Overview of Treatment & Management of Breast Cancer

Cancer Connect

Medically reviewed by Dr. C.H. Weaver M.D. Medical Editor 8/2020

In general treatment for breast cancer may require surgery, radiation, and/or systemic therapy with chemotherapy, immunotherapy or precision cancer medicines. The specific treatment for each person is individualized and is based on the stage of the cancer and its genomic profile.

Breast Cancer Surgery

Nearly all women with breast cancer will undergo some kind of surgery as part of their diagnosis and/or treatment. The extent of surgery for breast cancer may range from removal of only a small piece of breast tissue to removing one or both breasts, including underarm (axillary) lymph nodes. In addition to treating the cancer, the purpose of surgery in the management of breast cancer is to obtain tissue to confirm an accurate diagnosis, determine the stage of the cancer, and provide for breast reconstruction to create a breast that matches the opposite breast.

Women should discuss breast reconstruction with their surgeon before breast cancer surgery - having information about breast reconstruction allows women to make more informed decisions about breast cancer surgery. (14)

Systemic Treatment for Breast Cancer

Systemic cancer treatment is administered to decrease the risk of cancer recurrence that occurs following treatment with surgery alone for most patients with early stage breast cancer. Systemic treatment may be given before (neoadjuvant) or after (adjuvant) surgery and may include chemotherapy, hormonal therapy, immunotherapy, or use of precision cancer medicines. Neoadjuvant therapy is typically used in individuals with “larger” cancers to shrink them before surgery in order to obtain a complete removal by surgery. Systemic therapy is the standard treatment with for all advanced breast cancers.

Precision Cancer Medicines: The purpose of precision cancer medicine is to define the genomic alterations in the cancers DNA that are driving that specific cancer. Precision cancer medicine utilizes molecular diagnostic testing, including DNA sequencing, to identify cancer-driving abnormalities in a cancer’s genome. Once a genetic abnormality is identified, a specific targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of the cancer cells. Precision cancer medicine uses targeted drugs and immunotherapies engineered to directly attack the cancer cells with specific abnormalities, leaving normal cells largely unharmed. Precision medicines are being developed for the treatment of colon cancer and patients should ask their doctor about whether testing is appropriate.

Chemotherapy: Chemotherapy uses medications that can be taken orally as a pill or are injected into a vein to kill cancer cells. In some situations chemotherapy is combined with immunotherapy or other precision cancer medicines to achieve the best results.

Hormonal Therapy: Estrogen is an essential female hormone that is produced by the ovaries and adrenal glands. Estrogen can cause some cancers to grow. The breasts, uterus and other female organs are composed of cells that contain estrogen receptors. When cells that have estrogen receptors become cancerous, exposure to estrogen increases the cancer’s growth. Cancer cells that have estrogen receptors are referred to as estrogen receptor-positive (ER-positive) cancers.The growth of ER-positive breast cancer cells can be prevented or slowed by reducing the exposure to estrogen. This is the goal of hormonal therapy for breast cancer.

Radiation Therapy & Breast Cancer

Radiation therapy uses high-powered energy beams, such as X-rays or protons, to kill cancer cells. Radiation therapy is almost always utilized as part of the overall breast-conserving strategy in early stage cancer and DCIS because radiation decreases the risk of local cancer recurrence and improves survival.

Surgery For Breast Cancer

Nearly all women with breast cancer will undergo some kind of surgery as part of their diagnosis and/or treatment. The extent of surgery for breast cancer may range from removal of only a small piece of breast tissue to removing one or both breasts, including underarm (axillary) lymph nodes. The purpose of surgery in the management of breast cancer is to:

  • Obtain a tissue sample for determining an accurate diagnosis.
  • Evaluate the tissue to determine if precision cancer medicines can be used to treat the cancer
  • Determine the stage of the cancer and whether additional treatment is necessary.
  • Treat the cancer locally.

The surgical procedures utilized in the management of breast cancer include the following. The type of surgery that a patient with breast cancer undergoes depends largely on the size and location of the cancer, the breast size, feasibility of breast reconstruction, and how important breast preservation is to the patient.

Biopsy

A biopsy is the removal of cells or tissue for further evaluation; it is often performed to determine whether cancer is present. A biopsy may involve surgical removal of all or a part of a breast lump, or use of a needle to remove tissue or fluid.

Treatment of Breast Cancer by Stage

Carcinoma In Situ: Approximately 15-20% of breast cancers are very early in their development. These are sometimes referred to as carcinoma in situ and consist of two types: ductal carcinoma in situ (DCIS), which originates in the ducts and lobular carcinoma in situ (LCIS), which originates in the lobules. DCIS is the precursor to invasive cancer and LCIS is a risk factor for developing cancer.

