Breast Cancer Treatment
There are many ways to treat breast cancer but the overall goal is to remove the cancer from the breast and reduce the risk of the disease returning in the future. The treatment of breast cancer is always tailored to an individual patient and often involves several different therapeutic approaches.
Local treatment involves surgery to remove all identifiable cancer from the breast and draining axillary lymph nodes and radiotherapy to treat any microscopic cancer cells that may be left in the breast/ chest wall after the operation. Based on the available evidence, the 10-year risk of breast recurrence in the chest wall after mastectomy is between 2-9%. This is very similar to the 10-year risk of cancer recurrence in a breast treated with a lumpectomy/ wide-local excision and radiotherapy (4-7%). Radiotherapy after mastectomy is advised in certain circumstances.
Systemic therapy involves giving medication as a tablet or intravenously so that the treatment is carried to every part of the body and includes hormone therapy, chemotherapy and monoclonal antibody therapy.
For some women, the safest operation to treat breast cancer is a mastectomy. Often this can be combined with an immediate breast reconstruction and in some cases the nipple can be preserved. Otherwise, the reconstructive surgery is delayed until all cancer treatment has been completed.
Perhaps the simplest way to reconstruct a breast is using a cosmetic breast implant. The implant can be placed under the pectoralis major muscle. This can be performed in two stages using a tissue-expander to create a space under the muscle, which is then exchanged for a permanent cosmetic implant several months later. A single stage approach is possible by using a mesh (usually an animal product) to cover the lower part of the implant. Sometimes the mesh can completely cover the implant so that it sits on top of the pectoralis major muscle. Some women have very ptotic breasts and their own skin can be incorporated within the reconstruction to cover the lower part of the implant (dermal flap). Implant based reconstructions have to be carefully considered in women who have had breast radiotherapy or are very likely to have radiotherapy. This is because radiotherapy can worsen the natural scarring that occurs around all implants leading to hardness, pain and cosmetic deterioration.
Another way to reconstruct a breast is using the latissimus dorsi (LD) muscle. The LD is a large back muscle, which gets its main blood supply from blood vessels in the armpit. This means that it can be disconnected from the back and swung round to the front to reconstruct a breast. Extra fatty tissue from the back can also be taken with the muscle to provide enough volume for a whole breast (extended LD reconstruction). The LD muscle can be used to cover a cosmetic implant for extra volume in the reconstructed breast. It is a useful technique for delayed reconstructions because skin from the back can also be moved to the front to replace the skin removed during the original mastectomy. Again, using an implant in a woman who is likely to have radiotherapy must be carefully considered but for patients who have had radiotherapy in the past this type of reconstruction is often a good option. Losing the LD muscle may reduce shoulder function and certain activities such as shutting a car boot may become difficult.
The third type of reconstruction involves using a patient’s own tissue to form a new breast. This type of surgery is undertaken by plastic surgeons that are trained in microvascular surgery. Fatty tissue, sometimes with muscle, is removed from one part of the body and transferred to make a breast. The blood vessels supplying the tissue are cut and then sewn onto blood vessels in the chest to keep the reconstruction alive. The usual donor area is the abdomen but other areas of the body can also be utilised. This is a very good reconstructive technique as it uses only ‘natural’ tissue and doesn’t depend upon an implant. For the right patient, it can be used immediately after a mastectomy or as a delayed procedure after radiotherapy.
If the sentinel lymph nodes are found to contain tumour cells then an axillary node clearance may be required to help plan further treatment and reduce the risk of breast cancer coming back in the armpit in the future.
There are many potential side effects associated with chemotherapy for breast cancer such as hair loss, nausea and an increased risk of infection. Each patient receiving chemotherapy will be given a supply of anti-sickness medication to have at home if needed and may also need medication to limit the risk of an infection. The oncology team have a 24-hour system of contact so that the patient can get expert advice by telephone day or night. The chemotherapy nurse specialists will offer women the option of using the ‘cold cap’ or ‘scalp-cooling’, which is a technique to try and limit the dose of chemotherapy that hair follicles receive and make it less likely that hair loss will occur. This technique is not always successful but should always be available if requested. For women who are still having periods, they may wish to be referred to a team of fertility experts if the woman expresses a wish to try and have a family in the future. This is because chemotherapy can cause infertility and bring on the menopause. This is more likely to happen the older the woman is at the time of diagnosis. Fertilised embryos and unfertilised eggs can be stored as long as this is done before chemotherapy starts.
While a patient is undergoing chemotherapy treatment, they will have close contact with the chemotherapy nurse specialists. This is to try and minimise the individual side effects that a woman experiences and to ensure that all is proceeding safely. The review process will include a blood test every third week to check liver and kidney function and that the immune system is satisfactory.
Radiotherapy is performed as an outpatient procedure and is usually administered daily (not week-ends) for three weeks. The therapy starts approximately 4 weeks after surgery.