Treatment Of Breast Cancer

Question 1

What are the key points regarding management of breast cancer?

Answer 1

• Treatment should be patient-centred, taking into account patients’ individual needs and preferences.
• Good communication is essential, supported by evidence-based information, to allow patients to reach informed decisions about their care.
• Discussion and involvement of patients’ families should, with their consent, be facilitated.
• Multidisciplinary treatment planning involving at least a breast surgeon, radiologist, pathologist and medical and radiation oncologists should be used to integrate local and systemic therapies and their sequence.

Question 2

What should be available for women undergoing mastectomy?

Answer 2

When a mastectomy has been necessary, breast reconstruction should be available.

Question 3

Why is immediate breast reconstruction recommended?

Answer 3

Immediate reconstruction may make the thought of losing a breast easier for some women but not all are suitable for immediate reconstruction.

Question 4

When are women advised against immediate reconstruction?

Answer 4

When radiation therapy is planned, some women will be advised against immediate reconstruction. Radiation may delay wound healing.

Question 5

Who are offered prophylactic bilateral mastectomy?

Answer 5

Prophylactic bilateral mastectomy may be offered to women who are at very high risk such as BRCA1 or BRCA2 carriers.

Question 6

What is recommended after wide excision surgery?

Answer 6

• Whole breast radiotherapy is recommended after conservative surgery.

It reduces the risk of local recurrence and also has a beneficial effect on survival.

Question 7

When is post-mastectomy radiotherapy recommended?

Answer 7

• Post-mastectomy radiotherapy is recommended for patients with four or more positive axillary nodes and is also indicated for patients with T3-T4 tumours (independent of the nodal status).

Question 8

What is recommended for women with triple negative breast cancer?

Answer 8

Adjuvant chemotherapy is recommended for patients with endocrine unresponsive tumours and for patients with HER2 over-expressing tumours.

Question 9

What are the two well-established surgical procedures for the local treatment of invasive or in situ breast cancer?

Answer 9

o Conservation surgery, which involves removal of the tumour together with a rim of surrounding normal breast tissue with retention of the breast.

o Mastectomy, involving removal of the whole breast.

Question 10

What are the indications for mastectomy?

Answer 10

Indications include multifocality, local recurrence, DCIS or invasion >4cm.

Question 11

Who shouldn’t have sentinel node biopsy routinely?

Answer 11

Do not perform SLNB routinely for women with a preoperative diagnosis of DCIS who are having breastconserving surgery, unless they are considered to be at high risk of invasive disease.

Question 12

When are DCIS patients classified as high risk for invasive cancer?

Answer 12

Palpable mass.

Extensive micro calcification.

Question 13

What is a complication of axillary node clearance?

Answer 13

Lymphoedema

Question 14

What is the aim of adjuvant therapy?

Answer 14

• The aim of adjuvant therapy is to increase the chance of cure by eradicating micrometastatic disease.

Question 15

What is used for adjuvant hormonal therapy in premenopausal women with ER positive breast cancer?

Answer 15

Tamoxifen remains the standard of care for premenopausal women.

Five years of adjuvant tamoxifen, a selective oestrogen receptor modulator, reduces the relative risk of relapse by 41% and death from breast cancer by 31%.

Question 16

What is used for adjuvant hormonal therapy in postmenopausal women with ER positive breast cancer?

Answer 16

For postmenopausal women, aromatase inhibitors have been shown to be superior to tamoxifen.

Question 17

When is chemotherapy treatment indicated in the management of breast cancer?

Answer 17

• Cytotoxic chemotherapy is indicated for advanced steroid hormone-receptor-negative tumours and for aggressive disease, particularly when metastases involve visceral sites (e.g., the liver) or if the disease-free interval following treatment for early breast cancer is short.

Question 18

Which chemotherapy drugs are used in the treatment of breast cancer?

Answer 18

• An anthracycline (such as doxorubicin or epirubicin) combined with fluorouracil and cyclophosphamide, and sometimes also with methotrexate, is effective.
• For metastatic disease, the choice of chemotherapy regimen will depend on whether the patient has previously received adjuvant treatment and the presence of any comorbidity.
• For women who have not previously received chemotherapy, an anthracycline alone or in combination with another cytotoxic drug is the standard initial therapy for metastatic breast disease.

Question 19

Which treatment is used for HER2 positive breast cancer?

