Treatment Options for Breast Cancer

Historical Aspects of Surgical Management
Surgical Options Currently Recommended for Treatment
Sentinel Node Biopsy
Chemotherapy
Irradiation
Local Recurrence and Systemic or Metastatic Disease


Historical Aspects of Surgical Management

We have known about breast cancer for thousands of years. The Smith Papyrus talks about breast cancer in 3000 BC. It was treated with a variety of topical agents or poultices and understandably, these women did not survive. There were early attempts to treat breast cancer surgically in the early 1100's.


Early Breast Surgery

Anesthesia was not developed until 1846 and antibiotics not until 1927. The breast was rapidly amputated with women awake. If the surgical procedure was not fatal, about 20% of these women died from infection. In 1893, William Halstead, M.D. (the father of American Surgery) developed an operation called the radical mastectomy. This operation removed the breast, chest wall muscles and the lymph nodes from under the arm. It was a very cosmetically deforming operation and women had a great deal of disability involving their extremity but there were long-term survivors from breast cancer. Women typically presented with large tumors or extensive disease (mammography was not utilized until the 1970's). This was the standard operation for the treatment of breast cancer through the late 1960's.



Extensive Breast Cancer

In the 1970's we began treating women with modified radical mastectomies. This operation removed the breast, preserving the chest wall muscles and sampling the axillary nodes. These women survived just as long as those women who had radical mastectomies did. Modified radical mastectomy then became the standard operation for the treatment of breast cancer and remains an option today.


Mastectomy

Italian investigators began doing early conservative breast surgery (lumpectomy and irradiation) in the early 1970's. The criteria that they used to select women for conservative breast surgery were the mass had to be less than 2 cm. in size and the lymph nodes were not enlarged on a clinical examination.


Surgical Incisions

A quarter of the breast was removed, the lymph nodes sampled and the breast irradiated. These women survived just as long as those that had modified radical or radical mastectomy. In the United States, the criteria that are used to select patients for conservative breast surgery are that the mass is less than 4 cm. in size, the lymph nodes can be clinically enlarged on a breast examination. These women are surviving just as long as those that had a modified radical or a radical mastectomy. The whole breast must be treated in some fashion, either removing it or irradiating the breast as breast cancer can be multifocal (involve multiple areas of the breast 23%-55% of the time).

However, not all women are candidates for breast conservation. The following may exclude from consideration some women from breast conservation.

1.

Certain cell types of breast cancer are prone to local recurrence if treated with conservative breast surgery.

2. Mammographic or clinical evidence of multifocal disease (tumor involving multiple areas of the breast).
3. Large tumor in a small breast. The results of conservative breast surgery may severely deform the breast making the cosmetic results unacceptable.
4. Inability to obtain microscopically free margins around the tumor

5.

Relative contraindications include collagen vascular disease and pregnancy.

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Surgical Options Currently Recommended for the
Treatment of Breast Cancer

1.

Simple mastectomy or lumpectomy (irradiation) without axillary dissection: for insitu lesions of the breast. Less than 1% of patients with intraductal lesions will have positive lymph nodes and therefore, the nodes are not sampled.

2. Conservative Breast Surgery: lumpectomy, axillary dissection and irradiation.
3. Modified Radical Mastectomy: removal of the breast and axillary dissection (sampling the lymph nodes)
4. Modified Radical Mastectomy and Primary Reconstruction: removal of the breast, axillary dissection and rebuilding the breast at the time of mastectomy (primary reconstruction). Reconstruction can be accomplished at any time after mastectomy.


Expander Implant

Expander Implant (Cross section)

 


Tram Flap Reconstruction

 


Latissimus Dorsi Flap
Reconstruction

Stage I and stage II lesions are treated in the above fashion. Stage III lesions are generally treated with chemotherapy first, then surgery and possibly irradiation. Tumors with greater than 4 positive lymph nodes, will generally receive adjuvant irradiation in addition to surgery and chemotherapy.

