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Breast Cancer: The treatment of breast cancer

Patients with breast cancer have many treatment options. Most treatments are adjusted specifically to the type of cancer and the staging group. Treatment options should be discussed with your health-care team. Below you will find the basic treatment modalities used in the treatment of breast cancer. 

• Surgery . Most women with breast cancer will require surgery. Broadly, the surgical therapies for breast cancer can be divided into breast conserving surgery and mastectomy. 
• Breast-conserving surgery. This surgery will only remove part of the breast (sometimes referred to as partial mastectomy). The extent of the surgery is determined by the size and location of the tumor. In a lumpectomy, only the breast lump and some surrounding tissue is removed. The surrounding tissue (margins) are inspected for cancer cells. If no cancer cells are found, this is called "negative" or "clear margins." Frequently, radiation therapy is given after lumpectomies.
• Mastectomy. During a mastectomy (sometimes also referred to as a simple mastectomy), all the breast tissue is removed. If immediate reconstruction is considered, a skin-sparing mastectomy is sometimes performed. In this surgery, all the breast tissue is removed as well but the overlying skin is preserved. 
• Radical mastectomy. During this surgery, the surgeon removes the axillary lymph nodes as well as the chest wall muscle in addition to the breast. This procedure is done much less frequently than in the past, as in most cases a modified radical mastectomy is as effective. 
• Modified radical mastectomy This surgery removes the axillary lymph nodes in addition to the breast tissue. Depending on the stage of the cancer , your health-care team might give you a choice between a lumpectomy and a mastectomy. Lumpectomy allows sparing of the breast but usually requires radiation therapy afterward. If lumpectomy is indicated, long-term follow-up shows no advantage of a mastectomy over the lumpectomy. 
• Radiation therapy Radiation therapy destroys cancer cells with high energy rays. There are two ways to administer radiation therapy: 

1. External beam radiation This is the usual way radiation therapy is given for breast cancer. A Team of radiation is focused onto the affected area by an external machine. The extent of the treatment is determined by your health-care team and is based on the surgical procedure performed and whether lymph nodes were affected or not. The local area will usually be marked after the radiation team has determined the exact location for the treatments. Usually the treatment is given five days a week for five to six weeks.
2. Brachytherapy This form of delivering radiation uses radioactive seeds or pellets. Instead of a beam from the outside delivering the radiation, these seeds are implanted into the breast next to the cancer. 

• Chemotherapy. Chemotherapy is treatment of cancers with medications that travel through the bloodstream to the cancer cells. These medications are given either by intravenous injection or by mouth. Chemotherapy can have different indications and may be performed in different settings as follows: Adjuvant chemotherapy: If surgery has removed all the visible cancer, there is still the possibility that cancer cells have broken off or are left behind. If chemotherapy is given to assure that these small amounts of cells are killed as well, it is called adjunct chemotherapy. Neoadjuvant chemotherapy: If chemotherapy is given before surgery it is referred to as neoadjuvant chemotherapy. Although there seems to be no advantage to long-term survival whether the therapy is given before or after surgery, there are advantages to see if the cancer responds to the therapy and by shrinking the cancer before surgical removal. Chemotherapy for advanced cancer: If the cancer has metastasized to distant sites in the body, chemotherapy can be used for treatment. In this case, the health-care team will need to determine the most appropriate length of treatment. There are many different chemotherapeutic agents that are either given alone or in combination. Usually these drugs are given in cycles with certain treatment intervals followed by a rest period. The cycle length and rest intervals differ from drug to drug.
• Hormone therapy. This therapy is often used to help reduce the risk of cancer reoccurrence after surgery, but it can also be used as adjunct treatment. Estrogen (a hormone produced by the ovaries) promotes the growth of a few breast cancers, specifically those containing receptors for estrogen (ER positive) or progesterone (PR positive). 

The following drugs are used in hormone therapy:

• Tamoxifen (Nolvadex): This drug prevents estrogen from binding to estrogen receptors on breast cells.
• Fulvestrant (Faslodex): This drug eliminates the estrogen receptor and can be used even if tamoxifen is no longer useful. 
• Aromatase inhibitors: They stop estrogen production in postmenopausal women. Examples are letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin).

Targeted therapy

As we are learning more about gene changes and their involvement in causing cancer, drugs are being developed that specifically target the cancer cells. They tend to have fewer side effects then chemotherapy (as they target only the cancer cells) but usually are still used in adjunct with chemotherapy. 

Targeting HER2/Neu protein

Monoclonal antibody: Trastuzumab is a engineered protein that attaches to the HER2/Neu protein on breast cancer cells. It helps slow the growth of the cancer cell and may also stimulate the immune system to attack the cancer cell more effectively. It is given IV either once a week or every three weeks.

Drugs that target new tumor blood vessels.

Tumors need new blood vessels to grow. The process of blood vessel growth is known medically as angiogenesis. New drugs are being developed to target this growth and fight certain cancers, including breast cancer.

Bevacizumab is a monoclonal antibody directed against vascular cells. Newer study results seem to indicate that this drug slows the cancer growth in some patients but did not improve survival. The use of this medication should be discussed with your health-care team. 

Alternative treatments

Whenever a disease has the potential for much harm and death we search for alternative treatments. As a patient or the loved one of a patient you want to try everything and leave no option unexplored. The danger in this approach is usually found in the fact that the patient might not avail themselves of existing, proven therapies. You should discuss your interest in alternative treatments with your health-care team and together explore the different options.

Breast Cancer: Family history can cause breast cancer

How can  Family history cause breast cancer ?
If you have a strong (positive) family history for breast cancer, ovarian cancer, or even prostate cancer, this information is relevant to your diagnosis. A strong family history in this case usually means that a mother, sibling, child, or father has had a related malignancy. Information about other family members (aunts, nieces, etc.) is also important. This is especially significant if the diagnosis of breast cancer was made at an early age or involved both breasts or a breast and an ovary in the same individual. A positive family history may necessitate a more comprehensive diagnostic workup, more involved treatment, and consideration of genetic testing, not only for you but for other family members.

What other studies should be done on my tissue biopsy?

Microscopic evaluation of the slides made from involved tissue provides critical information about the tumor. A reasonably accurate prediction of tumor behavior can be made based on the appearance of the cancer cells, their size and similarity to one another, and the presence or absence of these cells in the lymphatic and blood vessels immediately adjacent to the tumor. This type of evaluation is a standard part of the diagnostic process.

However, there are additional relevant data which the laboratory should obtain, and this analysis is directed by the pathologist at the time of diagnosis. This information includes, at a minimum, an assessment of the estrogen and progesterone receptors on the malignant cells and the status of at least one oncogene, called her-2-neu. An oncogene is a gene that plays a normal role in cell growth but, when altered, may contribute to abnormal cell division and tumor growth.

Currently, these tests (estrogen and progesterone receptors and her-2-neu) have an accurate enough predictive value that their status should be determined in all cases of breast cancer. Test results are available within a few days to a week after removal of the tumor tissue. The results of these tests should then be taken into account in the final decision-making about treatment. These tests are constantly evolving and changing, and your treatment team will be able to discuss the current standard and advanced testing available.