Treatment for breast cancer almost always begins with a decision about the type of surgery. The options are mastectomy, a procedure that involves removal of the entire affected breast; or lumpectomy, a procedure to remove the malignant lump and a margin of healthy tissue around all edges of the tumor. A lumpectomy also is called breast-conserving therapy, or BCT. When a lumpectomy is performed, it generally is followed by radiation therapy to prevent the cancer from recurring in the same breast. The goal of BCT is to maintain the cosmetic appearance of the breast without decreasing a woman's chance of surviving breast cancer.
Up to 80 percent of women with early-stage breast cancer can be treated with BCT. For these women, mastectomy and lumpectomy with radiation offer the same chance of long-term survival.
A woman is considered a good candidate for lumpectomy if her tumor is localized to one area of the breast. Most women with breast cancer qualify as candidates for lumpectomy. However, there are other considerations:
- Cosmetic results may not be good in women who have relatively large lumps in small breasts.
- If there is more than one lump, there is concern that other areas of the breast could have cancer as well. In this case, a mastectomy is the preferred therapy.
- Women who are unwilling or unable to have follow-up radiation treatments may not be good candidates for lumpectomy. Radiation typically is given five days a week for five to six weeks after surgery. Patients who live far from a hospital or medical center that provides radiation therapy may find it impossible to travel back and forth for daily treatment.
- Women who previously have had radiation therapy to their breast or chest area might not be able to undergo further breast radiation. In this case, mastectomy is the preferred therapy.
A mastectomy usually involves removing the breast and some lymph nodes located under the arm (an axillary lymph node dissection). After the lymph nodes are removed, they are examined by a pathologist to check for cancer cells. The information about the presence or absence of cancer cells in the axillary lymph nodes is essential in determining the patient's prognosis and stage, and the need for further therapy.
It's important to consult a plastic surgeon before surgery. This consultation can help women make a better decision about whether to have the reconstruction done immediately (during the surgery) or defer it to a later time.
The number of days spent in the hospital varies. Occasionally, mastectomy without reconstruction may be performed as same-day surgery. After surgery, most women need to do special exercises to overcome stiffness and regain mobility in the arm on the side of the mastectomy.
Removing Lymph Nodes
Most breast-cancer surgery requires the removal of some axillary (underarm) lymph nodes to check for the presence of cancer cells. The most commonly performed procedure is called an axillary dissection — the removal of a wedge of fat from the underarm that usually contains between 10 and 15 lymph nodes. An alternative method, called sentinel-node mapping, relies on identifying and removing only the one or two lymph nodes closest to the tumor. If no cancer is found in the sentinel nodes, then no more lymph nodes are removed.
The lymph nodes can be removed in the course of a mastectomy. With lumpectomy, a separate incision usually is made to remove the wedge of fat that contains the nodes. Either way, most patients wake up from surgery to find a drain emerging from the underarm area to remove any fluid that accumulates.
After the lymph nodes are removed, they are examined under the microscope to check for the presence of cancer cells. The need for additional treatment after surgery depends on whether some nodes are positive for cancer.
Several potential complications are associated with lymph-node removal. One potential side effect is lymphedema, a swelling in the arm caused by the accumulation of fluid that doesn't drain properly. Lymphedema occurs much less often today because the current surgical techniques involve the removal of fewer lymph nodes than the more extensive procedures of the past. Swelling can range from barely noticeable to an obvious enlargement of the arm. It can be either painless or painful.
Another potential complication is some loss of sensation under your arm. When the surgeon makes an incision in your skin, it can damage nerves in the area. The numbness won't affect the use of your arm.
Radiation therapy (sometimes called radiotherapy) almost always is recommended after lumpectomy to destroy any cancer cells left behind and to prevent local recurrences in the breast. Without radiation therapy, the odds of a local recurrence increase by about 25 percent. Radiation therapy is also sometimes recommended after mastectomy, depending on the size and other characteristics of the breast tumor.
Fatigue is a common side effect of radiation, and many women experience swelling or a sensation of heaviness of the breast. Most of these changes in the breast are temporary and will go away within a few months to a year. Some women, however, notice that their breasts are smaller and firmer after the treatment. This can be permanent. Radiation therapy is not given to pregnant women because it can cause birth defects.
After surgery, certain patients will be offered chemotherapy (anti-cancer drugs) to improve their chance of survival. In other cases, chemotherapy may be recommended before surgery to shrink the tumor before it is removed. Before recommending chemotherapy, your doctor will consider the stage of your cancer and the prognosis. If chemotherapy is necessary, treatment typically is given over a period of three to six months. Usually a combination of drugs is used. The specific combination depends on the individual case.
Chemotherapy commonly causes side effects. The severity and type of symptoms experienced varies with each person and with the type of drugs given, the dosage of the drugs and the length of time the patient is treated. Fatigue is the most common side effect associated with chemotherapy. The gastrointestinal tract often is damaged temporarily by the chemotherapy drugs, so nausea, vomiting, mouth sores and decreased appetite are common. Many patients also experience hair loss and menstrual irregularities. Chemotherapy can inhibit the production of blood cells in the bone marrow. This can:
- Cause anemia (by inhibiting the production of red blood cells)
- Increase your risk of infection (by decreasing the number of your infection-fighting white-blood cells)
- Lead to bleeding (by causing your platelet counts to drop).
Side effects from chemotherapy are treatable. A variety of medications are available to minimize nausea and vomiting. If blood counts fall dramatically, medications that stimulate the bone marrow to boost production of blood cells may be given.
Hormonal therapy works by inhibiting tumor growth that is stimulated by hormones. Tumors that are estrogen- or progesterone-receptor positive are more likely to respond to hormonal therapy than are tumors without these hormone receptors. There are several drugs that act as estrogen blockers. Tamoxifen has been around the longest. It is prescribed for women with early stage breast cancer and for women at high risk of developing breast cancer. iIt can cause hot flashes and. Tamoxifen also increases the risk of blood clots and uterine cancer.
For patients with metastatic breast cancer, hormonal therapies are often given to prolong life expectancy and reduce symptoms. It may be given with chemotherapy. Premenopausal women are often treated with tamoxifen and a second medication to suppress hormonal production by the ovaries. Postmenopausal women may be treated with a variety of medications to block the estrogen receptor, including tamoxifen, anastrozole, letrozole, or exemestane.