20th June 2023

Treatment

Surgical management of breast cancer includes breast conservative surgery which is the removal of the tumour by wide local excision (WLE). Patients who are not suitable for conservative surgery undergo mastectomy with or without reconstruction. Breast cancer during pregnancy, prior radiotherapy to the breast or chest wall, tumour >5 cm, women <35 years or pre-menopausal with BRCA 1, BRCA 2 mutation, inflammatory breast disease, and multifocal disease are contraindications to breast conservation surgery.
Sentinel node biopsy is widely used in clinically node-negative breast cancer. However, patients with clinically positive nodes will undergo axillary dissection during primary breast surgery.
Radiotherapy is recommended for all patients with invasive cancer who received breast conservative surgery. Axillary radiotherapy is used if lymph node positive on sampling and surgical clearance is not performed.
Adjuvant systemic treatments such as chemotherapy, hormonal therapy and trastuzumab provide survival benefit in suitable patients. Anthracycline based chemotherapies (e.g., AC regime – Doxorubicin and Cyclophosphamide) were some of the widely used regimes for adjuvant therapy. However, cardiac-related toxicity can be a limitation to using anthracyclines, particularly in patients with underlying heart disease. The addition of taxanes (paclitaxel and docetaxel) has provided additional benefits to adjuvant treatment regimes. Taxanes act by inhibiting microtubular depolymerisation causing cancer cells to stop dividing and slowing the growth of cancer or killing the cells.
Patients with hormone receptor positive tumours should be considered for adjuvant hormonal therapy to block the oestrogen stimulus. In pre-menopausal women, tamoxifen (with or without ovarian suppression) is the standard choice. Tamoxifen is a selective oestrogen receptor modulator (SERM) and inhibits breast cancer cells by acting as a competitive antagonist at the oestrogen receptor. Side effects include an increased risk of uterine cancer and thromboembolic events. Aromatase inhibitors which block the conversion of androgens to oestrogen are used in post-menopausal women. The adjuvant use of trastuzumab, a monoclonal antibody targeted towards HER2 receptor, in selected HER2 positive breast cancer patients showed a reduction in recurrence and mortality. However, cardiac toxicity is the most concerning side effect associated with this medication.
Patients with metastatic breast cancer can present to A&E with acute oncology problems. Patients with bone metastasis can present with malignant hypercalcaemia which needs urgent medical treatment. Some patients with spinal metastasis can present with metastatic cord compression which needs urgent referral to acute oncology team and MRI whole spine. The treatment approach for metastatic breast cancer is generally considered non-curative in nature and is aimed at palliation, improving quality of life and prolonging survival. Bisphosphonate therapy together with adequate calcium and vitamin D supplementation is helpful in reducing skeletal related events in patients with bony metastasis.