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Breast Cancer - How to prevent?

Breast Cancer - Treatments

Treatment of breast cancer often involves more than one therapy, and may be a combination of therapies.

Treatment recommendations depend on factors such as the cancer type, stage of the cancer, size of the tumour in relation to the breast size, whether breast preservation is desired and the patient’s general health.

Personal preferences de-termine certain choices, if the option is available, such as the options for the type of surgery. Being diagnosed with breast cancer and having to decide on the treatment options may be difficult. The support of friends and family during the consult and discussion on the results of tests and treatment is recommended.

treatment types for breast cancer

Local and Systemic Therapy

  • Local therapy includes surgery and radiotherapy. It treats the cancer at the site e.g. the breast and axilla (armpit) without affecting the rest of the body.
  • Systemic therapy refers to the use of drugs which enter the bloodstream to reach the rest of the body, targeting cancer cells anywhere in the body. Chemotherapy, hormone therapy, and targeted therapy are systemic therapies.

In early breast cancer, surgery is the first treatment of choice. Chemotherapy, targeted and hormonal therapy may be used before surgery (neoadjuvant therapy), or after surgery (adjuvant therapy). Radiotherapy is usually given after surgery.

In stage IV cancer, the goal is to stabilise the disease with systemic therapy. However, local treatment of tumours with radiation therapy or surgery may be recommended when symptoms need to be alleviated.

LOCAL THERAPY

Surgery

Surgery for breast cancer is considered in two parts: breast and axillary lymph nodes.

I. Surgery (Breast)

The two broad options are breast-conserving surgery (BCS) or mastectomy.

1. Breast-Conserving Surgery (BCS)

  • Wide Excision Breast-Conserving Surgery
    In this surgery, the breast cancer and a rim of normal surrounding breast tissue are removed. The breast will remain; a scar and some changes in shape and size of the breast are expected. Patients can go home on the same day or the next day.

    After recovering from breast-conserving surgery, radiation therapy to the breast (Mon to Fri) for 3 to 6 weeks is recommended. It helps to reduce the risk of recurrence.

    A second operation is needed if cancer cells are noted at the edge in the histological (microscopic) assessment of the removed portion. This occurs in 10 to 15 percent of patients.

breast cancer treatment - breast-conserving surgery wide excision

  • Oncoplastic Breast-Conserving Surgery
    In some patients undergoing breast-conserving surgery, additional procedures may be recommended to prevent severe deformities of the breast.
    • Breast-Conserving Surgery with Mammoplasty (Reshaping with Breast Uplift / Breast Reduction)
      To avoid significant breast deformity after breast-conserving surgery (wide excision), breast reshaping (mammoplasty) may be performed. This is possible if the patient has sufficient remaining breast volume, and often takes the form of a breast uplift or breast reduction. Excess skin may need to be removed, and the exact scar depends on the size of cancer removed and the patient’s existing breast shape.

      The most common scars are illustrated (below). If a large reduction is needed, and significant asymmetry in breast volume is anticipated, surgery to the opposite breast may be performed to improve final breast symmetry. This may be performed at the same surgery or as a delayed procedure after cancer treatment.
    • breast-conserving surgery with mammoplasty

    • Partial Breast Reconstruction – Volume replacement with a local perforator flap
      Fatty tissue next to (or below) the breast is used to fill the space in the breast as a result of cancer removal. This maintains breast volume and contour, maintains the nipple position and greatly reduces breast deformity.
  • breast cancer treatment - lateral intercostal artery perforator (LICAP)
    breast cancer treatment - anterior intercostal artery perforator flap (AICAP)

Image-Guided Localisation for Surgery

For non-palpable tumours that need to be removed with surgery, localisation with a hookwire or a localising substance under image guidance done prior to the surgery is needed.

This procedure is performed under local anaesthesia, prior to surgery. Mammogram, ultrasound or MRI guidance is used to accurately locate the site for surgery.

A fine wire (hookwire) is inserted or a radioactive substance is injected into the breast, within or in close proximity to the lesion of interest, which will be removed during the surgery.

breast cancer treatment - image-guided localisation for surgery

2. Mastectomy

Mastectomy is the removal of the whole breast (incorporating the breast tumour). In general, there are two types of mastectomy:

  • Simple Mastectomy
    In a simple mastectomy, the breast, including the nipple-areola complex is removed. After surgery, the chest is flat, with a scar across it. A drain, which is a soft tube, is placed during surgery with the accompanying bottle to remove blood and tissue fluid accumulated at the operated site.

