What treatments are available to cure breast cancer?
Treatment for breast cancer almost always begins with a decision about the type of surgery. Apart from removal of the tumor itself, operations may be performed to improve the appearance of the chest after breast surgery, to discover whether or not cancer has spread to the lymph nodes, or to relieve some of the symptoms of late-stage disease.
The most recent trend in breast cancer surgery is the use of breast-saving lumpectomy (removal of the tumor and its margins) plus radiation therapy for the treatment of early breast cancer. This method has been found to be as effective as mastectomy (complete removal of the breast), while sparing the breast.
In addition, sentinel lymph node biopsy - a more exacting, less invasive form of lymph node biopsy - is becoming an acceptable alternative to axillary (armpit) dissection during surgical staging. Lumpectomy removes the cancer, a surrounding border of cancer-free tissue (roughly 3/4 in), and the nearby lymph nodes. Lumpectomy is, by definition, a form of breast-conserving surgery (BCS). Partial mastectomy is a non-specific term for surgery in which part of the breast is removed. If the tumor is located in the upper breast, the incision often is made in a curved line, close to the areola (dark, circular area around the nipple). If the tumor is located in the outer breast near the armpit, the tumor and nearby lymph nodes may be taken out through the same incision. If the tumor is located in the lower breast, the surgeon usually makes a radial incision (one that extends from the center of the breast outward towards the edges). The axillary (underarm) lymph nodes are removed through the original incision or via a separate incision in the armpit itself. In general, between 10 and 15 lymph nodes are removed during partial mastectomy.
Radiation therapy, sometimes called radiotherapy, almost always is recommended after lumpectomy to destroy any cancer cells left behind and to prevent the cancer from returning. Without radiation therapy, the odds of the cancer returning increase by about 25 percent. Radiation therapy is used as a local adjuvant treatment in patients having a lumpectomy. It is also used, sometimes, after a mastectomy for women with large cancer tumors or with four or more positive lymph nodes; or when the margins of resection are involved with cancer. Such treatment can help destroy breast cancer cells that may have been left behind in the area where the breast had been (this area is called the "chest wall"). Such treatment helps to eliminate any cancer cells that may remain in the breast. Radiotherapy is used to prevent local recurrence (regrowth of breast cancer at the original site) and to avoid the need for mastectomy. Recent follow-up studies indicate that women who undergo lumpectomy with radiotherapy survive as long as women who undergo mastectomy. Unfortunately, women who develop a local recurrence usually require mastectomy, because a cancerous breast cannot be irradiated twice without damaging side effects (for example, death of normal breast tissue, skin ulceration, or radiation-induced cancer).
The need for chemotherapy depends on how much the cancer has spread. In some cases, chemotherapy will be recommended before surgery to shrink a large tumor so that it can be removed more easily. Chemotherapy involves a combination of anticancer drugs. These drugs are powerful and can have many side effects. Anticancer drugs are given by mouth or by injection into a blood vessel. Either way, the drugs enter the bloodstream and travel throughout the body. Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most patients receive treatment in an outpatient part of the hospital or at the doctor's office. Adjuvant chemotherapy usually lasts for three to six months. Chemotherapy is almost always necessary if cancer recurs. A form of chemotherapy called hormonal chemotherapy usually is recommended when the pathology report shows that the cancer is estrogen-receptor positive. In hormonal chemotherapy, the drug tamoxifen (Nolvadex) is taken daily, by mouth, for two to five years. Tamoxifen locks estrogen out of breast cancer cells that are estrogen-receptor positive, which may reduce the cancer recurrence rate by up to 30 percent.
In the past, precancerous DCIS was treated as if it were breast cancer, but now it appears that less aggressive treatments may be equally effective. Though mastectomy sometimes still is done for DCIS, lumpectomy with radiation also is commonly done. In some women, lumpectomy without radiation also may be effective. Because LCIS itself doesn't lead to cancer, no treatment is required, but women with this condition should have regular mammograms and breast exams by a physician.
Hormone therapy deprives cancer cells of the female hormone estrogen, which some breast cancer cells need to grow. For many women, hormone therapy is treatment with the drug tamoxifen, or, for postmenopausal women, an aromatase inhibitor, such as anastrozole (Arimidex) and letrozole (Femara). Some premenopausal patients may have surgery to remove their ovaries, which are a woman's main source of estrogen. Or they may be treated with a medication to reduce ovarian function. Like anticancer drugs, tamoxifen and the aromatase inhibitors are taken once a day by pill and are absorbed into the bloodstream. Most women take hormone therapy for five years. Two studies confirmed benefits for breast cancer patients taking adjuvant tamoxifen for five years, but saw no added benefit and noted potentially negative effects for patients taking tamoxifen longer than five years.
Breast implants (artificial cushions that are filled with a soft, breast-like substance - usually saline [salt water] or gel) have been used extensively for breast reconstruction. Breast implants are not placed under the skin, but rather are inserted under the pectoral (chest) muscle in a surgically-made pouch. Sometimes the chest muscle must be pre-stretched by a temporary device before placement of the permanent implant.
The major advantage of using an implant is that it can be inserted easily and quickly. The disadvantages are the continual risk of implant failure in the form of infection, rupture, breakdown, capsular contraction (tissue hardening around an implant), and the need for tissue pre-stretching. The lifespan of implants beyond 10 to 20 years is still unknown, as is the relationship - if any - to autoimmune disease. For these reasons, the use of the woman's own tissue has become the method of choice for breast reconstruction. Specifically, surgeons have begun to use skin and fat from elsewhere in the woman's body (e.g., the abdomen) to create a more natural-looking breast.