Understanding Treatment Options

Facing breast cancer treatment can be a bewildering and frightening experience. Coping with a new diagnosis of cancer is difficult because of the uncertainty about what the future will hold. Part of this uncertainty relates to your treatment options. The purpose of this booklet is to help you understand some of those options.

The options available to you will depend upon a number of factors; including the type of tumor, the extent of the disease at the time of diagnosis, and your age and medical history. Your personal feelings about the treatment and your self-image will also be important considerations in your doctor’s assessment and recommendations. You should discuss the treatment methods and how they apply to your particular situation with your doctors.

You may have several doctors involved in your treatment, including a surgeon, a medical oncologist, a radiation oncologist, and a plastic surgeon. Whether you will need to see a doctor in each of these fields will depend on your particular situation.

Treatment for breast cancer has advanced tremendously in recent years. Breast cancer treatment can include surgery, chemotherapy, radiation, and reconstructive surgery. The techniques in each of these fields have improved, leading to treatments that were not previously available. Consequently, breast cancer treatment has become more effective and the cosmetic results have improved.

Breast Cancer Surgery

The surgical treatment of breast cancer usually begins with a biopsy. Further treatment will usually include surgical removal of the tumor. This may be done by a lumpectomy (also known as a partial mastectomy) or by a mastectomy (removal of the whole breast).

Because breast cancer may spread to lymph nodes in the axilla (armpit), breast cancer surgery can also include removal of some of these lymph nodes. Techniques for this include sentinel lymph node biopsy and axillary dissection.

Lumpectomy (Partial Mastectomy)

Lumpectomy is the the removal of the tumor and a surrounding rim (margin) of normal breast tissue. The majority of the breast tissue is undisturbed. Radiation treatment will then be necessary for the breast. In combination with radiation, lumpectomy is as successful as mastectomy in treating breast cancer. This cosmetic result is usually excellent.

Depending on the location and size of the tumor, some women may not be candidates for this procedure, and may need to have a mastectomy. Also, some women may prefer to have a mastectomy, possibly with breast reconstruction, instead of lumpectomy and radiation. Occasionally, if microscopic analysis of the lump later reveals that the margins are not clear of cancer, a return to surgery for further removal of tissue or mastectomy may be necessary.

Modified Radical Mastectomy

This procedure removes the entire breast and the axillary lymph nodes. The removal of the axillary lymph nodes is called an axillary dissection. This may be the best option for women with certain types or stages of breast cancer. Some women may also prefer this treatment to a lumpectomy with radiation. If desired, a reconstruction of the breast can be performed by a plastic surgeon. A mastectomy with reconstruction is a more extensive operation and requires a longer recovery. Reconstructions may be performed at the time of mastectomy or at a later date. Usually one or two drain tubes are placed at the time of surgery and are removed one or two weeks after surgery. Additional drain tubes may be necessary if a reconstruction is performed.

Simple (Complete) Mastectomy

This type of surgery removes the entire breast without performing an axillary dissection. It may be combined with a sentinel lymph node biopsy in certain situations. A simple mastectomy may also be performed when a mastectomy is being done for prophylaxis, in other words to prevent breast cancer for women with high risk for future breast cancer.

Axillary Dissection

Axillary dissection is the removal of lymph nodes from under the armpit. This is done to determine if there has been spread of cancer to these lymph nodes and to remove such cancer. The lymph nodes are removed from an area that has certain anatomic boundaries. Anywhere from 5 to 25 lymph nodes may be present in this area. The lymph nodes will be analyzed in the laboratory to determine if cancer is present. Your oncologist will use this information to make decisions about chemotherapy.

The advantage of axillary dissection is that it is the most complete way to assess and treat for cancer that has spread to the lymph nodes. The disadvantage is that axillary dissection can be associated with swelling of the arm called lymphedema. There is also the possibility of nerve damage leading to numbness or muscle weakness, fluid collections in the wound cavity, and limited mobility of the arm.

These problems, however, are not very common. A drain tube will also be placed at the time of surgery and will remain for one to two weeks.

Sentinel Lymph Node Biopsy

Sentinel lymph node biopsy is a less invasive way to evaluate the axillary lymph nodes. Instead of removing many lymph nodes as in an axillary dissection, typically only 1 – 3 lymph nodes are removed. The advantage is that there is quicker recovery and lower risk of post-op problems. A drain tube is usually not necessary. If the sentinel node is found to have cancer in it, then an axillary dissection will be necessary. The disadvantage is that there is a small “false negative” rate; in other words the sentinel node may be negative but cancer is present in other lymph nodes. This could lead to under-treatment of the cancer.

Breast Reconstruction

If you consider mastectomy as a treatment option, you should be aware of breast reconstruction: a way to recreate the breast shape after mastectomy. Most women who have had a mastectomy can also have a breast reconstruction, but there are exceptions. If you are considering reconstruction, you will be referred to a plastic surgeon who will discuss the various techniques with you. The surgery is fairly lengthy and requires longer postoperative recovery in the hospital.

Radiation Therapy

Used in conjunction with surgery particularly a partial mastectomy. Chemotherapy radiation therapy is administered by a radiation oncologist in one of two forms:
External beam radiation – the radiation is administered 5 days a week over approximately 6 weeks.

Partial breast irradiation – administered via a balloon device placed into the breast and is usually completed in 7 – 10 days. A consultation with a radiation oncologist is recommended prior to initiating radiation therapy.

Chemotherapy

Chemotherapy also has an important role in the treatment of breast cancer. If chemotherapy is appropriate for you, a medical oncologist will discuss the best form for you. Chemotherapy may be in the form of a pill taken daily or may involve intravenous medications. You may need a special IV catheter if you will be receiving intravenous medications.

Risks of Breast Surgery

As with any surgery, there are risks and possible complications, although these are generally quite rare. Scarring or deformity of the breast after lumpectomy may occur. Numbness under the arm after axillary dissection is common.

Other risks can include:

• Complications from anesthesia
• Bleeding
• Infection
• Lymphedema
• Muscle weakness
• Fluid collections
• Limited range of motion of the shoulder
• Bruising, swelling or scarring
• Pain
• Cancer Recurrence

There may also be other complications not listed here.