The breast cancer treatment depends on patient’s menopausal status, whether the disease is hormone receptor positive, Her-2 Neu positive or triple negative, the type of breast cancer, stage and grade of the tumor, and patient’s performance status, along with other factors. Following are the preferred treatment approaches for different stages of breast cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.
Localised Breast Cancer Treatment [With Images and Video]
If we see the localised disease in detail, it includes cases till T3, that is tumor more than 5 cm but not infiltrating the skin or chest wall, or N1, that is presence of mobile axillary lymph nodes.
In early stage disease, the decision to move ahead with BCS depends on patient as well as oncologist. The patient has to be willing for it and give consent for the same, and oncologist has to look for any contraindications for the procedure. If everything is in favor, and the tumor size is small, breast conservation surgery maybe done directly.
Whereas if the tumor is large, we first have to give neo-adjuvant chemotherapy to shrink the tumor, and then reassess for breast conservation surgery, depending upon the response to chemotherapy.
So, the decision to add chemotherapy in the neoadjuvant or adjuvant setting is taken on an individual patient basis, after discuss in a tumor board. Also the decision to add hormonal therapy and targeted therapy is taken depending upon the ER, PR and her-2 receptor status and along with other factors.
After Breast Conservation Surgery, radiation therapy is given in all the cases. Where as after modified radical mastectomy, the decision to add radiation therapy is taken by the radio oncologist depending upon the T-status, N-status, margins of resection along with other factors.
Locally Advanced Breast Cancer Treatment [With Images and Video]
Locally advanced breast cancer includes cases with a T4 disease, that is infiltration of the chest wall or skin or N2 or N3 disease, that is, fixed or matted axillary lymph nodes.
This figure shows T4 disease, with infiltration into the chest wall or skin, and N2 or N3 disease, with a presence of matted or fixed axillary lymph nodes.
These cases are not upfront resectable. That is why, neoadjuvant chemotherapy, that is, chemotherapy before surgery, is required in almost all the cases of locally advanced breast cancer. The neoadjuvant chemotherapy will be different for triple negative, Her-2 neu positive and hormone receptor positive disease.
One exception is T3N1 disease, that may be upfront resectable, but neo adjuvant chemotherapy may be required in these cases if planning for breast conservation surgery, in these cases.
In locally advanced disease also, the decision to do BCS or MRM is taken after neoadjuvant chemotherapy, depending upon the response to chemotherapy, as we have discussed previously for localized disease.
So the decision to add neoadjuvant or adjuvant chemotherapy is taken in an individual basis, after discussion in the tumor board. The decision to add hormonal therapy or targeted therapy depends upon the ER, PR and HER-2 status, as we discussed previously for localized disease.
Radiation therapy is required in almost all cases of locally advanced disease but the final decision is taken by the radiation oncologist by completely assessing the patient.
This brings us to the end of treatment for locally advanced breast cancer.
Metastatic Breast Cancer Treatment [With Images and Video]
Metastatic disease constitutes for 5-10% of the cases of breast cancer.
The treatment options for metastatic breast cancer are chemotherapy, hormonal therapy for ER PR positive disease, and anti Her-2 therapy for Her-2 positive disease. Radiotherapy or surgery may be added for palliation, i.e., reduction of symptoms, and bone redirected therapy may be given in presence of bone metastasis.
Remember cure is not the intent for giving treatment in metastatic disease. It is mainly given to prolong the life, reduction of symptoms, and improvement of quality of life. Treatment for metastatic disease is decided based on the site of metastasis, previous treatments taken, ER, PR, HER-2 status, performance status of the patient and the comorbidities in the patient.
This brings us to the end of the stagewise treatment for breast cancer including surgery, chemotherapy, targeted therapy and hormonal therapy.