Stage I: Cancer is confined to a single site in the breast, is less than 2 centimeters (3/4 inch) in size and has not spread outside the breast.

Stage IIA: Cancer has spread to involve underarm lymph nodes and is less than 2 centimeters (3/4 inch) in size or the primary cancer itself is 2-5 centimeters (3/4-2 inches) and has not spread to the lymph nodes

Stage IIB: Cancer has spread to involve underarm lymph nodes and/or the primary cancer is greater than 5 centimeters (2 inches) in size and does not involve any lymph nodes.

Stage IIIA: Cancer is smaller than 5 centimeters (2 inches) and has spread to the lymph nodes under the arm or the lymph nodes are attached to each other or to other structures or the primary cancer is larger than 5 centimeters (2 inches) and has spread to the lymph nodes under the arm.

Stage IIIB: Cancer directly involves the chest wall or has spread to internal lymph nodes on the same side of the chest.

Inflammatory: Inflammatory breast cancer is a special class of breast cancer that is rare. The breast looks as if it is inflamed because of its red appearance and warmth. The skin may show signs of ridges and wheals or it may have a pitted appearance. Inflammatory breast cancer tends to spread quickly.

Stage IV - Metastatic Breast Cancer has spread to distant locations in the body, which may include the liver, lungs, bones or other sites.

Local Recurrence of Breast Cancer the breast cancer has progressed or returned (recurred/relapsed) in the breast or chest wall following initial treatment.

References:

  1. Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer 2003;98(4): 697-702.
  2. Edge SB, Niland JC, Bookman MA, et al. Emergence of sentinel node biopsy in breast cancer as standard-of care in academic comprehensive cancer centers. Journal of the National Cancer Institute2003;95:1514-1521.
  3. Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. The New England Journal of Medicine 2003;349:546-553.
  4. Gelber RD, Goldhirsch A, Piccart M, et al. HERA TRIAL: 2 years versus 1 year of trastuzumab after adjuvant chemotherapy in women with HER2-positive early breast cancer at 8 years of median follow up. Presented at the 37th Congress of the European Society for Medical Oncology (ESMO), Vienna, Austria, September 28-October 2, 2012. Abstract LBA6.
  5. businesswire.com/news/home/20170908005162/en/
  6. FDA approves new treatment for late-stage breast cancer. [FDA News Release]. U.S. Food and Drug Administration website. Available here
  7. FDA approves Perjeta for neoadjuvant breast cancer treatment. [FDA Announcement]. U.S. Food and Drug Administration website. Available here
  8. Patnaik A, Rosen LS, Tolaney SM, et al. Efficacy and safety of abemaciclib, an inhibitor of CDK4 and CDK6, for patients with breast cancer, non-small cell lung cancer, and other solid tumors [published ahead of print May 23, 2016]. Cancer Discov. 2016;6:740-753.
  9. Tripathy D, Sohn J, Im S, et al. First-line ribociclib or placebo combined with goserelin and tamoxifen or a non-steroidal aromatase inhibitor in premenopausal women with hormone receptor-positive, HER2-negative advanced breast cancer: results from the randomized Phase III MONALEESA-7 trial. Presented at the San Antonio Breast Cancer Symposium (SABCS), December 6, 2017, San Antonio, Texas (abstract#S2-05).
  10. Turner NC, Ro J, André F, et al. Palbociclib in Hormone-Receptor–Positive Advanced Breast Cancer. New England Journal of Medicine. June 1, 2015DOI: 10.1056/NEJMoa1505270.
  11. Robson M., Im SA., Senkus E., et al, OlympiAD: Phase III trial of olaparib monotherapy versus chemotherapy for patients (pts) with HER2-negative metastatic breast cancer (mBC) and a germline BRCA mutation (gBRCAm), Presented at the American Society of Clinical Oncology Annual Meeting, Chicago; June 2-6, 2017.
  12. Keytruda®/Halaven® May Be Effective in Advanced Triple-Negative Breast Cancer
  13. Tolaney SM, Kalinsky K, Kaklamani V, et al. Phase 1b/2 study to evaluate eribulin mesylate in combination with pembrolizumab in patients with metastatic triple-negative breast cancer. Presented at: 2017 San Antonio Breast Cancer Symposium; December 5-9, 2017; San Antonio, TX. Abstract PD6-13.
  14. Alderman AK, Hawley ST, Waljee J et al. Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer. Cancer [early online publication]. December 21, 2007.
  15. Oncologic Safety of Nipple Sparing Mastectomy in Women with Breast Cancer, Journal of the American College of Surgeons. DOI:
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