Breast Cancer Conservation Therapy (Breast Cancer)

Overview of Breast Cancer Conservation Therapy

Breast cancer is among the leading causes of cancer-related deaths in women all over the world. The primary treatment for noninvasive and localized invasive breast cancer is surgery. This might be partnered with hormone therapy, chemotherapy, or radiation treatment. The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 trial proved that for tumors less than 4 cm, partial mastectomy (removal of part of the breast) paired with radiation is just as effective as a full mastectomy (removal of the whole breast), making it a standard treatment option.

Many studies, including a 20-year follow-up of the NSABP B-06 trial, have confirmed these results. Partial mastectomy followed by breast radiation remains an appropriate treatment for smaller invasive breast cancers. Moreover, for localized intraductal breast cancers (cancer that starts in the milk ducts), combining radiation with breast conservation therapy (BCT – preserving as much healthy breast tissue as possible) became the standard treatment after the NSABP B-17 trial. This trial showed that adding radiation significantly decreased the chance of cancer returning.

Advantages of BCT include less time in surgery, less emotional impact compared to full mastectomy, better cosmetic results, and fewer side effects. However, other studies found that after one year, there was no significant difference in levels of depression in women who had a full mastectomy, BCT, or breast reconstruction.

Correctly assessing the stage of the cancer is vital for planning the treatment and surgery. In 2018, the American Joint Committee on Cancer updated the Breast Cancer Staging Manual. The updated staging considers factors such as the size and location of the tumor (T), whether cancer has spread to lymph nodes (N), and if the cancer has spread to other parts of the body (M). Biological markers, including indicators of hormone sensitivity, and the grade of the tumor (how different it is from normal tissue) and other gene tests were added to help determine the likely course of the disease and the best treatment options.

Why do People Need Breast Cancer Conservation Therapy

Breast-Conserving Therapy (BCT) is a type of treatment a surgeon might consider if they believe a tumor can be removed completely, leaving clear edges, while still maintaining a good appearance of the breast. This treatment is typically recommended for certain types of tumors – those that are small in size (DCIS/Tis and T1-2 tumors). The decision to undergo BCT may also involve considering post-surgery radiotherapy because this method helps reduce the chance of the cancer returning in the same area, although it doesn’t necessarily improve overall survival.

In some cases, getting radiotherapy after surgery might not make a difference to survival rates. For example, in people aged 70 and older with a low-stage, hormone-receptive cancer, research shows that skipping radiotherapy but taking hormone-blocking medication (tamoxifen) may be a reasonable approach.

There have been studies that look at the role of BCT in treating larger tumors, particularly those that measure more than 5 cm. In these cases, the size of the breast overall and the size of the tumor relative to the breast might be more important than the exact measurement of the tumor. Since the chemotherapy given before the surgery (neoadjuvant chemotherapy) has been shown to be as effective as chemotherapy given after surgery (adjuvant therapy) in terms of survival rates, it might make it possible for patients with larger tumors to undergo BCT. This is especially possible in patients with large local tumors who respond well to chemotherapy before the surgery. In such cases, BCT may be a safe surgical choice when compared to removing the entire breast (mastectomy).

Historically, men with cancer have been advised to have a mastectomy. While this is typically the recommended procedure, BCT can also be an option for men with other health conditions or for those who wish to keep their nipple and areola. Studies show that the type of surgery doesn’t significantly affect survival rates in men with breast cancer. However, men who undergo BCT are typically advised to receive radiotherapy after the surgery to reduce the risk of the cancer recurring.

When a Person Should Avoid Breast Cancer Conservation Therapy

There are certain conditions under which it might not be safe or advisable to go ahead with specific breast cancer treatments. Here’s what this means:

Relative Contraindications

These are situations where the treatment might need to be reconsidered. They include:

• If the breast or chest wall has had radiation therapy in the past.
• If the patient has an active disease that affects the connective tissues and skin, like scleroderma.
• If there are extensive positive pathological margins, which means the cancer cells are close to the edge of the tissue that has been removed.
• If the tumor is larger than 5 cm.
• If the tumor is big compared to the size of the breast.
• If the patient has a known or suspected genetic condition called Li-Fraumeni syndrome.
• If the patient is known or suspected to have a genetic disposition to breast cancer due to certain genes (BRCA1, BRCA2).

