Catherine Plzak, MD, Breast Surgeon
Penn Medicine Chester County Hospital
Published: October 21, 2013
Where breast cancer is concerned, the statement "live and learn" has real meaning. For many years, breast cancer was considered a single disease, and treatment was a one-size-fits-all approach. Mastectomy was the only surgical option. Chemotherapy and radiation were given either routinely, or were planned based on tumor size and lymph node involvement but with the awareness that not all large tumors were aggressive and not all small tumors were "well-behaved."
As our knowledge of the behavior of breast cancer cells (tumor biology) has increased, it is ever clearer that breast cancer is a wide spectrum of diseases, and that treatments can be individualized to give each person the greatest benefit with the least risk and fewer long-term side effects. By knowing how an individual tumor is likely to behave, by determining its strengths and by pinpointing its weaknesses, treatments can be directed specifically at each person's breast cancer.
Today, tests are routinely done on the breast cancer tissue removed from the body to look at the receptors and genes of the cancer itself. At times, this may tell us that chemotherapy can be avoided with the knowledge that hormone-related medications with fewer side effects will work equally well to prevent a tumor from recurring. If tests show that hormone-related medicines are not equivalent, then more aggressive chemotherapy treatments are recommended recognizing that there is benefit to be gained. Some breast cancers contain particular proteins at which medicines can be directed, affecting the cancer cell specifically while leaving other cells less affected.
Surgical choices have evolved, and options continue to increase as research develops. In the shift from mastectomy to lumpectomy, the extent of the surgery is less and the recovery has become easier. Newer options include nipple sparing mastectomy, done with minimal visible scarring, and with reconstruction to restore the original breast contour as closely as possible. In some situations, chemotherapy may be given before surgery to improve the likelihood of complete tumor removal and to achieve a better appearance. The choice of procedure may be affected by tumor size and location, by patient age and body build, and by patient preference.
As living a long and healthy life after treatment for breast cancer becomes the expectation, we are more intensely focused on minimizing the long-term side effects as much as possible. Swelling of the hand or arm (lymphedema) was a significant complication when removing most of the lymph nodes under the armpit (axillary dissection) was a standard treatment. In an effort to decrease lymphedema, the technique of sentinel lymph node biopsy was developed. For most individuals, dye is injected into the breast at the time of surgery to identify which lymph nodes are first in line to filter lymphatic fluid draining from the breast, and thus the most likely to contain tumor cells. If there are no tumor cells in these sentinel lymph nodes, no other nodes need to be removed and the risk of swelling in hand or arm is extremely low. Recent evidence shows that even in some individuals with tumor cells in sentinel lymph nodes, it is not always necessary to remove additional lymph nodes.
Radiation has also undergone evolution to allow better and more individualized treatment, and to increase options too. Though radiation to the whole breast is still indicated in most people who undergo lumpectomy, it may not be necessary for everyone. Tests that look at the genetic make-up of the tumor itself may be able to identify those at low risk for recurrence if radiation is not given. Individuals over 70 may not always require radiation either, and efforts progress on determining more precisely the specific benefit for each person. For some, radiation can be given directly to the area of the breast where the cancer has been removed, thus giving treatment from inside the breast. It is an option that can shorten the length and inconvenience of treatment.
Though there is still more learning to be done, it is real progress that treatment can now be so specifically directed to the benefit and circumstances of each person.
Live and learn? Actually, learn and live...that sounds better. And for most, that is exactly what is happening.
This article was published as part of the Daily Local News Medical Column series which appears every Monday. It has been reprinted by permission of the Daily Local News.