Treatment of Breast Cancer

Treatment options for breast cancer are dependent on many different factors. You and your doctor need to consider the type of breast cancer, the stage, and the aggressiveness of the disease. A variety of options are available including surgery, radiation therapy, chemotherapy, targeted therapy, and endocrine therapy. Each patient’s disease is unique and therefore, medical management should be personalized for each patient. Below is an explanation of treatment options that your doctor may recommend.

Treatment of breast cancer by stage

Stage I breast cancer is relatively small and either hasn’t spread to nearby lymph nodes or has a tiny area of cancer that has spread to the lymph node. Treatment can include breast conserving surgery or mastectomy and may also include radiation therapy, chemotherapy, targeted therapy, and endocrine therapy.

Stage II breast cancer is larger and/or has spread to a few nearby lymph nodes. Treatment may include either breast conserving surgery or mastectomy and may also include radiation therapy, chemotherapy, targeted therapy and endocrine therapy.

Stage III breast cancer is large, growing into nearby tissues, or has spread to nearby and more distant lymph nodes. Treatment will often include surgery (probable mastectomy), radiation therapy, chemotherapy, targeted therapy and endocrine therapy.

Stage IV breast cancer has spread beyond the breast and lymph nodes to other organs in the body.  Surgery and radiation may be used in addition to systemic therapy. Systemic therapy will usually consist of chemotherapy, targeted therapies, endocrine therapy, or a combination of these treatments.

Surgical Therapy

The majority of women with breast cancer will need to have some type of surgery. The goal of surgery is to remove breast tumor. The options for surgery include breast-conserving surgery and mastectomy. Surgery also might be needed to check the lymph nodes under the arm to check if the cancer has spread.

Breast Cancer Surgery

Breast-conserving surgery or lumpectomy –Only the part of the breast with the tumor and some surrounding tissue is removed.

Mastectomy – Removal of the entire breast and often some surrounding tissue. There are many subtypes of mastectomy:

  • Simple mastectomy: Removal of entire breast (including nipple and areola), but does not remove underarm lymph nodes or muscle tissue underneath the breast. Most common type of mastectomy.
  • Skin-sparing mastectomy: Most of the skin over the breast is spared, not including the nipple and areola, for women considering immediate breast reconstruction. Skin-sparing mastectomy may not be suitable if the tumor is large or close to the surface of the skin.
  • Modified radical mastectomy: Removal of entire breast and axillary (underarm) lymph nodes
  • Radical mastectomy: Removal of entire breast, axillary lymph nodes, and pectoral muscles underneath the breast. Radical mastectomies are rarely performed anymore.

Lymph node surgery – This surgery involves removing one or more of the lymph nodes (which are studied under the microscope to assess whether cancer has spread to the nodes). This is used to stage breast cancer.

Pharmacological therapy – administered by Medical Oncologist

Chemotherapy

Chemotherapy treatment is the use of cytotoxic drugs to destroy cancer cells. Often, these drugs are used in pairs to treat patients with breast cancer. These drugs can be delivered directly to the bloodstream (intravenously) or taken by mouth. Chemotherapy may be given before surgery (neoadjuvant therapy) and/or after surgery (adjuvant therapy). Importantly, chemotherapy has risks and it is important for the doctor and patient to thoroughly discuss the benefits and risks of the medications being considered.

Groups of chemotherapy:

  • Anthracyclines: Damage the genetic material of cancer cells to kill them.
  • Example of Anthracyclines: doxorubicin, epirubicin, and daunorubicin.
  • Taxanes: interfere with the cell division of cancerous cells.
  • Example of Taxanes: Taxol, Taxotere, and Abraxane.

Standard chemotherapy regimens:

  • AT: Adriamycin® (doxorubicin) and Taxotere® (docetaxel)
  • AC ± T: Adriamycin® (doxorubicin) and Cytoxan® (cyclophosphamide), with or without Taxol® (paclitaxel) or Taxotere® (docetaxel)
  • CMF: cyclophosphamide, methotrexate, and 5-FU

Common chemotherapy drugs:

  • Nab-paclitaxel (brand name: Abraxane®)
  • Doxorubicin (brand name: Adriamycin®)
  • Carboplatin (brand name: Paraplatin®)
  • Cyclophosphamide (chemical name: Cytoxan®)
  • Daunorubicin (brand names: Cerubidine®, DaunoXome®)
  • Liposomal Doxorubicin (brand name: Doxil®)
  • Epirubicin (brand name: Ellence™)
  • Fluorouracil (also called 5-fluorouracil or 5-FU; brand name: Adrucil®)
  • Gemcitabine (brand name: Gemzar®)
  • Eribulin (brand name: Halaven®)
  • Ixabepilone (brand name: Ixempra®)
  • Methotrexate (brand names: Mexate®, Folex®)
  • Mutamycin (brand name: Mitomycin®)
  • Mitoxantrone (brand name: Novantrone®)
  • Vinorelbine (brand name: Navelbine®)
  • Paclitaxel (brand name: Taxol®)
  • Docetaxel (brand name: Taxotere®)
  • Thiotepa (brand name: Thioplex®)
  • Vincristine (brand names: Oncovin®, Vincasar PES®, Vincrex®)
  • Capecitabine (brand name: Xeloda®)

