Tumor size, along with the status of the lymph nodes and the biologic behavior of the individual cancer impacts the therapy and prognosis of the disease. Many advances have been made in the treatment of women with early-stage breast cancer.
The primary treatment for most breast cancer remains surgery. Up until the 1960-70’s, the Halsted radical mastectomy was the surgical procedure most commonly performed. In addition to removal of the breast, it also involved removal of the pectoralis muscle off of the ribs and a large number of underarm lymph nodes. The result was a significant deformity of the chest, as well as difficulty with arm movement and a high rate of lymphedema, or permanent swelling of the arm. The modified radical mastectomy was developed which still involved removal of the breast, but the muscle was not removed, and fewer lymph nodes were removed from the underarm. Currently, we are able to remove only a small number of lymph nodes (see below) in many cases. In addition, most often today if a mastectomy is performed, a skin-sparing and even a nipple-sparing approach is used, which combined with immediate reconstruction usually results in an improved cosmetic result.
As screening mammography became more more widespread, breast cancers were detected at a much smaller size than in prior years. The need to remove the entire breast for these small tumors was questioned. Lumpectomy, which involves removal of the tumor and a small rim of surrounding breast tissue (called the “margin”) was compared to mastectomy, and it was found that there was no difference in long-term survival between the two procedures. In other words, women do not live any longer if they have the entire breast removed. If radiation treatment is not performed after lumpectomy, the risk of the cancer returning in the breast is quite high, so this is a necessary step for successful breast conservation. Currently, lumpectomy with radiation treatment is considered to be the standard of care for most women with small breast cancers. The use of ultrasound in the operating room can better pinpoint the tumor and leads to reduced rates of 2nd surgery (sometimes needed to obtain a clean margin). Oncoplastic techniques (combining cancer surgery and plastic surgery) can result in an improved cosmetic outcome after breast-conserving surgery.
Removal and evaluation of the underarm lymph nodes has always been a part of breast cancer surgery – knowing if the cancer has spread to the underarm nodes is important to help make treatment decisions such as the need for chemotherapy. Despite our advances in imaging such as ultrasound, MRI and PET scans, removal of the lymph nodes and evaluation by the pathologist remains the most accurate way to tell if the cancer has spread into the lymph nodes. Since less than 20% of women with early-stage breast cancer have spread of the cancer to the lymph nodes, the sentinel lymph node mapping technique was developed so that the surgeon can identify the just the first one or more lymph nodes that drain the breast, and only those nodes are removed. The risk of lymphedema from a sentinel lymph node dissection is lower than after standard axillary node dissection, and discomfort and arm mobility problems are reduced.
Radiation therapy is most often used after breast conserving lumpectomy, but it is also recommended in certain situations after mastectomy. Standard radiation therapy after lumpectomy is given over the course of 6 weeks, but newer protocols call for just 3-4 weeks of treatment. Some patients may qualify for accelerated shortened courses of radiation delivered either externally (through the skin) or internally to the site where the tumor was removed. Intraoperative radiation therapy is delivered in one dose while the patient is in surgery for the lumpectomy. Not all radiation therapy techniques are available at all facilities.
Chemotherapy is used in 2 situations with breast cancer – one is if the cancer has already spread to the underarm lymph nodes or other areas of the body. The other is if the cancer shows aggressive behavior – this may be determined from basic or more advanced tumor evaluation. Sophisticated molecular biology techniques such as the Oncotype Dx or MammaPrint tests can help identify which women will most benefit from chemotherapy. Hormonal therapy (sometimes known as “estrogen blockade”) may also be recommended in addition to or sometimes instead of chemotherapy in certain cancers.
I cannot stress enough that there is no “one size fits all” treatment when it comes to a woman with breast cancer. Your individual situation as well as factors such as tumor size and biology will be taken into account prior to recommending a specific course of treatment.
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