Breast Cancer Treatments Simplified..(Well Almost… )

Screen shot 2014-11-08 at 11.37.02 PMThe intense fear we have about cancer relates not only to the deadliness of the disease but the overwhelming nature of treatments involved. Time-and-again cancer proves that it certainly is a worthy enemy. Rationally then, we must use the most effective and powerful defenses available in medicine to fight it.

The treatments we have to fight breast cancer have three broad categories- 1) Surgery 2) Radiation and 3) Medical therapy which includes chemotherapy, endocrine therapy and biologic treatments.

Given that each breast cancer is unique, not each of these treatments is needed in every case. A surgical oncologist, breast surgeon or general surgeon usually does the surgery; the radiation oncologist plans the radiation; and the medical oncologist administers the medical therapies such as chemotherapy. In the course of treatment, the patient often has to go from one specialist to the other. This can often be a haphazard process that causes considerable confusion and anxiety. It is helpful to find a specialist that can outline a complete treatment plan from the beginning. (Fig) Clear expectations and plans allow patients to better plan their life and finances around treatments from the beginning. Breast cancer treatments have evolved considerably to be more effective and less invasive.

On the surgery front, removal of the breast i.e. a mastectomy need not be the disfiguring operation it is often feared to be. In a nipple and/or skin-sparing mastectomy, the entire skin envelope of the breast can be preserved and the breast replaced with an implant or a patient’s own tissue or flap. The reconstruction can often be performed at the same time as the cancer operation, which improves cosmetic outcomes. When the cancer is small enough, the patient can undergo a lumpectomy i.e. removal only of the part of the breast bearing the tumor. When combined with radiation, it allows the breast to be preserved (breast conservation therapy) and is as effective as mastectomy in treating the cancer. Lumpectomy is now being performed with oncoloplastic techniques that preserve aesthetic appearance of the breast. If the tumor is too large for lumpectomy, chemotherapy can be used before surgery to decrease its size. Surgery for the lymph nodes under the armpit is also part of the breast cancer operation. When feasible, this is minimized and only a few lymph nodes are sampled (sentinel node biopsy). The remaining nodes are only removed when the sampled sentinel nodes are found to have cancer. Side effects like arm swelling or lymphedema can thus be minimized.

On the medical therapy front, we increasingly have “smart treatments” that are customized to attack the specific tumor type. The medications used in breast cancer chemotherapy have become more effective over the years and there are better treatments for expected side effects such as nausea and vomiting. When chemotherapy is given through a ‘port’ implanted under the skin, discomfort of repeated IV sticks is avoided. Hair-loss from chemotherapy is still common, but almost always temporary. Not everybody with breast cancer may need chemotherapy and some tumors may be adequately treated with an oral anti-estrogen pill. This treatment called endocrine therapy is usually well tolerated and may be prescribed for 5 or more years.

On the radiation front, treatments have gotten more precise and safe. Unwanted radiation to organs such as heart and lungs is minimized during treatment of the breast. In selected cases after a lumpectomy, shorter treatment courses (1 week instead of the standard 5-6 weeks) can be used. Radiation is a painless treatment and when it targets the breast, it should not cause nausea vomiting or other such problems. The most common side effects pertain to irritation of the radiated skin and will improve after treatment is completed. Some patients that undergo a mastectomy for an early cancer, may avoid radiation altogether.

Survivorship issues after cancer treatments are not discussed as much as they ought to be. Completing cancer treatments is an arduous task and treatment completion does bring quite a relief. However most patients will tell you however that life after cancer is different and the change is real. Certainly acceptance of this change is a better strategy than denial, but several challenges prevent patients from returning to a “normal” life. Whether it is a change of self image, fear of recurrence or lingering side effects of treatment, it is better for patients to talk about their concerns than not. It helps to talk to the doctors about the new normal. It is important to know which of the lingering symptoms can be treated, which ones will improve over time and which ones the patient will eventually learn to live with. Patients will also worry about recurrence, but the truth is that worrying about recurrence doesn’t prevent it. I often tell patients that if you’re amongst the women that won’t ever have a recurrence, you’ve wasted precious life years worrying for nothing. If you are amongst the unfortunate ones that will, again you’ve wasted precious time worrying that you could have spent living. Its good to know that there are still treatment options for recurrences.

 Remember that we fight cancer not because it’s an enemy worth fighting, but because life is worth living. If a patient can get back to living the joyous life she deserves, as long as it may be, to me she’s a winner.

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