    The drain will be removed when the drainage is less than 30 ml a day after 1 to 2 weeks. Drain and wound care will be taught to patients and their caregivers before discharge and patients can go home the next day.

breast cancer treatment - mastectomy

  • Mastectomy with Whole Breast Reconstruction
    Breast reconstruction is surgery to ‘recreate’ a breast using one's own body tissue or implant after mastectomy. It provides the breast shape, but has no natural feeling.
    • Immediate breast reconstruction is when reconstruction is done at the time of mastectomy.
      • Skin-sparing mastectomy is where most of the skin of the breast will be preserved.
      • Nipple-sparing mastectomy is considered for suitable cases, where the nipple may be preserved if tissue from the base of the nipple shows no cancer cells when tested at the time of surgery. However, if the final histology results show cancer cells behind the nipple, a simple surgery to remove the nipple will be recommended.
    • Delayed breast reconstruction may also be done at a later stage, separate from the initial breast surgery.

Types of Post-Mastectomy Reconstructions

i. Flap reconstructions

Skin, fat and sometimes muscle (a flap) from another part of your body may be used to make into a breast shape. This operation takes about 6 to 8 hours and requires a hospital stay of between 1 to 2 weeks. Several drains are used and removed after 1 to 2 weeks. Flaps may be from the following areas:

  • Back (latissimus dorsi)
  • Buttock
  • Thigh
  • Abdomen
    • TRAM (transverse rectus abdominis myocutaneous) flap
    • DIEP (deep inferior epigastric perforator) flap, taking skin and fat only

breast cancer treatment - flap reconstruction

Additional procedures to improve the look of the breast after the initial surgery may include adding a nipple, surgery to the opposite breast to create a good match, or refining the shape of the recreated breast.

ii. Breast implants

Silicone implants may be used to create a new breast and the operation takes about 4 to 5 hours. There are usually 2 to 3 drains inserted and the hospital stay is 2 to 5 days.

A 1-stage procedure is when the permanent implant is inserted at the time of mastectomy. A 2-stage procedure is when a temporary expander is placed at the time of mastectomy and gradually expanded to stretch the skin. The expander will be exchanged for a permanent implant at a later surgery.

breast cancer treatment - breast implant

breast cancer treatment - breast reconstruction

II. Surgery (Axillary Surgery)

Sentinel Lymph Node Biopsy (SLNB)

Sentinel Lymph Node Biopsy (SLNB) is recommended for early-stage breast cancer when the lymph nodes in the armpit do not appear to have cancer.

Sentinel lymph nodes (SLN) are the first few lymph nodes in the armpit where the lymphatic vessels from the breast drain to. These will be removed during surgery and examined under the microscope (frozen section) to determine if cancer has spread to the SLN.

This is done under general anaesthesia (GA). A blue dye or a radioactive substance is injected around the cancer site or at the nipple prior to surgery to locate the SLN. The radioactive substance will be injected before the operation. The blue dye will be injected during the operation.

If cancer is detected in the SLN, lymph nodes in the axilla will be removed. If no cancer is detected in the SLN, no further surgery is needed.

The final histology (microscopic assessment) will be reviewed about 1 week after surgery. In up to 5 percent of cases, the final assessment of the SLN may be different from the initial frozen section result and a second operation may be recommended.

If the dye or radioactive substance is not able to identify the SLN, removal of all the lymph nodes (axillary clearance) will be done.

breast cancer treatment - sentinel lymph node biopsy (SLNB)

Axillary Clearance

Axillary Clearance is the removal of all lymph nodes from the underarm when the lymph nodes are found to have cancer cells.

Side effects of axillary clearance include shoulder stiffness and numbness of the inner part of your upper arm. Lymphoedema (swelling of the arm) may occur in 10 to 15 percent of women. This is because lymph nodes drain fluid from the arm and their removal may cause fluid to accumulate in the arm on the operated side.

A separate axillary incision is often needed for patients undergoing breast conserving surgery.

