Breast Cancer Management – Recent Advances
By:  CH Yip, Professor, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur
Date: Aug 2003

Introduction

Breast cancer is the commonest cancer in women in Malaysia.  There are many therapeutic (treatment) options, hence the need for clinical practice guidelines based on the best current evidence.  The modern management of breast cancer requires a team comprising of the surgeon, radiologist, pathologist, plastic surgeon, oncologist and a nurse counselor.
 

Initial Diagnosis – Close Teamwork between Surgeon, Pathologist and Radiologist

The initial diagnosis of breast cancer requires close cooperation between the surgeon, pathologist, and radiologist. The well-known triple assessment of clinical assessment, radiological assessment and fine needle aspiration cytology is still the mainstay of diagnosis. However in recent times, fine needle aspiration biopsy is slowly being replaced by core needle biopsy. The reason for the change is because of the increasing incidence of ductal carcinoma in situ in countries where mammographic screening has led to an increase in the proportion of in-situ cancers, which requires histology (tissue) rather than cytology (cells) for diagnosis.
 

After the Diagnosis of Breast Cancer is Established

Once a diagnosis of breast cancer is made, the primary treatment in clinical Stage 1, 2 and some operable Stage 3 breast cancer is surgery.  If properly carried out, breast conserving surgery (BCS) gives the same results as modified radical mastectomy.  BCS cannot be done if there are multifocal lesions, large tumours and pregnancy.

Controversy remains regarding the extent of dissection of the axilla.  Is axillary dissection a therapeutic (treatment) or a staging (to classify the stage of the breast cancer) procedure?  Randomized prospective studies have not proven any survival benefit in axillary clearance versus sampling, although regional recurrence is higher if axillary clearance is not done.  However it must be remembered that the clinical assessment of the axilla is inaccurate and axillary nodal status is the single most important prognostic factor in breast cancer. 

Local and regional treatment

Currently, the options for local treatment of breast cancer are a modified radical mastectomy (where the breast is removed with all the lymph nodes under the armpit, but the underlying muscles are left behind) and breast conservation surgery  (where the tumour is removed with a margin of normal tissue, the lymph nodes under the armpit are removed, and the rest of the breast is treated with radiotherapy). Breast conservation surgery is appealing to women because it does not involve loss of the breast, but it is suitable only for small tumours less than 4 cm, depending on the size of the breast.  Clinical studies have shown no difference in the survival between women treated with modified radical mastectomy and breast conservation surgery.  There is a small risk of tumour recurring in the breast after conservation surgery, of 10% over 10 years. However if the tumour recurs, a mastectomy can be done without any difference in survival. 

After breast conservation surgery, radiotherapy is mandatory to the rest of the breast.  After a modified radical mastectomy, radiotherapy to the chest wall is not required if the tumour is small, lymph nodes are not involved and the margins are clear. 

If the cancer is not suitable for breast conservation, and the woman does not want to lose her breast, reconstruction of the breast can be carried out together with the mastectomy. 

After mastectomy, the skin of the breast area may feel tight, and the muscles of the arm and shoulder may be stiff.  Exercises are important to regain movement and strength in the arm and shoulder.  As the nerves are cut during surgery, there may be numbness and tingling in the chest, underarm, shoulder and arm.  These feelings usually go away within a few weeks or months.  Removing the lymph nodes may also give rise to swelling of the arm, and it is easier for infection to occur in the arm. The arm and hand on the treated side need to be protected from injury. 

In Stage 4 (advanced) breast cancer, where the cancer has spread to other parts of the body, local treatment may not be required, unless it is to get rid of a breast tumour which is bleeding, ulcerated or infected.  In such disease, systemic treatment is required.
 

Systemic treatment

Even in early breast cancer, cancer cells could already have spread through the blood stream, giving rise to what is known as micrometastases, in a percentage of women.  These micrometastases may be present in other organs in the body such as the lungs, liver and bones.  Months or years after the treatment of cancer, they may be reactivated and grow to become obvious metastases in these organs.  Systemic treatment is required to eliminate these micrometastases.  The larger the tumour, the more likely that micrometastases are present.  If the lymph nodes in the armpit are involved, then the chance of micrometastases is even higher.  Hence tumour size, lymph node involvement and survival are all related.  Local treatment will have little bearing on the treatment of metastases. 