Answer 19

• About 15% of breast cancers have amplification of the HER2 gene and these cancers have an intrinsically worse prognosis than other cancers.
• Trastuzumab is a monoclonal antibody against the extracellular domain of the HER2 receptor and given every three weeks for a year, improves disease-free survival and overall survival

Question 20

What treatment is used to facilitate conservative surgery in patients with large tumours?

Answer 20

Neoadjuvant therapy.

• Patients with large tumours currently not suitable for conservative surgery can be treated with pre-operative chemotherapy, HER2 targeted therapy, or endocrine therapy to downstage the tumour and to facilitate breast-conserving surgery.

Question 21

When should give bisphosphonates as adjuvant therapy in breast cancer patients?

Answer 21

postmenopausal women with nodepositive invasive breast cancer.

postmenopausal women with nodenegative invasive breast cancer and a high risk of recurrence.

Question 22

Diagnosis and assessment of advanced breast cancer

Answer 22

o The presence and extent of visceral metastases should be assessed using a combination of plain radiography, ultrasound, CT and MRI.

o Positron emission tomography fused with computed tomography (PET-CT) should only be used to make a new diagnosis of metastases for patients with breast cancer whose imaging is suspicious but not diagnostic of metastatic disease.

o Oestrogen receptor and HER2 status should be assessed at the time of disease recurrence if receptor status was not assessed at the time of initial diagnosis. Biopsy of a metastasis may be used to assess ER and HER2 status in the absence of tumour tissue from the primary tumour.

Question 23

What is the treatment of advanced breast cancer?

Answer 23

o Endocrine therapy should be offered as first-line treatment for the majority of patients with ER-positive advanced breast cancer.

o For patients with advanced breast cancer who are not suitable for anthracyclines (because they are contra-indicated or because of prior anthracycline treatment either in the adjuvant or the metastatic setting), systemic chemotherapy should be offered in the following sequence:
First-line: single-agent docetaxel.
Second-line: single-agent vinorelbine or capecitabine.
Third-line: single-agent capecitabine or vinorelbine.

o For patients who are receiving treatment with trastuzumab for advanced breast cancer, discontinue treatment with trastuzumab at the time of disease progression outside the central nervous system but not if disease progression is within the central nervous system alone

Question 24

How do you manage the complications of advanced breast cancer?

Answer 24

o Bisphosphonates should be offered to patients newly diagnosed with bone metastases, to prevent skeletal-related events and reduce pain.

o External beam radiotherapy in a single fraction of 8 Gy should be used to treat patients with bone metastases and pain.

o Surgery followed by whole brain radiotherapy should be offered to patients who have a single or small number of potentially resectable brain metastases, a good performance status and no or well-controlled other metastatic disease.

Question 25

Should you terminate pregnancy if diagnosed with breast cancer?

Answer 25

• Although breast cancer - especially in the younger woman - may well be hormone-dependent, termination of pregnancy (TOP) is not recommended, as it does not seem to improve survival.

Question 26

Is chemotherapy teratogenic?

Answer 26

• Treatments like radiotherapy and chemotherapy are toxic to the foetus and TOP may be considered depending upon the mother’s preference, stage of the disease, the current gestation and the mother’s chance of survival.
• It may be possible to defer treatments other than surgery depending upon stage.
• Chemotherapy should not be given in the first trimester but after that it can cause intrauterine growth restriction or premature labour.

Question 27

Should breast cancer patients breastfeed?

Answer 27

• If the mother is postpartum then lactation should be stopped. This is required before surgery, as lactation makes the breasts large and very vascular. Many chemotherapeutic agents cross into the milk.

Question 28

Why is breast reconstruction recommended after mastectomy?

Answer 28

• Post-mastectomy breast reconstruction is associated with improved body image, quality of life, self-confidence and well-being.
• Breast reconstruction should be discussed with all women who undergo mastectomy.

Question 29

How do surgeons achieve symmetry with the unaffected breast after mastectomy?

Answer 29

• Breast reconstruction restores breast symmetry after a mastectomy by creating a breast mound, similar in size, shape, contour, and ‘out of bra position’ to the contralateral breast.

Question 30

Who can perform breast reconstruction using lipomodelling?

Answer 30

• Breast reconstruction using lipomodelling after breast cancer treatment should only be carried out by surgeons with specialist expertise and training in the procedure.

Question 31

When can breast reconstruction be carried out?

