Treating Breast Cancer

If you have been diagnosed with cancer, you will be assigned a Multidisciplinary team. This team involves a group of doctors specialized in different fields such as radiologists, surgeon, and oncologists who will get together with you and plan your treatment.

The methods of treatment available for breast cancer can be classified into:

1. Loco-regional treatment
2. Systemic treatment

Loco-regional treatment

Loco-regional treatment is aimed to control the disease in the breast, chest wall, and the axillary lymph nodes.

Local treatments include surgery, radiotherapy, or both.

Surgery

In the past, the complete removal of the breast (mastectomy) has been the usual practice, however, now, breast conservation surgery has become more prevalent.

• Breast conservation surgery

This is the modern practice used for breast cancer. This involves removing the tumor with a 1cm margin of the surrounding normal breast tissue, which is followed by radiotherapy to the breast to minimize local recurrences. This is also known as Wide Local Excision (WLE). In this procedure, the skin is usually spared and is only removed if there is tethering of the skin.

Wide Local Excision is only indicated if:

1. The tumor is less than 4cm in size.
2. Tumor is more than 2cm away from the nipple.
3. Patient wishes to undergo a WLE.
4. Patient gives consent to undergo radio therapy.

Sometimes, your doctor may prescribe you chemotherapy drugs (Neoadjuvant chemotherapy) to help to reduce the size of the tumor and make it operable by a wide local excision.

Sometimes, a quadrantectomy is performed, which removes the tumor with a quadrant shape resection. However, this method yields a poor cosmetic result.

• Mastectomy

Those who do not meet the selection criterion will undergo a mastectomy. In the 1880s, the practiced method was a radical mastectomy, which involved the removal of the entire breast, axillary lymph nodes, and both the pectoralis major and minor muscles. Later, this techniques was revised and a modified radical mastectomy was done. This involved the removal of the complete breast, axillary lymph nodes, and the pectoralis minor muscle (pectoralis major is preserved). Modern practices now preserve both the pectoralis major and minor muscles, and this simple mastectomy is now the standard practice for invasive breast cancer.

• Reconstructive surgery

Patients having a mastectomy can now have a breast reconstruction. The aim is to restore the natural breast shape, re-establish symmetry, and to create a nipple-areolar complex. Reconstruction of your breasts can be done either using implants, or with flaps using your muscles, skin, and fat.

• Axillary surgery.

During triple assessment, an ultrasound scan of your axilla (arm pit) is also done. If the radiologist finds any suspicious nodes, a FNAC or a core biopsy will be done. If the results come positive, then clearing of your axillary lymph nodes is suggested. If the biopsy result is negative, then a sentinel node biopsy is offered.

A sentinel node is the first node that is likely to get affected if the cancer begins to spread. 12 hours before the mastectomy or WLE, a radioactive isotope bound to albumin is injected. Before the surgery begins, a blue dye is also injected around the nipple. The surgeon uses a device to locate the sentinel node or searches for lymph nodes that have turned blue. Once the sentinel node is found, a small incision is made and this node is excised and sent for histology. If cancer cells are found in this node, the surgeon will then move on to remove the rest of the lymph nodes in your axilla. This may be done either during the same biopsy procedure, or in the next visit.

Systemic therapy

Systemic therapy aims to delay or prevent the spread of breast cancer. This is usually done by chemotherapy, hormonal therapy, and biological therapy.