Absolute Contraindications

These are situations where the treatment should not be given under any circumstances. They include:

• If the patient is in the first trimester of pregnancy. However, breast cancer treatment (BCT) may be reasonable for some in their 2nd and many in their 3rd trimester, who can receive radiation after delivery.
• If the patient has multicentric disease, which means multiple tumors in different quadrants of the breast.
• If there are widespread suspicious or malignant appearing microcalcifications, which are tiny deposits of calcium in the breast tissue.
• If the patient has extensive DCIS (ductal carcinoma in situ), which is a non-invasive breast cancer.
• If the patient has inflammatory breast cancer, a rare and aggressive form of breast cancer.
• If it’s impossible to get clear margins with lumpectomy (removal of tumor and some surrounding tissue) without adversely affecting the appearance of the breast.
• If the patient has a mutation in both copies of the ATM gene.

Preparing for Breast Cancer Conservation Therapy

If a doctor spots something worrying on a scan, such as a lump or unusual calcium deposits, they might want to take a small sample (biopsy) to further examine it. Rather than remove the whole area, they’ll usually take a narrower core needle biopsy. The doctor will then mark this spot with a tiny clip that can be seen on future scans, like a bookmark, signifying where they examined. This clip is particularly essential when the lump is hard to feel (nonpalpable) or when it’s a specific type of breast cancer known as DCIS. It’s also crucial for people having chemotherapy before surgery, as the tumor may shrink and become harder to locate.

One common method used to mark the location of the abnormal tissue for the surgeon is wire-guided localization. This usually takes place on the very day of the surgery, performed by a radiologist or the operating surgeon. With the help of live imaging, a wire is inserted through the skin and directed right to the abnormal tissue. They then take a soft mammogram- an image of the breast- to confirm the wire’s position. The wire not only helps the surgeon plan, but it also guides them while removing the affected tissue.

However, there are drawbacks associated with using a wire to mark the location. For example, there may be discomfort for the patient, the potential for the wire to move or break, wound or internal injury, and even a collapsed lung (pneumothorax) in rare cases. These challenges have triggered the creation of alternative methods. Organizing the operation can also be more challenging if the wire is not inserted in the operating room, as it requires proper coordination with the radiologist.

Therefore, non-wire marking techniques are becoming increasingly popular. These techniques include using markers that operate on radiofrequency, radar or infrared, or apply paramagnetic iron oxide. Radio-guided occult lesion localization involves an injection of a nonspecific radio-isotope (commonly technetium-99) into the tumor, which can then be detected during surgery with a hand-held gamma probe. This method is proving to be quite practical. Other lesser-known techniques include using ultrasound to guide the surgery in real-time, quick-freezing (cryoprobe-assisted) localization, and marking with carbon, methylene blue dye, or near-infrared fluorescence optical imaging.

How is Breast Cancer Conservation Therapy performed

The process of removing a lump from your breast, known as lumpectomy, is carried out with the patient lying flat on their back, with the concerned arm extended to a right angle. The spot where the cut is made can depend on different factors and can be either near or far from the tumor. When possible, the cut is made over the tumor within the natural skin folds to reduce visible scarring. The size and shape of the cut can vary depending on the size of the tumor.

The cut is then gently opened, and the lump is reached by carefully separating the surrounding breast tissue. Enough fat is left under the skin to allow blood to continue flowing freely. If the lump is close to the skin or affects blood flow, the skin may also need to be removed. The lump is carefully removed, ensuring clean edges. If a needle was used to locate the lump, it can also help figure out how much tissue needs to be removed. The breast muscle and lining are only removed if necessary to make sure the lump has been entirely removed. Once removed, the lump is checked to make sure all of it has been taken out.

A picture of the removed lump is usually taken during the operation to confirm if everything has been removed. If a part of the lump is still in place, more tissue might be removed. Clips are placed around the area where the lump was to guide future radiation treatments. Some doctors also remove an extra thin layer of tissue around the tumor’s removed area, which may reduce the chances of having to do more surgery in the future.

Depending on the situation, oncological plastic surgery techniques might be used to avoid the need for breast reconstruction. Oncological cosmetic surgery helps to ensure an acceptable cosmetic outcome following the partial removal of the breast. Even though this form of surgery is becoming more common, it should be avoided in certain patients, such as smokers or those with other health conditions that might affect wound healing.

