The Non Surgical Management of Breast Cancer from the perspective of the Clinical Oncologist
By: Dr Mohd Ibrahim Abdul Wahid, Consultant Clinical Oncologist/Radiotherapist

(This paper was presented on 2 Sep 2003 at the Launch of the 2003 College of Radiology’s Breast Cancer Awareness Campaign)
 

Breast cancer is the commonest malignancy among women in Malaysia. There are about 4500 new cases being diagnosed annually and the risk of developing the cancer is 1 in 19 women. In Malaysia the incidence is about half of that seen in the UK or US where the incidence has been increasing over the last few decades. Breast cancer is one of the leading causes of death. However, in US there is a slight decline in the death rate from breast cancer recently. This is due to early detection and advances in treatment especially in the use of chemotherapy for early stage cancers. It is therefore important that we should also initiate a program for early detection and understand the treatment options so that we can achieve a similar decline in the number of breast cancer deaths in Malaysia. 

In general, the treatment for breast cancer includes the following.

1. Surgery
2. Radiotherapy or radiation therapy
3. Chemotherapy
4. Hormonal therapy
5. Others e.g. herceptin

Patients must be aware that breast cancer cannot be treated by one person. It requires the contribution of many medical specialties e.g. pathology, radiology, surgery and oncology. While surgery remains the standard primary treatment, the oncologists usually manage the patients for further therapy. Patients will first have to be carefully assessed using X-rays or scans and cancer tissue should be studied for any high-risk features. The patients will then be staged as either having early (stage 1 and 2) or late stage (stage 3 and 4) cancer. 

Early stage disease means that the cancer is non-bulky and is confined to the local area. These cancers are highly curable without the need for any extensive surgery.  The aim of treatment is clear for the early staged cancer. These are:

1. To improve the local control following surgery
2. Increase the survival rate
3. Decrease the relapse / recurrence  rate
4. Prevent new cancer in the opposite breast

Late stage disease especially stage 4 is generally incurable and the aim of the treatment will no longer be curative but palliative. Palliation means to give treatment with the intention of controlling the disease for as long as possible and to ease symptoms such as pain or shortness of breath and to improve quality of life.  

Choosing the appropriate treatment following surgery will depend on several factors. This will include the stage of the cancer, age of patient, menopausal status, hormone receptor status and pathology (tissue specimen) report. Combination therapy is essential for achieving high cure rates in breast cancer. Hence giving chemotherapy, radiotherapy and/or hormone therapy even for early stage but high risk disease will improve treatment outcome and survival.  

In Malaysia approximately 50% to 60% of patients who present at the cancer centers are in the curable or Stage I & II disease. However, approximately 15-20% of patient may be incurable as they present late or in the 4 Stage disease. In contrast, over 80% of patients in UK and US fall into the curable category. The cause of late presentation in this country may be multi factorial. These include the lack of insight about the disease, delay in making the diagnosis, patient seeking alternative therapy or fear of hospitals and treatment. In the Klang Valley there are at least 9 cancer treatment centers while the other states have only 1-2 centres. There are 4 states in Malaysia that do not have any oncologists or oncology centers. So patients in Kedah, Perlis, Terengganu and Pahang may present early to the surgeons but the nearest cancer center is several hundred miles away! 

The final concern is that our public has a very misinformed view about cancer treatment especially for chemotherapy and radiotherapy. The use of inappropriate terminology like radiotherapy burns the skin and chemotherapy kills all the good cells as well as the bad cells (and eventually the patient) makes patients very apprehensive about receiving proper treatment.  The negative publicity and lack of understanding about cancer therapy also makes some patients turn to alternative medicine as first line treatment. They believe that alternative medicine & herbs cause less harm and side effects and some even promise high cure rates.  

It is surprising to see that some of the patients who seek alternative treatment are the well-educated upper middle class professionals who have access to the Internet and read health literature widely. This group of patients usually makes their own decision on therapy based on their reading and understanding of the information (actually misinformation) they obtain and hope to seek cure with little or no side effects by using alternative medicine as 1^st line therapy. It is unfortunate that we see high mortality rates among these women who should have been cured of their cancer but come to the hospital only in the terminal stages. These women suffer unnecessary pain with the enlarging or fungating cancers as the alternative practitioners tell them that this is a natural path and part of the “healing process.”  

It is therefore important that the cancer awareness campaigns not only focus on early detection and treatment but also on the need to get appropriate therapy. Early detection and proper treatment will save many lives and cost!

Know your treatment options

The treatment should take into account the patient’s physical, emotional,
psychological and rehabilitation needs.

Breast reconstruction may not be for every patient but do not discount how it can help you feel better, look better and therefore smoothen and quicken your road to recovery. Our psychological well being is equally important.