One hears a diagnosis of breast cancer and immediately thinks the worst. Many patients have been conditioned to respond this way. This is understandable, but is wrong. The vast majority of women with breast cancer survive their disease and live happy and productive lives after the diagnosis. And survival statistics are improving every day as better treatments evolve. Don’t despair. And most importantly, get treatment. It is not as harsh or disfiguring as it was in the past.
The three pillars of breast cancer treatment are surgery, radiation therapy, and chemotherapy. Not all patients need all three treatments. Doctors involved in your care will have these three treatment approaches available to them and will select along with you the combination best suited to your case.
Before deciding on a treatment plan, your cancer will need to be worked up. The team of treating oncologists needs to know whether the cancer is in just one place in your breast or is in multiple spots or in both breasts. They will need to know whether your lymph nodes may harbor cancer or not. They will need to know whether the cancer has escaped out of the breast and lymphatic area under the arm to other organs in the body. And from biopsies and evaluation of tissue they will want to know just what the pathology of your tumor is. Radiological studies including mammography, sonography, MRI, and CT scans will help to address these issues.
Surgery is performed to remove the tumor both for treatment and to subject the tumor to a more complete and sophisticated analysis. Surgery involves either a lumpectomy (removing the cancerous lump with a margin of uninvolved tissue) or a mastectomy (removal of the entire breast). If one must or prefers or must have a mastectomy, immediate reconstruction can be done in conjunction with a plastic surgeon.
Depending on the type of tumor being treated, lymph nodes in the axillary area need to be evaluated surgically. Whether one opts for a lumpectomy or a mastectomy, lymph node harvesting is done with a special technique called a sentinel lymph node biopsy. The patient preoperatively is injected with either a blue dye or a radio labelled substance that concentrates in the lymph nodes under the arm. The node or nodes in which the dye or that radio labelled substance concentrates in identifies the node or nodes that the cancer is most likely to spread. These surgically harvested nodes are then evaluated by the pathologist and are important in determining additional treatment.
Radiation therapy is used when breast preservation is preferred and the breast tissue remaining after lumpectomy is at risk. Radiation therapy essentially stuns the remaining breast cells so that they are prevented from proliferating in a manner that leads to the development of subsequent cancers. Radiation therapy has been proven to reduce the subsequent development of breast cancer in a breast that has already produced a cancer. Radiation therapy is also used after mastectomy when a significant number of lymph nodes are involved.
Both surgery and radiation therapy are used to control the tumor locally (in the breast) and regionally (in the lymph nodes). Chemotherapy, on the other hand addresses tumor cells that may have leaked out or spread to areas outside the breast or axillary area. It is delivered through the blood and reaches all areas of the body to combat cells that may have spread or lodged in these areas. If chemotherapy is used after lumpectomy and radiation therapy or after mastectomy, it is called adjuvant chemotherapy. Adjuvant chemotherapy has been proven to improve survival.
Generally, chemotherapy involves the use of cytotoxic agents that destroy cancer cells (and some normal cells also) or agents that disrupt the hormonal role in the development of breast cancer. The cytotoxic agents, as the name implies, are generally more toxic to the patient and are responsible for the side effects of chemotherapy so feared by patients. The anti hormonal treatments are far less toxic.
Chemotherapy is also used to directly reduce the tumor itself. Some cancers are best treated by giving chemotherapy first, followed by surgery, possibly followed by radiation therapy. This is called neoadjuvant therapy. There are certain advantages to this type of treatment as it can directly demonstrate the effectiveness or lack of effectiveness of the chemotherapy.
A number of myths about these treatment recipes need to be clarified:
More is not necessarily better. More radical surgery is not necessarily better or more effective and will not allow you to avoid chemotherapy. One of the most important decision a patient needs to make is whether or not to have a lumpectomy or a mastectomy. In a small number of cases, a mastectomy is absolutely necessary. But for the vast majority of cases, patients can choose either a lumpectomy or a mastectomy. The good news is that it has been proven that there is no difference in survival whether one chooses a lumpectomy or one chooses a mastectomy. So more radical surgery is not necessarily better. The decision as to whether one will need chemotherapy or not has nothing to do with the type of surgical treatment you choose.
Radiation therapy will not make you glow in the dark. The radiation is directed to the breast only and is absorbed by the cells. Afterwards it does not emit radiation on its own that can harm people with whom you have contact. So, one can go about their lives almost normally and with a minimal disruption. The downside of radiation is having to go for treatments almost every day, but radiation centers are generally accomodating.
Chemotherapy has a terrible reputation and deservedly so if one considers the early days of chemotherapy or has watched a loved one in the past receive it. This has changed considerably with improvements in the drugs and improvements in delivery regimens. Also contributing to this is that support medications to blunt the damage done to normal cells in the process of killing cancer cells have been developed and are now widely used.