Complications from Surgery

As with all surgical procedures, complications can occur. Risks of general anaesthesia include allergy to anaesthetic agents, heart attack, stroke and deep vein thrombosis, especially for longer surgeries.

Our anaesthetists will assess all patients before surgery to ensure they are optimised and prepared for surgery to minimise these risks.

Surgical complications include:

  • Intraoperative injury to blood vessels and nerves in the axilla
  • Early post-operative complications of bleeding and wound-healing such as:
    • Skin and tissue necrosis and infection
    • Seroma formation (accumulation of tissue fluid in wounds)
  • Long-term effects of:
    • Lymphoedema (swelling of the arm)
    • Shoulder stiffness
    • Numbness of the breast or chest wall and inner upper arm

Breast Care

After surgery is planned, referral to the Breast Care Nurse (BCN) Service is necessary. Our Breast Specialist Nurse will explain and explore concerns and issues pertaining to breast cancer and the treatment options, and plan pre-operative, operative and post-operative management to ensure successful treatment and recovery.

Consult time for individual patients vary from 30 to 75 minutes. A personal contact number will be provided for convenience and the BCN will be a resource person for patients and their families in the coordination of the various appointments before and after surgery in the treatment journey.

Post-operative services include wound and drain care, rehabilitation, education programmes and prosthesis-fitting.

breast cancer treatment - journey

Radiation Therapy

What is it?

Radiotherapy is a form of cancer treatment where cancer cells are damaged and killed with high energy radiation. Together with surgery and other treatments, radiotherapy reduce the amount of cancer in your body and increases the chance of you staying cancer free.

radiotherapy cancer treatment

When is it done?

Radiotherapy is almost always recommended after breast-conserving surgery and often in patients with high risks disease after mastectomy. This include patients with large tumours and those where the cancer has spread to involve multiple lymph nodes. Almost always, radiotherapy is performed after surgery and chemotherapy, when needed.

How is it done?

Radiotherapy is performed over a period of about 3 weeks. The actual treatment duration may be adjusted further based on an assessment of your needs.

Following a consultation with your specialist, an appointment will be made for scans to be performed of the part of the body to be irradiated. This process is called Simulation.

Your doctor and team of specialists will then perform a personalized planning for radiotherapy according to your needs.

Radiotherapy is delivered every day, 5 days a week for the duration of the treatment. Daily treatment lasts for under an hour and is performed on an outpatient basis. Treatment is entirely painless and without any perceptible sensation.

What side effects can I expect?

During the weeks of radiotherapy, you would notice redness of the skin on the irradiated breast. This may be accompanied by dryness, itch and occasionally, pigmentation and mild discomfort from temporary swelling. These effects are short-term and would resolve rapidly in the weeks to months following the completion of radiotherapy.

In the longer term over months and years, a small proportion of patients may experience progressive hardening of the breast and the overlying skin which may lead to a shrinking or distortion of the breast or chest wall. Other late complications to the heart and lungs are much rarer and your doctor will advise you further as the risks vary between patients.

Intraoperative Radiotherapy (IORT)

What is it?

Intraoperative Radiotherapy (IORT) is a specialized form of radiotherapy used in the treatment of breast cancer. Like all radiotherapy, high energy radiation is used to damage and kill cancer cells, so as to reduce the amount of cancer in your body and increases the chance of you staying cancer free.

When is it done?

IORT is performed only in patients undergoing breast-conserving surgery. Additionally, IORT is suitable only for patients with early stage cancers and meet conditions that your radiation oncologists will advise you on.

How is it done?

In suitable patients, IORT is performed during the cancer surgery immediately upon removal of the tumour. A specialized applicator will be placed into the excision cavity to irradiate the immediate breast tissue from inside out hence limiting the dose to the rest of the involved breast and normal organs. As patients will remain under anesthesia, IORT is completely painless.

For most patients, this single fraction IORT will be the only radiotherapy they require, hence the treatment burden in well selected patients can be reduced. Occasionally, the surgery and subsequent examination of the cancer may reveal additional information about the cancer which may lead to your doctor recommending for the use of additional external beam RT after IORT.

What side effects can I expect?

Patients will experience the usual symptoms relating to breast cancer surgery. In addition, some patients may experience a slower resolution of the seroma associated with the surgical cavity. A smaller group of patients may find localized hardening of the breast tissue and skin in the region of the operation. Rarely, this may lead to a distortion of the breast in the long term.