Answer 31

• Breast reconstruction can be performed at the time of mastectomy (immediate/primary) or at any later date (delayed/secondary).
• Patients who are uncertain about reconstruction are best advised to consider delayed reconstruction.

Question 32

What is the main advantage of immediate breast reconstruction?

Answer 32

• The main advantage of immediate reconstruction is preservation of the native breast skin envelope and inframammary fold, which enables a more natural and symmetrical outcome.

Question 33

What is the main disadvantage of immediate breast reconstruction?

Answer 33

immediate reconstruction can delay adjuvant therapy if postoperative complications arise.

Question 34

Which patients are suitable for delayed breast reconstruction?

Answer 34

• Delayed reconstruction is best for patients who want to focus on the cancer treatment or need more time to consider the various breast reconstruction options.

Question 35

What are the problems with delayed breast reconstruction?

Answer 35

• Delayed breast reconstruction is technically more challenging because the native skin envelope is removed at the time of standard mastectomy.
• Extra skin must therefore be recruited from skin expansion or from a donor site. This can result in a less natural and symmetrical appearance and longer scars.

Question 36

What are the complications of breast cancer?

Answer 36

• The diagnosis of breast cancer often has profound psychological implications. These can be reduced by adequate counselling, less destructive surgery, including nipple preservation, and even reconstructive surgery at times.
• Postoperative complications are as for any surgical procedure.
• Chemotherapeutic agents have a range of adverse effects.
• Lymphoedema of the arm is an additional hazard, especially where lymph nodes have been irradiated.

Movement of the shoulder may be impaired.

Question 37

Which imaging is used to follow up patients after treatment of breast cancer?

Answer 37

Mammography

Question 38

How often should you offer mammogram to patients after treatment of breast cancer?

Answer 38

• Offer annual mammography to all people with breast cancer, including DCIS, until they enter the screening programme.
• People diagnosed with breast cancer who are already eligible for screening should have annual mammography for 5 years.

Question 39

Should you offer ultrasound or MRI as post treatment surveillance?

Answer 39

• Do not offer mammography of the ipsilateral soft tissues after mastectomy.
• Do not offer ultrasound or MRI for routine posttreatment surveillance in people who have had treatment for invasive breast cancer or DCIS.

Question 40

What should be included in the care plan of people who have had treatment for breast cancer?

Answer 40

o designated named healthcare professionals
o dates for review of any adjuvant therapy
o details of surveillance mammography
o signs and symptoms to look for and seek advice on
o contact details for immediate referral to specialist care and
o contact details for support services, for example, support for people with lymphoedema.

Question 41

What might people be worried about after having cancer?

Answer 41

• Perhaps she is worried about returning to work.
• Has she been under financial strain as a result of not working?
• Will people treat her in the same way as they used to?
• Does she have the same priorities in life as she did before?
• Maybe she is suffering ongoing side effects from treatment.
• Has her diagnosis and treatment had an impact on her relationship?
• Is she worried about the cancer coming back?
• Has her body image changed?
• Has her experience of breast cancer led to any positive changes in her life?

Question 42

Why are all cancer patients managed by a MDT team?

Answer 42

Patients cared for by a multidisciplinary team are more likely to:
• receive accurate diagnosis and staging
• be offered a choice of treatments decided by a group of experts, rather than by one doctor
• receive better coordination and continuity of care through all stages of the cancer
• be treated in line with locally agreed policies and national guidelines
• be offered appropriate and consistent information (because the person giving the information should be aware of the team’s strategy for your care)
• have their psychological and social needs considered - communication between different team members is better where they have a formal working relationship.

Question 43

What is PREDICT?

Answer 43

Predict is an online tool that helps patients and clinicians see how different treatments for early invasive breast cancer might improve survival rates after surgery.

PREDICT is an online tool used to estimate breast cancer survival and the benefits of hormone therapy, chemotherapy and trastuzumab.

Question 44

What is shared decision making?

Answer 44

1) This is the conversation that happens between a patient and their health professional to reach a healthcare choice together.
2) Health professionals give patient information about all the treatment options for the health problem and also the option that is medically better for a person based on patient’s medical history and test results.
3) Patients give professionals information about their life and experiences of illness and treatment.
4) The shared decision making conversation needs both the patient and professional to understand the other’s point of view and agree the reasons why the treatment chosen was the best one for the patient.