Breast Cancer Treatment Options: Making Informed Decisions

Significance of understanding breast cancer treatment options

Treatment of breast cancer has undergone a change over the years. 2 decades ago, it was believed that initial surgery followed by standard chemotherapy was sufficient treatment for breast cancer. However, the theory of ‘one size fits all’ is no longer valid. Customized treatment is now required for patients. 

Breast cancer diagnosis and treatment is stressful.  Mental and financial pressure can exert a huge burden.  A good Medical Oncologist and an idea about the treatment line, can help in relieving this stress.

Understanding Breast Cancer Treatment in India

Risk Factors in Breast Cancer:

Female sex, increasing age, age 40 years and above, a positive family history for breast or ovarian cancer, being a carrier of hereditary, high-risk cancer-causing mutations are risk factors.

Screening & Early Detection in Breast Cancer:

Breast cancer can be cured if detected early. The latest screening techniques now enable detection of breast cancer when only a few mm in size. if treated at this stage, the cancer can be eliminated.

Women 40 years of age and above, must undergo an annual digital Mammogram+Ultrasonography for breast cancer screening. Annual screening allows early detection and cure.

Types of Breast Cancer:

Invasive Ductal Carcinoma, Invasive Lobular Carcinoma and Ductal/Lobular Carcinoma in Situ are the types of Breast Cancer.

Breast Cancer Treatment Approaches

Breast cancer treatment is a complex procedure. To provide a cure, a multimodal approach is required which is coordinated by the Medical Oncologist. 

Molecular profiling determines the sequence of the treatment modalities. This involves assessment of ER/PR/HER2/KI-67 markers for every breast cancer. The treatment for every individual patient is then customized based on their presence or absence.

The size of the tumour, the stage it is detected in, whether it is localised, is locally advanced or has metastasised, the presence of axillary lymph nodes involved by the cancer, lymphovascular and perineural invasion and age of the patient, are the other factors required to customize the treatment.

The presence of hereditary mutations like BRCA, must also be factored in, if detected.

Breast Cancer Stages and Treatment

 Stages:

Stage 0 and Stage 1 are the early stages of breast cancer, when the tumour is still small and localised.

Stage 2 refers to the breast cancer being detected when it has already increased in size, though there is still no significant spread.

Stage 3 means that the breast cancer is large, and locally advanced. The regional axillary lymph nodes and surrounding tissues are involved by the cancer.

Stage 4 means the cancer is metastatic. It has spread to involve distant organs like the lungs, liver and/or bones.

If detected in the initial stages breast cancer can be cured.

Once the cancer has started spreading, the cancer cannot be cured, but it can be effectively controlled, allowing the patient to lead a normal life.

All breast cancers which are ER/PR/HER 2 negative or HER 2 positive (irrespective of ER/PR status) require chemotherapy and targeted therapy irrespective of the primary tumour size and lymph node status.

The chemotherapy can be omitted only in ER/PR positive/HER 2 negative low grade breast cancers which are detected when small in size, with no local or regional spread.

All other ER/PR positive/HER 2 negative breast cancers require chemotherapy followed by targeted therapy.

All breast cancers which are triple negative-ER/PR/HER 2 negative or HER2 positive (irrespective of ER/PR status), must receive chemotherapy plus targeted therapy upfront, pre-surgery, as the first treatment modality.

Performing a surgery initially in these patients compromises the long- term survival and increases the risk of a recurrence.

Breast Cancer Surgery Options and Considerations 

Breast Cancer Surgery:

 Is performed:

-when a breast cancer is localised within the breast, with no spread, and can be completely removed.

-when the breast cancer has spread to multiple organs, but the primary cancer has increased in size and broken through the breast skin.

 Types of breast cancer surgery:

•  Modified Radical Mastectomy (MRM)– which involves removal of the entire breast with the cancer lump & the draining axillary lymph nodes.

This surgery is usually preferred by elderly women who wish to avoid local radiation to the operated site post- surgery. Large breast cancers & locally advanced cancers also require a breast removal for complete clearance. 

Younger women who undergo this procedure can opt for a breast reconstruction following the completion of the cancer treatment.

•  Lumpectomy:  involves removal of the breast cancer lump & draining axillary lymph nodes. The entire breast is not removed. Only the cancerous part is taken out. Such patients require local radiotherapy post- surgery. It is given to the affected breast & is necessary to reduce the risk of local recurrence of the breast cancer.

Both MRM & lumpectomy are equally effective in treating the primary breast cancer. The overall control & survival rates are the same. 

The procedures are safe and well tolerated. All patients require physiotherapy for the arm & shoulder on the affected side. This is necessary to prevent post-operative pain, stiffness & swelling. 

Factors Influencing Treatment Decisions:

Molecular profiling is necessary upfront. An initial biopsy of the breast lump, followed by assessment of the ER/PR/HER2 status & the KI-67 percentage is essential to plan out the treatment line.

An assessment of the size of the breast cancer lump and the extent of the disease, whether the cancer is localized or metastatic, is necessary before planning the treatment.

Genetic tests must be performed to screen the patient for the high risk, cancer- causing mutations like BRCA 1 &2. 

These genetic tests are necessary in women below the age of 60, those with a strong family history of breast or ovarian cancer, those with a prior history of ovarian cancer, women with triple negative breast cancer or bilateral breast cancer.

 Age of the patient, a family history of breast or ovarian cancer, the overall general condition & the presence of co-morbidities are the other factors to be taken into consideration.

Breast Cancer Radiation, Chemotherapy, and Targeted Therapy in India

Radiation in Breast Cancer:

Radiation is given to the entire breast with a boost at the site of the breast cancer lump, post lumpectomy.