Oncoplastic procedures are divided into two levels. Level 1 procedures are considered when less than 20% (about a fifth) of the breast tissue is removed in small to medium-sized breasts. These procedures use careful cuts and breast tissue adjustment to reduce the gap left by the tumor. On the other hand, Level 2 procedures are used when 20 to 50% (about a quarter to a half) of the breast tissue needs to be removed from large breasts. These often involve reshaping the breast tissue and the skin around it. If more than half of the breast needs to be removed, then a full breast reconstruction might be considered.

Finding and removing the sentinel lymph node, the first lymph node likely to have cancer cells, helps assess how far the cancer has spread (node staging). These nodes are often found and removed through an armpit incision. Special dyes or a radioactive substance can be used to help identify these nodes. If only one or two sentinel nodes are affected, you might not need more surgery in the armpit, especially if you’re going to have radiation therapy on the whole breast.

Possible Complications of Breast Cancer Conservation Therapy

There are several possible complications that might occur following therapy to preserve the breast during breast cancer treatment. These include:

1. Seroma: This is a build-up of fluid in the area where surgery was performed.

2. Hematoma: This is a collection of blood outside the blood vessels, which is also a result of the surgery.

3. Fat necrosis: This happens when fatty tissue in the breast becomes damaged, creating a lump that can feel like a cancerous lump.

4. Infection: Like all surgical procedures, there’s a risk of infection. It could lead to skin redness and swelling, referred to as cellulitis, or a pocket of pus, known as an abscess.

5. Altered sensation: Post-surgery, some people may feel a different sensation or a loss of feeling in the breast or nipple.

6. Close or positive margins: This means that some cancer cells may remain in the breast because the surgeon was not able to remove all of it safely.

7. Poor cosmetic outcome: In some cases, people may be unhappy with the look of their breast after surgery.

8. Lymphedema: This is a condition of local fluid retention and tissue swelling caused by a compromised lymphatic system, often from the removal of lymph nodes during surgery.

9. Wound dehiscence: This is when a surgical incision reopens after the operation. It mostly happens when a special breast surgery technique known as oncoplastic surgery is used, especially in characteristic incision patterns like the inverted T-junction in a wise incision pattern.

What Else Should I Know About Breast Cancer Conservation Therapy?

Patients dealing with invasive breast cancer often face a treatment known as Breast-conserving therapy (BCT). Designed to leave as much healthy breast tissue as possible, BCT goes hand-in-hand with radiation treatments, as recommended by the National Comprehensive Cancer Network. The goal of these radiation treatments is to destroy any lingering microscopic cancer cells in the breast tissue. This not only helps to prevent the cancer from returning at the same location, but also helps to stop it from spreading throughout the body. Studies have shown that adding radiation to the treatment plan can cut down the chance of the cancer returning by half, and can lower the chance of death from breast cancer by 5% after 15 years.

Recently, there’s been growing interest in alternative radiation techniques, such as faster partial breast radiation, radiation during surgery, and brachytherapy. The latter involves placing small radioactive pellets or seeds into the cancerous tissue.

Additional treatments for breast cancer can include hormone-based therapies, chosen based upon the status of hormone receptors (structures that receive and respond to certain hormones) within cancer cells. These receptors can receive signals from estrogen, progesterone, and human epidermal growth factor receptor 2. For those who have an absence of these three receptors (a condition called triple-negative expression), they should consider BCT, though chemotherapy is often suggested.

For individuals diagnosed with ductal carcinoma in situ (a term representing cancer cells that aren’t spreading past the milk ducts in the breast), they also should weigh the benefits and drawbacks of BCT as part of their treatment plan.

Following a successful treatment of non-spreading breast cancer with breast-conserving therapy, it’s crucial to monitor the area for recurrence with imaging follow-up visits. The recommended procedure involves a mammogram (an x-ray of the breast) 6 to 12 months after radiation treatment, and then annually, alongside twice-yearly breast examinations. Routinely getting an MRI, which captures more detailed images, isn’t generally suggested — unless the person is at a greater risk of recurrence (for example, those with family history of breast cancer, dense breast tissue, or who were diagnosed before turning 50). This MRI should not replace the usual mammogram, but be used alongside it.