Breast Cancer

There are different types of breast cancer the most important differences are the degree of aggressiveness, i.e. the ability to grow quickly and spread. Examination of the whole or a piece of the cancer (after it has been prepared and allowed to fix in special fluids for 24 hours) with the microscope can tell us how aggressive it is. This aggressiveness is graded from I to III, Grade I being the least aggressive and Grade III the most. This type of cancer is called invasive cancer.

There is another type of cancer called in-situ cancer (rather than invasive) which, in reality, is a pre-invasive cancerous state which, as it is, will not spread to lymph glands and other organs of the body but, if left untreated, over some years may change to an invasive cancer and behave as such. Often in-situ cancer cannot be felt by examining the breast and it can be widespread in the breast (or breasts) as little nests. To diagnose this condition histology (i.e. examination of a piece of the breast under the microscope) rather than cytology (simple needling to examine the cells under the microscope) is needed.

Management of Breast Cancer – In Brief

Once breast cancer has been diagnosed, staging tests are carried out to see if the cancer has spread to other parts of the body. These tests are:

Blood tests
Radio-isotope bone scan - to look at all the bones in the body. In this test an injection is given into a vein and a scan is carried out a few hours later.
X-rays of chest and sometimes of spine and pelvis
Ultrasound scan of the abdomen (tummy) and pelvis to study the liver, uterus and ovaries in particular.

Note: points C and D can be replaced with CT scan of neck, chest abdomen and pelvis.

The treatment of breast cancer is always along the following lines:

1. Surgery

The aim and The Golden Rule is to remove the cancer as a whole and completely to include a rim of normal breast surrounding the cancer. In the majority of cases this would mean removing a part of the breast (rather than the whole breast) commonly referred to as a lumpectomy we surgeons use a more accurate description of the procedure, i.e. wide local excision.

Sometimes when the cancer is large in relation to the breast or if it is placed centrally in the breast or if the cancer is the type which is spread throughout the breast (as small nests of cancer cells, for example in-situ cancer) to apply the rule of removing the cancer as a whole and completely means a mastectomy (removing the whole of the breast). If this operation becomes necessary, in suitable cases, immediate (i.e. at the time of the operation) reconstruction of a new breast with a prosthesis is always available if desired. This is a complex procedure but does produce good cosmetic effects. The areola and nipple part of the new reconstructed breast is usually added some months later. In some cases of in-situ cancer which are widespread throughout the breast it is permissible to remove the breast tissue from under the breast skin, preserving the skin, areola and nipple this is called a subcutaneous mastectomy and after it is complete a prosthesis can be inserted under the skin or chest wall muscle to recreate the breast.

In cases of invasive cancer (but not in-situ cancer or a tiny invasive cancer) it is usually necessary to remove the lymph nodes from the axilla (armpit). This operation is called axillary lymph node clearance and is carried out in the same operative session as the breast surgery. The breast, like other organs, generates a fluid called lymph, which, through slender but long channels, returns to the blood stream to go on re-circulating. Lymph nodes are about 1cm kidney-bean shaped nodules through which lymph passes and, in some ways, they are filter stations. Most of the lymph from the breast travels upwards to pass through the axillary lymph nodes there are about 15 or so. Unfortunately cancer cells can also travel through these channels and get deposited in these nodes. It is for this reason that the lymph nodes need to be removed for examination with the microscope (histology). In suitable cases, it is possible to remove one or two of the lymph nodes which are the first to receive lymph from the breast cancer. If these are clear of tumour, when examined carefully then the inference is that the rest of the lymph nodes are also free of tumour and a full dissection of the axilla to remove the rest of the lymph nodes is not necessary. The procedure is called Sentinel Lymph Node Biopsy. Carrying out an axillary lymph node clearance to remove the lymph nodes means that fluid from your upper limb (arm, forearm and hand) will need to find other channels to return to the main circulation. New channels open and existing ones may enlarge to make up for the lost lymph channel to return lymph from your upper limb (arm, forearm and hand) the circulation. Nevertheless, this could be a disadvantage in circumstance when fluid load in the upper limb increases - for example, after it is injured or infected when transient swelling may occur. Some months or years after the operation there is a small chance of swelling of the arm/forearm/hand which may be temporary or sometimes permanent. This is a small risk for us to accept as the benefits of removing the glands are substantial.

2. Radiotherapy

After lumpectomy (wide local excision) the remaining breast is exposed to a pre-calculated amount of radiation, called radiotherapy, to reduce the chances of the cancer returning. This is normally carried out 1–2 weeks after surgery, when all the wounds are fully healed. The whole course takes 1–2 months. There are various regimes, for example, radiotherapy is given on every weekday. After marking the area which is going to be treated (called planning) each treatment takes a short time; the exposure period is a matter of minutes. The Consultant Radiotherapist and his or her team will explain everything to you. Radiotherapy is also given to the chest wall after a Mastectomy, in certain circumstances. If this is thought to be necessary, then Breast Reconstruction, following Mastectomy is delayed by 1–2 years.

3. Hormone Treatment

Nolvadex (also known as Tamoxifen) has a beneficial effect in breast cancer, greatly protecting against the cancer recurring and prolonging survival. It also probably protects against getting a new breast cancer (for example, in the other breast). Tamoxifen has other beneficial effects in preventing ovarian cancer, thinning of the bones after the menopause and, possibly, preventing heart attacks and strokes. It is remarkably free of side effects but has only one important undesirable effect which is producing thickening of the lining of the womb (called endometrium) leading to polyp formation and even cancer of the womb. This effect,in the early stages is reversible if the drug is withdrawn and for this reason, patients who are on Tamoxifen (and have not had a hysterectomy) need to have ultrasound scans of their womb at no less than yearly intervals to check and measure the girth of the endometrium. Newer medicines with similar or better effects and lesser side effects are now used more frequently and will replace Tamoxifen. Examples are Anastrozole (also known as Arimidex) and Lentrozole (also known as Femara).

4. Chemotherapy

This refers to medicines which are, in effect, poisonous designed to kill cancer cells but, unfortunately, also damage the normal cells. The normal cells have a greater ability to repair themselves compared to tumour cells and the net effect is beneficial. New drugs are becoming available all the time. The aim is and research is directed towards finding a specific drug that will select tumour cells and attack them leaving normal cells alone. Progress is being made rapidly but, for the moment, we need to accept some side effects. The commonest include nausea (a feeling if sickness) but this is often remedied by new and excellent medications. Hair loss may occur with some chemotherapy agents but can be reduced or prevented by cooling the scalp. If hair loss does occur, it always grows back again (in 6 months or so) and is usually much thicker and of better quality! Usually a combination of drugs is needed. The whole course takes about 5–6 months i.e. 6 courses at 21 day intervals. The Oncologist, the Oncology team of nurses, counselors etc. will explain everything to you. Chemotherapy is usually recommended in cases of invasive cancer (but not in-situ cancer or small cancers detected by screening mammography) when the cancer has spread to the axillary (armpit) lymph nodes referred to as node positive and also in some node-negative cases where the cancer is unfavorable, i.e. is of Grade III and/or is large.

After treatment is complete, patients are seen at regular intervals of initially 3 months, increasing gradually to 4 or 6 months and on to one year. Mammography and Breast Ultrasound Scans are necessary at yearly intervals and sometimes, staging tests are carried out depending on circumstances.