Where do I begin?
The right treatment choice for breast cancer is as unique as the individual selecting it.
A woman’s age and menopausal status, her stage of disease, her tumor type, and her personal preferences all have important influence on the appropriate treatment for her breast cancer.
The most important factor in the whole treatment process is communication– with your physicians, your family, and your friends.
By asking questions, the better ability you’ll have to pick the right treatment for you, and the greatest peace you’ll also carry with the decision you’ve made.
Breaking it down
We’ll briefly discuss some general principles about breast cancer treatment.
The most simple way to break down cancer treatment is by stage.
If breast cancer has not become metastatic, then it is classified into a stage between Stage 0 and Stage IV.
The larger the stage, the more advanced the cancer.
Stage 0
Stage 0 applies to cells found on biopsy which appear pre-cancerous. The medical term for this is carcinoma in-situ. The two types of carcinoma in-situ are Ductal Carcinoma In-Situ (DCIS), and Lobular Carcinoma In-Situ (LCIS).
Note that carcinoma in-situ actually is not an invasive cancer. You can think of DCIS as pre-cancerous. If left alone, the probability is high that these cells will eventually become an invasive cancer. Therefore, it is important to treat DCIS accordingly.
LCIS lesions are not considered to be direct precursors to invasive cancer themselves. However, the presence of LCIS does signal a higher risk for the development of invasive cancer. Therefore, it is important to seek consultation with medical oncologist to determine whether any other therapy, such as hormonal therapy, is indicated in order to decrease the risk of invasive cancer from occurring.
Back to DCIS. Since these lesions are considered to be direct precursors to an invasive cancer, DCIS requires intervention.
The first step is surgery. There are two surgical options: mastectomy, or a breast conservation surgery (e.g., lumpectomy).
For many women, a lumpectomy is an acceptable and preferred option, as long as the DCIS is of a small enough size to achieve an acceptable cosmetic outcome after the surgery.
Some women may have circumstances where mastectomy may be more appropriate, especially if the lesion is large. However, the trend over the past few decades for patients with DCIS have been moving away from mastectomy, since it may be an overly aggressive approach for many DCIs patients, and because the long-term outcomes for DCIS patients who get mastectomy or lumpectomy and radiation are comparable.
Speaking of which, following lumpectomy, radiation therapy to the breast is still considered a standard part of treatment. This is based on multiple large trials which looked at women who had lumpectomy alone or with radiation afterwards. The women who received radiation after lumpectomy reduced their chances of having DCIS or an invasive cancer come back in half.
There has been debate about whether the use of radiation therapy after surgery for DCIS is “overkill” too. There is some small evidence showing that less-aggressive appearing DCIS under the microscope may have a smaller benefit from radiaton therapy afterward. Suffice it to say that the jury is still out on that issue, and for now, most would recommend that all DCIS patients should get radiation after surgery until more daata comes along that can help us predict who would benefit the least from breat radiation.
Following radiation therapy, there is yet another way to decrease the risk of having DCIS or an invasive cancer to come back. This is through the use of hormonal therapy.
Patients who are candidates for hormonal therapy have breast tumors that are sensitive to estrogen and/or progesterone–two very important hormones in the female body.
Certain drugs, such as Tamoxifen and Arimidex, can stop the ability of these hormones to stimulate the growth of breast cancer tumor cells that have estrogen and/or progesterone receptors (abbreviated, ER and PR). A consultation with a medical oncologist is needed in order to determine if hormonal therapy is right for you.
Stage I, IIA, IIB, and some IIIA
For women with invasive breast cancer, the approach to treatment depends largely on how advanced the disease is; this is reflected in the stage of the cancer.
In general, women with breast cancer that typically undergo surgery first are Stage I, IIA, some IIB, and some IIIA patients.
For these women, the following illustration below demonstrates a treatment path that many women with these stages of breast cancer follow. Not each of these components will necessarily apply, and this will depend on the specific situation.
Some women with small Stage I breast cancers may meet with their chemotherapy doctor, and the recommendation may be such that chemotherapy is not needed. This is because their risk of having the cancer come back somewhere else in the body (metastatic disease) is so low, that the side effects from receiving chemo outweighs the possible benefit.
The decision on whether or not a patient will need to receive radiation therapy after surgery also depends on certain factors. Patients who undergo lumpectomy will require radiation afterwards to help decrease the chance for the cancer to come back in that breast. If a patient undergoes a mastectomy, there are certain situations where she may still require radiation afterwards too. These situations arise when certain post-surgical findings indicate a high risk for the cancer coming back in the post-surgical areas.
Hormonal therapy may also be helpful in further decreasing the risk for cancer recurrence as well. Patients who are candidates for hormonal therapy have breast tumors that are sensitive to estrogen and/or progesterone–two very important hormones in the female body.
Certain drugs, such as Tamoxifen and Arimidex, can stop the ability of these hormones to stimulate the growth of breast cancer tumor cells that have estrogen and/or progesterone receptors (abbreviated, ER and PR). A consultation with a medical oncologist is needed in order to determine if hormonal therapy is right for you.
Locally advanced breast cancer
Some women are not suitable for surgery first. These women generally are in more advanced stages, such as Stage IIIB and Stage IIIC. Some Stage IIA, IIB, and IIIA patients also fall into this category, for reasons discussed below.
For these women, chemotherapy and/or hormonal therapy play a central role in treatment. This may be because there is a high risk for the patient to have metstatic disease elsewhere, and therefore a treatment that involves areas outside the breast takes precedence. This also may be because the involvement of the cancer in the breast and/or lymph node regions is too advanced for surgery to take care of in an effective manner at this time.
Another situation where a woman could receive chemotherapy first prior to surgery is whenever someone desires breast conservation, but the tumor is too large for this to be feasible. These women are generally IIA, IIB, or IIIA patients. In certain settings, these women can receive chemotherapy first in an attempt to shrink down the tumor. After chemotherapy, another assessment is then performed to see if the tumor is then amenable for lumpectomy. If so, the patient then can be eligible for breast conservation treatment. The following is an illustration of this pathway; again, not all of the components are necessarily required, and this depends on the specific clinical situation.
Metastatic breast cancer (Stage IV)
If the cancer has become metastatic, that means that breast cancer cells have begun to invade other organs of the body. The most common places where breast cancer can metastasize to are: other bones (such as the spine or hips), or the brain. When cancer has become metastatic, then it is classified as Stage IV.
For Stage IV disease, hormonal therapy or chemotherapy become the primary methods of treatment. Radiation therapy is used when areas affected by cancer cause symptoms, such as pain. Surgery does not usually have a prominent role in the treatment of Stage IV disease.
It is important to realize that with the recent advances in cancer treatment, there has been a greater variability seen in terms of how long patients can live with Stage IV breast cancer. There are more and more women living every day “with” cancer, and many of them enjoy a high quality of life.
Stage IV breast cancer encompasses such a diverse population of people, that it would be inapprorpriate to generalize treatment recommendations for these patients. Some Stage IV patients live with breast cancer for many years, and therefore, the treatment goals may be very different than a woman who has an aggressive cancer and is not expected to perform as well.
The most important approach for women with Stage IV breast cancer is to communicate effectively with their physicians. Together, they can work toward management approaches that make the most sense– for their well-being and for sustaining a fulfilled and pleasing quality of life.