It is also given to the chest wall and at times the draining lymph nodes, following removal of the entire breast, if the breast cancer lump was large, 5cm or above in size or it is large & locally advanced with involvement of the overlying skin.

The primary purpose of the radiotherapy is to reduce the chances of local recurrence at the site of the breast cancer mass.

There are various methods & dose schedules for the radiation therapy. A decision is taken on a case- to- case basis. Intensity-modulated radiation is one of the techniques used.

The new radiation techniques & machines ensure minimal side-effects during the therapy. The procedure is well tolerated.

Chemotherapy & Targeted Therapy:

 Both form an integral part of breast cancer treatment.

They work in conjunction to potentiate the effects.

They are essential in providing a cure in localized & locally advanced breast cancers, pre- or post- surgery. Here, they downstage large cancers, achieve control of the breast cancer and eliminate the microscopic cancer cells circulating in the blood stream in both, small & large breast cancers.

In stage 4 breast cancer, they function by killing the active cancer cells. This helps in obtaining disease control and prevents the cancer from spreading further. They therefore improve the quality of life and extend survival substantially.

They have played a huge role in converting stage 4 breast cancer into a chronic illness, allowing these patients to live for extended periods, with appropriate treatment.

Molecular profiling, ER/PR/HER 2 status, KI-67 percentage, presence of BRCA mutations, age of the patient, tumour size, stage of the cancer & axillary lymph node status are all factors that need to be taken into consideration when planning the chemotherapy/targeted therapy treatment protocol.

Chemotherapy when used is given in schedules depending on the patient’s age & tolerance. Young women receive a dose dense schedule, of 8 cycles of chemotherapy, administered every 15 days. This protocol has been shown to improve survival rates in younger women when compared with the standard 21- day regimens.

Older women receive 8 cycles of chemotherapy at 21- day intervals. At times, the last 4 cycles may be divided into 12 weekly doses, when Paclitaxel forms a part of the protocol. 

Chemotherapy administration is a painless procedure. It is given intravenously, as a day care therapy. An overnight hospital stay is not required. The side-effects are manageable, generally involving taste change, loss of appetite & mild weakness, all of which resolve within a few days. Hair loss does occur with the chemotherapy. The onset is 14 days following the first cycle. Hair regrowth begins a month after the completion of therapy. Devices like a cooling cap are available, which help to minimize the hair loss. This cap must be worn during the chemotherapy administration. 

Maintaining a healthy diet during chemotherapy by consuming fruits & vegetables, staying well hydrated, avoiding crowds to reduce the risk of infection, all help in reducing the side-effects.

Targeted therapy:

Is used in triple negative breast cancers and in HER2 positive breast cancers, both in the neoadjuvant & adjuvant set-up for a cure & in stage 4 breast cancers for disease control. 

Immunotherapy is used in triple negative cancers, Pembrolizumab is currently the approved drug. 

Trastuzumab & Pertuzumab are the drugs used in HER2 positive breast cancers. Treatment is initiated pre-surgery in combination with chemotherapy. Trastuzumab is then continued to complete 12 months of targeted therapy. Pertuzumab is also continued for a year in patients at a high risk of recurrence.

T-DM1 is one of the other HER2 directed therapies used.

Lapatinib & Neratinib are the oral HER2 directed therapies available.

Hormone Therapy In Breast Cancer Treatment:

Is used in the treatment of ER/PR + breast cancer. It is given as adjuvant treatment in localised breast cancer after surgery or post chemotherapy drugs. 

 In stage 4 breast cancer it is combined with another tablet called Palbociclib or Ribociclib. Both therapies work in conjunction to control the cancer cells. In this situation, it is usually administered upfront, as first line treatment.

The drugs used are Tamoxifen-in premenopausal women & the Aromatase Inhibitors (Letrozole, Exemestane & Anastrazole), used in post-menopausal women & in premenopausal women in combination with a GHRH agonist or post oophorectomy.

Both classes of drugs are given orally. They work by blocking hormonal stimulation of the cancer cells by Oestrogen & Progesterone.

Tamoxifen use carries a risk of endometrial cancer. There is also a risk of blood clots resulting in the possibility of cardiac events, stroke, pulmonary embolism & deep venous thrombosis.

Patients on Tamoxifen require close monitoring. Regular pelvic sonographies are necessary to monitor the endometrial thickness.

Aromatase inhibitors carry a risk of Osteoporosis, muscle & joint aches & pains. Their use must be supplemented with calcium & vitamin D.

Fulvestrant is an injectable targeted therapy. It acts as an Oestrogen receptor antagonist preventing hormonal binding with the Oestrogen receptors of the cancer cells & thereby neutralising them.

Complementary & Alternative Treatments:

 Currently they have no recommended role in breast cancer treatment & should not be attempted. 

Clinical Trials & Emerging Therapies:

 There are multiple clinical trials ongoing for breast cancer. 

New drugs, both oral & injectable are under evaluation. 

It is a hope that a revolutionary breast cancer treatment will emerge which will not only supplant chemotherapy rendering it redundant, but will also cure all stages of the breast cancer.

Medical Tourism in India:

India possesses one of the best health care facilities in the world. 

Every Oncology drug & treatment is available in our country, at a fraction of the cost in comparison to other countries. 

Navigating the Indian Health Care System:

It is best to consult the treating Medical Oncologist in this regard. The doctor is the appropriate person to provide guidance with respect to the hospital, the admission, treatment & the insurance.

Conclusion:

To summarize, in today’s day & age breast cancer is no longer a fatal illness. It can be treated and patients can expect to live a normal life. Gone are the days of ‘one size fits all’. Customized care is the name of the game.