Stage IIIB and inoperable stage IIIC breast cancer

• Systemic chemotherapy. • Systemic chemotherapy followed by surgery (

breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.

Stage IV and metastatic breast cancer

• Hormone therapy and/or systemic chemotherapy with or without trastuzumab (Herceptin).

• Tyrosine kinase inhibitor therapy with lapatinib combined with capecitabine.

• Radiation therapy and/or surgery for relief of pain and other symptoms.

New types of treatment are being tested in clinical trials.

High-dose chemotherapy with stem cell transplant

• High-dose chemotherapy with stem cell transplant is a way of giving high doses of chemotherapy and replacing blood -forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are given back to the patient through an infusion.

High-dose chemotherapy with stem cell transplant

• Studies have shown that high-dose chemotherapy followed by stem cell transplant does not work better than standard chemotherapy in the treatment of breast cancer.

Tyrosine kinase inhibitors as adjuvant therapy

• Tyrosine kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow. Tyrosine kinase inhibitors may be used in combination with other anticancer drugs as adjuvant therapy.

Tyrosine kinase inhibitors

• Lapatinib is a tyrosine kinase inhibitor that blocks the effects of the HER2 protein and other proteins inside tumor cells. It may be used to treat patients with HER2-positive breast cancer that has progressed following treatment with trastuzumab.

Clinical trials

• . Shorter Course of Radiation Might Be Just as Effective with Early Breast Cancer

(Posted: 05/23/2000, Updated: 10/14/2008) - For some women with early breast cancer, a shorter, more intense course of radiation therapy after surgery may be just as effective as the standard longer course, according to updated results presented at the 2008 annual meeting of the American Society for Therapeutic Radiation and Oncology

Clinical trials

• . Preventive Surgery Can Reduce Cancer Risk in Women with BRCA Gene Mutations(Posted: 05/28/2002, Updated: 10/04/2006) - Two separate studies in the May 23, 2002, issue of the New England Journal of Medicine support the practice of recommending preventive surgery in women with a genetic mutation that puts them at high risk of developing breast and gynecologic cancers.

Clinical trials

• Radiation Therapy Helps Prevent Recurrence of DCIS After Breast-Conserving Surgery(Posted: 07/12/2006) - The addition of radiation therapy to breast-conserving surgery for ductal carcinoma in situ reduced the risk of local recurrence by 47 percent, reinforcing the benefit of radiation therapy for these women, according to a report published June 26, 2006, in the online version of the Journal of Clinical Oncology.

Clinical trials• . Sentinel Node Biopsy Improves Quality of Life

in Early-Stage Breast Cancer(Posted: 05/10/2006) - In the May 3, 2006, issue of the Journal of the National Cancer Institute, investigators report results from the first multicenter randomized trial to compare postoperative quality of life between patients with early-stage breast cancer who underwent sentinel node biopsy and those who underwent standard axillary lymph node clearance.

Clinical trials

• Surgery Alone Not Sufficient for Ductal Carcinoma in Situ of the Breast(Posted: 02/22/2006) - Researchers examined whether some women with ductal carcinoma in situ (DCIS) can safely be treated with surgery alone and found that, in the absence of radiation therapy, the rate of local recurrence was unacceptably high, according to the March 1, 2006, issue of the Journal of Clinical Oncology.

The prognosis• The stage of the cancer• The type of breast cancer. • Estrogen-receptor and progesterone-receptor levels in

the tumor tissue. • Whether the cells have high levels of human epidermal

growth factor type 2 receptors. • How fast the tumor is growing. • A woman’s age, general health, and menopausal status

(whether a woman is still having menstrual periods). • Whether the cancer has just been diagnosed or has

recurred (come back).

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