Chemotherapy (treatment with anticancer drugs) can kill cancerous cells in the body, but it affects normal cells as well.  If administered after local treatment in early breast cancer (Stage 1 and 2), it is known as adjuvant chemotherapy.  If administered in Stage 3 cancer to shrink the tumour before local treatment, it is known as neo-adjuvant chemotherapy.  If administered in Stage 4 breast cancer, where local treatment is only for palliation, it is called primary chemotherapy. 

Clinical studies have shown that adjuvant chemotherapy definitely increases the survival of patients with breast cancer where the lymph nodes are involved.  However recent studies have shown that even without lymph node involvement, chemotherapy has a beneficial effect, especially in young breast cancer patients.  Whether or not chemotherapy is required in this group of “node-negative” patients is however, still controversial.  Other factors that measure the aggressiveness of the tumour, such as size and grade of tumour, and age of patient need to be considered. 

Chemotherapy consists of a combination of drugs injected through a vein, usually at three-weekly intervals,  for a duration of 6 cycles.  Common side effects are nausea, vomiting, loss of hair, and a drop in the red cell count, white cell count and platelets in the blood. 

Hormones secreted by the endocrine glands can affect the growth of breast cancer.  The cells in the tumour can be hormone receptor positive, that is, they contain hormone receptors, or negative.  Hormone therapy with tamoxifen, an antioestrogen drug taken orally for five years have been shown to improve survival in patients with breast cancer that is oestrogen receptor positive.  It has little side effects, although it may cause weight gain, hot flushes and irregular periods in younger women.  There is also a fear of inducing uterus cancer with prolonged usage.  Tamoxifen has been shown to reduce the risk of breast cancer in the opposite breast.  A large study in the United States have shown that Tamoxifen can be used to prevent breast cancer as there was a 45% reduction in breast cancer incidence in women on Tamoxifen.  However these results were not repeated in similar studies in Europe, and further information is required before Tamoxifen can be routinely prescribed as a breast cancer chemopreventive agent. 

In premenopausal women with advanced breast cancer, removal of the ovaries can be carried out to decrease the oestrogen levels in the blood stream.    

Emotional, psychological and other needs of a breast cancer patient
A woman’s psychological adjustment to breast cancer depends a lot on her attitude towards hospitalisation and medical practices in general and on the specific treatment involved.  Communication is very important. Many women complain of inadequate information and insufficient time to ask questions. This is when a breast counsellor, who is specially trained in counselling women with breast cancer, has an important role in encouraging the woman to talk about her fears and anxieties, and how her mastectomy may affect her husband's feelings, her relationship with her family and friends, the clothing she may wear, and her future activities. 

Although it is important that the woman be comforted and reassured, she should not be given false assurances that “everything will be fine”.  She should be told about the side effects and the degree of incapacitation that can be expected from mastectomy and other treatments, and she should be given information on the time required for rehabilitation.  Depression is normal and may recur from time to time. 

Rehabilitation after surgery includes regaining physical strength, returning to previous activities, and coping with the emotional problems associated with the loss of a breast and having a serious disease.  Advice on exercises, diet, breast prosthesis and clothing are important. 

A woman’s ordeal with breast cancer also affects others close to her.  Her husband, children, parents and siblings experience many of the same emotional trauma she herself endures.  Although primary medical support is given to the woman, other professionals such as psychiatrists, psychologists and counsellors, can help the woman and her family talk about and work through their problems.  The woman should be reassured that cancer is not infectious and cannot be spread to her family. 

After treatment self-monitoring and professional checkups
Regular follow up examinations are very important after cancer treatment to detect whether the cancer has returned.  The woman should inform her doctor if she has any problems that come up, such as pain, cough, loss of appetite or weight, dizziness or headaches.  The commonest sites of systemic recurrence are the bones, lungs and liver.  A mammogram of the opposite breast should be done every 1-2 years and after breast conservation surgery, mammographic screening to look for a local recurrence is important.  Studies world-wide have shown no survival benefit to routine scans of the chest, liver and bones, and hence in most breast clinics, routine scans and blood tests are not routinely done, unless the woman has symptoms that suggest recurrence. 

Active after treatment self-monitoring and professional checkups are therefore essential. 

Finally, it should be reiterated that an individual’s outcome would be influenced also by the general health, attitude towards the disease and other factors that remain unknown.
 

Know your treatment options

The treatment should take into account the patient’s physical, emotional,
psychological and rehabilitation needs. We want to keep the health intact, cure and suppress disease.