(breastcancer.org)

Common side effects:

  • Hair loss and nail changes
  • Mouth sores
  • Change in appetite
  • Nausea and vomiting
  • Low blood cell counts

Radiation Therapy – delivered by a Radiation Oncologist

Radiation therapy (RT), or radiotherapy, is the use of ionizing radiation to eliminate cancer by damaging the DNA of the cancer cells. RT is often used as part of a multi-pronged approach in combination with surgery and other agents.

External beam radiation therapy

External beam radiation therapy is the most common form of radiation therapy. High-energy machines using rays or particles focus radiation on the tumor site and surrounding areas. The treatment typically takes less than 30 minutes and is repeated daily for 5 consecutive days over the course of 4-6 weeks.

Internal radiation therapy (Brachytherapy)

Internal radiation therapy, also known as brachytherapy, is a form of radiotherapy in which small radioactive seeds or pellets are place in the site where the tumor was removed. Radiation emitted from the radioactive seeds deliver a high level of radiation to the tumor site while reducing harm to the surrounding healthy tissue. Treatments usually are given twice a day for 5 consecutive days, though other techniques are being evaluated to reduce this time considerably.

Common side effects of RT include fatigue, mild to severe skin reaction, and swelling

Targeted Therapy

Targeted therapy uses a class of drugs that destroy cancer cells while minimizing damage to normal, heathy tissue. This is achieved by designing drugs that affect critical functions required for tumor cells to survive. Many of these drugs target the same mutations that cause a cell to become cancerous. Mutational analysis is often required to determine if a targeted therapy is appropriate. Notably, fewer side effects are associated with targeted therapies compared to chemotherapy.  Her2/Neu is a protein commonly found on some breast tumors and has several different drugs that can target it in patients with breast cancer.

Common HER2/neu targeted therapy drugs:

  • Trastuzumab (brand name: Herceptin®)
  • Pertuzumab (brand name: Perjeta™)
  • Ado-trastuzumab emtansine (brand name: Kadcyla™)
  • Lapatinib (brand name: Tykerb®)

Common side effects include potential heart muscle damage and diarrhea (applies to Lapatini)

Hormone Therapy

Hormone therapy targets hormones in the blood that affect breast cancer.  Estrogen receptor (ER) and progesterone receptor (PR) are proteins commonly found on some breast tumors and have several different drugs that can target them.  Estrogen helps ER-positive and PR-positive breast cancer cells grow. There are several drugs that stop cancer cells from attaching to estrogen. Hormone therapy reaches cancer cells throughout the whole body and not just in the breast. It is recommended for patients with hormone receptor-positive (ER-positive and/or PR-positive) breast cancer but would not be effective for patients whose tumors are hormone receptor-negative (both ER- and PR-negative).

Companion Diagnostics

Companion diagnostics are medical tests that make personalized medicine possible. Designed to be paired with a specific drug, companion diagnostics help healthcare professionals determine which patients could be helped by that drug and which patients would not benefit, or could even be harmed.

“To learn which patients would benefit from a particular drug therapy or, conversely, which patients should not receive the medication, the Food and Drug Administration works with drug and device manufacturers that are developing certain tests called companion diagnostics.” (http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm407297.htm)

How to test

Companion diagnostics are often done by a blood sample to determine if a patient has a disease or infection. Companion diagnostic tests may also involve tumor testing. Tumor or somatic testing looks only at the cells of a tumor.

