INVASIVE BREAST CANCER

Any operation for a breast cancer involves surgery to the tumour itself and also removing some of the lymph nodes under the arm at the same time

Most patients will have a choice between either having the tumour removed with a small rim of normal healthy tissue (wide local excision) or removal of the whole breast (mastectomy) with or without a breast reconstruction.

If a patient has a wide local excision there is a small chance of needing a second operation if the cancer is too close to the cut edge of the tissue removed. Patients who have a wide local excision will also be recommended radiotherapy to their breast after surgery, in order to reduce the chance of the tumour recurring in the breast.

If a patient has a mastectomy, then radiotherapy is much less likely unless her tumour is large or has involved any of the lymph nodes removed. Whilst breast reconstruction is an option for many patients, it is a very personal decision and it is important that all the advantages and disadvantages of reconstruction are discussed with a patient considering reconstruction.

Patients with breast cancer who have lymph nodes which appear uninvolved before surgery will normally be offered a Sentinel Lymph Node Biopsy (SLNB) rather than a full lymph node clearance. A SLNB removes a small number of lymph nodes from under the arm rather than removing all the nodes which occurs during a clearance operation. This means that SLNB is often less painful and has a lower chance of causing swelling of the hand and arm after surgery, a condition called lymphoedema.

Before a SLNB, a patient has an injection of a low dose of radioactive “dye” into the breast which helps the surgeon to find the lymph nodes which need to be removed. This is a very low dose and does not put you or people around you at risk.  A medical blue dye can also be used to help identify these lymph nodes too, and tends to be given when the patient is asleep.

As with any operation there are potential risks including bleeding and bruising, wound infection, lymphoedema, developing a collection of blood (haematoma) or wound fluid (seroma) at the site of surgery, developing a blood clot in the leg or lung and changes to the shape of the breast after treatment. Thankfully, many patients who undergo breast surgery do so without significant problems or complications.

Radiotherapy has been used in the treatment of breast cancer for many years. It involves delivering a treatment to the breast or chest wall for a few minutes each day for approximately 4 weeks after surgery has been completed, similar to having an X-ray.

You will meet with an oncologist who specialises in radiotherapy to discuss treatment before it starts, including having a CT scan to plan the area it will be targeted to.

Radiotherapy tends not to make patients feel ill or unwell, but can lead to skin changes and a transient sun-burn effect to the skin so moisturising and skin care is important during treatment. Patients will often feel tired and fatigued towards the end of radiotherapy too, but some patients are less affected and drive to their treatment sessions and may even be able to work during their treatment.

Chemotherapy will not be necessary for all patients who are diagnosed with breast cancer. It may become clear during pre-operative tests or after surgery that chemotherapy may be beneficial for a patient, but as there are potential side effects to this treatment it is important that the risks and benefits are discussed with a medical cancer specialist (oncologist).

Chemotherapy is normally given as a slow intravenous drip or infusion over a couple of hours. The regimen may vary for some patients, but often there is about three weeks between individual treatments, with a total of six treatments being given. The time between treatments is in part to allow patients and their immune system to recover and tolerate their next treatment.

Whilst some patients struggle with side effects whilst on chemotherapy, many patients find that they experience fewer side effects than they had feared. Side effects during treatment may include:

Nausea and vomiting
Hair loss
Diarrhoea
Increased risk of developing an infection
Skin and nail changes

During treatment with chemotherapy, patients will be given contact numbers so that they can get in touch with members of the oncology team at any time of day or night in case they are concerned about serious side effects. They will also be followed up between treatments to check that their immune system and other vital organ systems are not being adversely affected by treatment.

Most breast cancers are sensitive to the female hormone oestrogen, and anti-hormonal therapy is useful in these tumours in helping to prevent disease from returning after successful treatment with surgery.

These are drugs including tamoxifen, anastrozole, letrozole and exemestane, and are normally offered to patients for a minimum of five years. The duration of treatment has been extended up to ten years for tamoxifen recently and it is possible the similar recommendations will follow for other forms of anti-hormonal treatment.

These drugs are taken as a tablet once a day, with many patients tolerating them well. Some patients do develop side effects, and if this occurs it is important to discuss them with you breast specialist as alternative treatment are likely to be available.

For post-menopausal patients who take medication like anastrozole and letrozole, it is important to bear in mind that they can contribute to osteoporosis (or bone weakening) over many years. Other treatments can be given to help protect against this, but if these are not used then a bone density scan should be carried out for these patients at regular intervals.

For women who take tamoxifen, it is important to bear in mind that it can very slightly increase their risk of developing a DVT or blood clot whilst on treatment. If a patient requires an operation whilst on tamoxifen, it is normally sensible to stop it for four weeks before and after surgery for this reason. Women may also rarely experience abnormal vaginal bleeding as it can cause changes in the lining of the womb. If this happens then women should discuss it with their breast care team so an ultrasound scan of the womb can be arranged to check that it looks healthy.

These are newer forms of medical treatment for breast cancer that have been developed following research showing us how breast cancer cells grow and behave, and thus offering us new targets for treatment.

Examples of these types of drugs include Herceptin (an antibody developed to target certain types of breast cancers) and Palbociclib (which slows or stops breast cancer cell growth).

Not all types of breast cancers will benefit from these types of treatment, for example only one in six breast cancers are likely to respond to Herceptin. The potential role of these drugs in your breast cancer treatment will be discussed with you when you meet with an oncologist.

Treatment regimes will vary considerably from one patient to the next and it is important that patients get information which is specific to their type and pattern of breast cancer.