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Sentinel Node Biopsy

Sentinel node biopsy is an experimental technique that utilizes a radioactive tracer or blue dye injected into the tumor. The contrast material is absorbed by the lymphatic system. The contrast material then travels to the first lymph node draining the tumor called the sentinel node. If the sentinel node is negative, a woman may not need a more extensive axillary dissection (sampling of the axillary nodes) and avoid the potential complications of axillary dissection (lymphedema: swelling of the arm secondary to lymphatic obstruction).


Sentinel Node Biopsy

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Chemotherapy

Prior to 1988, if a woman had pathologically negative axillary nodes (no tumor in the lymph nodes under the microscope) chemotherapy was not recommended. In 1988, the NIH (National Institute of Health) recommended that all women receive chemotherapy. Seventy percent of women achieve long-term disease free survival with surgery alone. Based on this recommendation, 100% of women would receive chemotherapy when only 30% would benefit. This recommendation was based on the observation that some women with stage I disease would recur 15-20 years later with a focus of breast cancer elsewhere (metastatic disease). As a result, our thinking about breast cancer has changed. Breast cancer may well be a systemic disease (microscopic disease elsewhere) at the time of diagnosis.

Nationally, this recommendation has been modified. Recommendations for chemotherapy are made for node negative women based on prognostic indicators. If the tumor is greater than 1 cm in size and the prognostic indicators suggest an increased recurrence rate, chemotherapy is recommended. Essentially all patients with positive axillary nodes receive chemotherapy.

A variety of chemotherapy agents are utilized in the treatment of breast cancer including cytoxan, methotrexate and 5-fluoruracil (CMF), adriamyacin and cytoxan (AC), Taxol or Taxotere and Tamoxifen. The medical oncologist selects these various agents based on the prognostic indicators, the age of the patient and underlying medical condition. Chemotherapy generally begins within 2 weeks of surgery and continues for several months. Chemotherapy can reduce the risk of recurrence by 30%-40% and reduce the risk of developing breast cancer on the other side by the same percentage. The side effects of chemotherapy vary depending upon the agents utilized and the individual.

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Irradiation

A wavelength of light used to treat the breast in conservative breast surgery, for consolidation of extensive local disease (large tumors or more than 4 positive axillary nodes) or local recurrence of breast cancer. Irradiation destroys the microscopic residual disease that remains after surgery or not apparent clinically. Like surgery, it is a local treatment, in contrast to chemotherapy, which is a systemic treatment. The side effects of irradiation include erythema of the skin (sunburn), turning into a brawny induration (thickening and increased pigmentation of the skin) and some shrinkage of the breast tissue with conservative breast surgery. Some women note fatigue after treatment. Irradiation generally occurs after chemotherapy, if chemotherapy is given. Irradiation can also be utilized for palliation (relief of symptoms, i.e. bone pain) with recurrent disease.

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Local Recurrence and Systemic or Metastatic Disease

At the time of diagnosis, breast cancer may be a systemic disease in other words there may be microscopic or macroscopic (larger lesions, clinically detectable through imaging) disease elsewhere. This is the reason for the current recommendations for chemotherapy. How do we know that you do not have disease elsewhere? Prior to surgery, a chest x-ray and blood tests looking at liver function studies and serum calcium will be obtained. If the results of these studies are negative, less than 4% of women will have disease that can be demonstrated elsewhere. This does not mean that microscopic disease is not present just that it cannot be demonstrated with additional imaging modalities. However, a CT scan of the chest and upper abdomen as well as a bone scan will generally be obtained during the course of your treatment to serve as base line studies to compare future studies. Routine annual imaging, other than mammography, is not accomplished, as there is no survival advantage in detecting an asymptomatic recurrence. Systemic recurrence is treated with chemotherapy.

Local recurrence after conservative breast surgery is treated with salvage mastectomy. Local recurrence with mastectomy is treated with wide surgical excision if possible and irradiation. Both are usually given additional chemotherapy.

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Quick Facts:

10% of breast cancer may present as an axillary node alone.
The key to surviving breast cancer is early detection.
80-90% of masses detected by clinical exam or mammography are benign.