SYSTEMIC THERAPY

1. Chemotherapy

This treatment uses anti-cancer drugs to prevent cancer cells from growing and reproducing themselves. These drugs are usually given by injection through veins into the blood stream to all parts of the body.

It is usually given over 3 to 6 months and may be used alone, before surgery (neoadjuvant) or after surgery (adjuvant) therapy, or together with targeted therapy to increase the effectiveness of the treatment, depending on the type and stage of cancer.

Chemotherapy is given in cycles. Each cycle consists of a treatment period followed by a resting (recovery) period. As cancer drugs also affect normal cells, the resting period is to allow the body to recover before the next treatment cycle starts.

  • Side Effects: There are side effects associated with chemotherapy such as hair loss, nausea and vomiting, loss of appetite, mouth ulcers and risk for infection. However, these are temporary and steps can be taken to prevent or reduce them.

2. Targeted Therapy

Breast cancers are also tested for special receptors. One such receptor is the Human Epidermal Growth Factor 2 (HER2) receptor. This receptor is over-expressed in about 25 percent of all breast cancers; the presence needs to be confirmed by laboratory tests performed on the biopsy specimen before the treatment is given.

The aim of the treatment is to reduce and hopefully eliminate existing cancer cells in the human body while minimising side effects on normal cells.

Trastuzumab, also known as Herceptin®, targets the HER2 (Human Epidermal Growth Factor 2) receptors on cancer cells to prevent cell growth and division.

Herceptin® has been shown to prolong survival in breast cancer patients with early and advanced disease (Stage IV) when used in combination with chemotherapy.

  • Side Effects: Patients who receive trastuzumab may complain of infusion-related reactions such as fever and chills. Rarely, weakening of the heart muscles (also known as cardiomyopathy) has been observed in some patients.

An increasing number of targeted drugs are becoming available for the treatment of breast cancer, including Lapatinib (which targets HER2 and EGFR) and Bevacizumab (which targets a factor associated with new blood vessel formation in tumours.

3. Hormonal Therapy

Breast cancers are tested for oestrogen receptors (ER) and progesterone receptors (PR) on their surfaces as such cancers can be stimulated by oestrogen or progesterone to grow.

Hormonal therapy is aimed at blocking this effect. The drug recommended is dependent on the menopausal status of the women.

Hormonal therapy can cause some side effects, and they are dependent on the type of drug taken and can vary from one patient to another.

  • Tamoxifen
    This drug blocks the action of oestrogen on the body but does not stop oestrogen from being produced. Tamoxifen may cause hot flashes, depression or mood swings, vaginal discharge or irritation, irregular menstrual periods and sometimes menopause.
    Any unusual bleeding should be reported to the doctor. It is recommended for pre-menopausal women, but can be used in postmenopausal women.
    • Side Effects: Serious side effects from Tamoxifen are rare but Tamoxifen can cause the formation of blood clots in the veins, especially in the legs. In a very small number of women, Tamoxifen can cause cancer in the lining of the uterus.

      You may be referred to a gynaecologist to evaluate any unusual bleeding.
  • Aromatase lnhibitors (AI)
    For post-menopausal women, another group of drugs called aromatase inhibitors (AIs) is also used in breast cancer hormonal treatment. Aromatase inhibitors work by blocking an enzyme called aromatase that the body uses to produce oestrogen.
    The current Als such as anastrozole, letrozole and exemastane, are welltolerated and are used in the treatment of early stage and advanced breast cancer.
    • Side Effects: Side effects of AI include hot flashes, mood changes, nausea, vaginal dryness, joint pain/stiffness, tiredness, lethargy and osteoporosis (including a higher risk of fractures compared to Tamoxifen).

Follow-Up Care

Regular follow up by the doctor after treatment is recommended due to the risk of developing breast cancer again.

This will include physical examination of the chest, underarms, neck, and the other breast with periodic mammograms.

Changes to look out for include:

  • Changes in the surgical scar and treated area
  • Any unusual changes in the treated or other breast
  • Swollen lymph glands
  • Bone pain
  • Persistent cough
  • Difficulty in breathing
  • Jaundice

Breast Cancer - Preparing for surgery

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