Breast Cancer Companion Diagnostics

  • INFORM HER-2/NEU: tumor test for the detection of Her-2/Neu gene amplification in the tumor.
    • Determines eligibility for treatment with Herceptin® (trastuzumab)
  • PATHVYSION™ HER-2 DNA Probe Kit: tumor test for the detection of Her-2/Neu gene amplification in the tumor.
    • Determines eligibility for treatment with Herceptin® (trastuzumab)
  • PATHWAY ANTI-HER-2/NEU (4B5) Rabbit Monoclonal Primary Antibody: tumor test for the detection of c-erbB-2 antigen in normal and neoplastic tissue.
    • Determines eligibility for treatment with Herceptin® (trastuzumab)
  • INSITE™ HER-2/NEU KIT: tumor test for the detection of c-erbB-2 antigen in normal and neoplastic tissue.
    • Determines eligibility for treatment with Herceptin® (trastuzumab)
  • SPOT-LIGHT® HER2 CISH Kit: tumor test for the detection of Her-2/Neu gene amplification in breast carcinoma tumor tissue sections using Chromogenic In Situ Hybridization (CISH).
    • Determines eligibility for treatment with Herceptin® (trastuzumab)
  • Bond Oracle Her2 IHC System: tumor test for the detection of Her2 (human epidermal growth factor receptor 2) oncoprotein status in the tumor.
    • Determines eligibility for treatment with Herceptin® (trastuzumab)
  • HER2 CISH PharmDx™ Kit: tumor test for the detection of Her2 gene and center region of chromosome 17.
    • Determines eligibility for treatment with Herceptin® (trastuzumab)
  • HERCEPTEST™: tumor test to determine Her2 protein overexpression in breast cancer tissues.
    • Determines eligibility for treatment with Herceptin® (trastuzumab), Perjeta (pertuzumab), or Kadcyla™ (adotrastuzumab emtansine).
  • INFORM HER2 DUAL ISH DNA Probe Cocktail: tumor test to determine Her2 gene status by enumeration of the ratio of the HER2 gene to Chromosome 17.
    • Determines eligibility for treatment with Herceptin® (trastuzumab).
  • HER2 FISH PharmDx™ Kit: tumor test to determine Her2 gene amplification in breast cancer tissues in patients with metastatic gastric or gastroesophageal junction adenocarcinoma.
    • Determines eligibility for treatment with Herceptin® (trastuzumab), Perjeta (pertuzumab), or Kadcyla™ (adotrastuzumab emtansine).

(http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm301431.htm)

Follow-up and Surveillance

After treatment of breast cancer, patients continue to follow-up with their healthcare providers. Regardless of stage, routine surveillance is used to monitor the body for cancer recurrence.

Cancer Caregiver:

A caregiver is anyone who provides physical, emotional, spiritual, financial, or logistical support to anyone suffering from a disabling or life threatening illness. Caring for a loved one with cancer is the role of caregivers but it is also important that caregivers take care of themselves. Finding a balance between helping your loved one and helping yourself is imperative for all caregivers.

Every caregiver is at a different point in their journey. Understanding the important role caregivers hold helps them be effective at embracing their new life. Caregivers may face many obstacles while adapting to their new role, but there are resources to help them along the way.  Some online resources include the American Cancer Society (cancer.org), the National Cancer Institute (cancer.gov), Cancer Support Community (cancersupportcommunity.org), OncoLink (oncolink.com), and Breastcancer.org.

Some tips that may help include:

Find support from others in similar positions: Communicating with other caregivers may help you relieve stress and become a better caregiver.

Educate yourself on their specific situation: Learning about what your loved one is going through will enable you to help them in many different ways.

Embrace new life changes: It is normal to feel like things are different and that they may never be how they once were. It is important to embrace your new situation and learn to adapt to the changes in life. Learning to balance what you have control of and what is out of your control may help remove some of the stress from your life.

Take time outs: It is ok to take time for yourself. Rejuvenating yourself is imperative to becoming the best caregiver you can be.

Remain connected with community, friends, and family: Becoming a caregiver should not involve you abandoning your old life. Being around people that love and care about you can recharge you and uplift your spirit. The level of involvement you have with friends and family may vary, but keeping them close can help give you strength and a positive attitude.

Allow help from others: Accepting help from others will take strain off of you and allow others to feel a part of caring for someone in need. People around you may want to help but don’t know how. If they ask to help, learn to say yes.

Maintain yourself physically, mentally, and emotionally: Taking care of yourself allows you to be a better resource to those in need. It is easy to overlook your personal wellbeing while taking on the role of a caregiver, but allowing time to keep yourself healthy will make you a more effective helper.

Find ways to relieve stress: It is important to plan stress relieving activities into busy schedules. Learning different ways that allow your body to relax can enhance the way your mind and body function.

Understand your limits: You can’t do everything, and that is ok. It is easy to get caught up feeling like you need to take care of every single responsibility. Ask for help when you need it, take a break when it’s hard, and try not to overwork yourself.

(Cancer.org)

(10 tips for caregivers: www.cancersupportcommunity.org)

Sources: Cancer.org, radiologyinfo.org, NCCN guidelines, cancersupportcommunity.org, cancer.gov, oncolink.com, breastcancer.org

Adriamycin, Taxotere, Cytoxan, Taxol, Taxotere, Herceptin, Perjeta, Kadcyla, Tykerb®, Abraxane,  Paraplatin, Cerubidine, DaunoXome, Doxil, Ellence, Adrucil, Gemzar, Halaven, Ixempra, Mexate, Folex, Mitomycin, Novantrone, Navelbine, Thioplex, Oncovin, Vincasar PES, Vincrex, Xeloda, PATHVYSION, INSITE, SPOT-LIGHT, PharmDx, and HERCEPTEST are either trademarks or registered trademarks of their respective owners.

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