Breast Cancer Treatment

Surgical treatment physically removes the tumour or pre-invasive cells from the breast with or without lymph nodes from the armpit. The cancerous cells must be removed with a clear margin of normal tissue and most tumours can be excised as a ‘lumpectomy’ or ‘wide-local excision’. In the UK, the margin of normal tissue needs to be 1mm or more. Sometimes the cancer is too small to feel and a fine wire is inserted into the breast to localise the tumour before surgery. Oncoplastic breast surgery employs techniques used in cosmetic breast surgery to remove breast cancer and ensure a good cosmetic outcome including breast reduction surgery and local flaps of tissue such as a LICAP. For some women, the safest/ most appropriate operation to treat breast cancer is a mastectomy. Often this can be combined with an immediate breast reconstruction. Otherwise, the reconstructive surgery can be delayed until all cancer treatment has been completed.

There are several ways to reconstruct a breast and deciding upon the best type of reconstruction depends upon many factors. Obviously, individual preferences are very important but sometimes a woman’s current or past health problems and the cancer treatment direct a patient towards a particular type of reconstruction.

Implant Reconstruction

Perhaps the simplest way to reconstruct a breast is using a cosmetic breast implant. This can be performed in two stages using a tissue-expander to create a space under the pectoralis major muscle, which is then exchanged for a permanent cosmetic implant several months later. A single stage approach is possible by using an animal based acellular dermal matrix (ADM) or Titanium Mesh to cover the implant. This can be performed either by putting the implant under or over 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 and pain. Also radiotherapy as well as a high body mass index, diabetes and smoking can all increase the risk of infection and wound breakdown which means that the implant may have to be removed.

Latissimus Dorsi Reconstruction

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.

Autologous Free Flap Reconstruction

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 (DIEP) 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.

Surgery in the armpit (axilla) may involve removal of all the lymph nodes (axillary lymph node dissection) if the lymph nodes are known to have significant deposits of cancer cells. If the axillary lymph nodes appear to be free of cancer deposits on ultrasound and or microbubble biopsy, then the more limited sentinel lymph node biopsy is the procedure of choice. The sentinel lymph nodes are the first lymph nodes in the axilla to receive tissue fluid draining from the breast. They are found during the operation following injection of a radioactive tracer and blue dye, which accumulate in sentinel nodes. The radioactive isotope is injected at the edge of the nipple either the day before or on the morning of surgery. The blue dye is injected at the time of surgery. The blue dye carries a very small risk of allergic reaction (0.9%). If the sentinel lymph nodes are found to contain tumour cells then an axillary lymph node clearance may be recommended. Alternatively, some patients are suitable for ‘axillary conservation’, which means no further surgery, or other treatment of the armpit is indicated. In the UK, all patients with micrometastases (cancer deposits less than 2mm) fall into this category as do those who are post-menopausal with small less than 20mm Grade 1 or 2 tumours that are estrogen receptor positive and Her-2 negative.

The mainstay of the treatment of early breast cancer is surgery, but despite this, a minority of women will have a recurrence of the same cancer some time later. This is because individual breast cancer cells manage to travel to another part of the body before the cancer is diagnosed. These rogue cells are known as micro-metastases. At the current time there is no scan or blood test recommended for routine use that can detect whether micro-metastases are present or not with 100% certainty. As a result, many women will be offered additional drug treatments after the operation as an ‘insurance policy’ to try and destroy any potential micro-metastases. These types of treatment would be recommended by a Consultant Oncologist and are called adjuvant or add-on treatments after the operation. The decision to recommend chemotherapy and/or hormonal therapies will depend on the type and extent of the breast cancer and the general health of the individual woman. The purpose of any of these drug therapies is to further boost the long-term chances of a woman being cured of breast cancer and to achieve this in the safest possible way.

Chemotherapy is the collective term for a family of drugs that attempt to kill cells that are growing. This is because in an adult human most tissues have stopped growing, but any cancer cells present will be trying to grow and hence are destroyed by the chemotherapy agents. Most often, chemotherapy is given by an injection into a vein in the arm and is a procedure that is conducted by a specialist nurse trained in chemotherapy administration. Chemotherapy is given in the day-case setting so patients do not need to stay in hospital overnight. Generally, chemotherapy is given once every 3 weeks and repeated for between 6 to 8 times. Each 3 week block of time is called a ‘chemotherapy cycle’. 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, she will be reviewed at least every 3 weeks by the oncologist and 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.

Two-thirds of woman with breast cancer in the UK will have a type of cancer that is sensitive to the female hormone estrogen. This is referred to as ‘estrogen-receptor positive’ breast cancer (ER positive) and is determined by the pathologist who examines the breast cancers cells under the microscope. ER positive breast cancer cells can be damaged and destroyed by treatments that either block estrogen binding to the breast cancer cells (such as the tablet tamoxifen) or lower the amount of oestrogen being produced in the body (zoladex or the aromatase inhibitor tablets). Many international clinical trials with these drugs support woman with ER positive breast cancer having 5-10 years of hormone therapy to prevent the growth of micro-metastases and show that even more women survive breast cancer than ever before. Hormonal treatments can be linked with side effects such as flushes and sweats, stiff and aching joints and weight gain. The specific treatment recommendation will be made in discussion with the oncologist and based on the type of breast cancer, whether a woman is pre- or post-menopausal and any previous health issues. Again, detailed information will be given with time for consultation and reflection.

As mentioned above, conventional chemotherapy is non-selective and will theoretically kill any cell that is growing at the time that it is administered which is why there are many potential side effects. In the last decade, a new class of ‘targeted’ treatments have been developed for cancer treatment. These are called monoclonal antibodies because they are based around the structure of an antibody that the immune system would use to seek out infections. These antibody molecules have been altered to specifically seek out a chemical that can be present on breast cancer cells: Her2 receptor. The pathologist determines the presence or absence of the Her2 receptor on a breast cancer cell. Roughly 15% of UK breast cancers are ‘Her2 receptor’ positive. Trastuzumab (Herceptin™) will be recommended along with chemotherapy if the breast cancer cells are Her2 receptor positive. If trastuzumab is part of the proposed treatment plan it will be given for a period of a calendar year with an intravenous administration once every 3 weeks. A patient having trastuzumab needs regular blood tests and a special ultrasound scan of the heart called an echocardiogram every 3 months. This is because trastuzumab can occasionally cause weakening of the muscle of the heart and this should be checked for. If heart function were deteriorating then the patient and the oncologist would meet to discuss this and involve a Consultant Cardiologist.

Radiotherapy uses X-rays to kill cancer cells and plays a key role in reducing the risk of cancer recurrence within the breast. Radiotherapy is almost always given to the affected breast following a cancer lumpectomy as it reduces the future risk of breast recurrence to levels similar to that seen after mastectomy. Sometimes radiotherapy is given to the armpit if several nodes are found to contain cancer cells. In some cases, radiotherapy may also be given to a patient’s chest wall after mastectomy. 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.