Breast cancer: Here's how breast cancer treatment changes with each stage
Before we talk about cancer treatment, we should also know about the importance of staging as the stage at which the breast cancer is diagnosed, the amount of treatment required will be extraordinary. Here's how breast cancer treatment changes with each stage
Breast cancer is mainly divided into 4 stages - stage 1 is where the lump is pretty small and it is confined to the breast, so usually we can say that it's less than 2 cm and the size of a gooseberry while in the second stage, the lump is the size of a lemon and it's without any change in the contour of the breast. When it goes to the third stage, there could be a small lump in the breast as well as the armpit or axilla. When it comes to stage 4,the disease in the breast is spread to a distant organ such as bones, lungs, liver and very rarely to the brain.
In an interview with HT Lifestyle, Dr Sushruta Mysore Shankar, Consultant Breast Surgeon and Surgical Oncologist at SPARSH Hospital, elaborated, “Like all cancers, breast cancer has the following stages - Early breast cancer: When the cancer is limited only to the breast. It is confined and very much inside the breast. Locally advanced breast cancer: The breast cancer involving the chest wall, the skin above or it is spread to the lymph nodes (the draining channels) in the axilla or armpit. Most advanced stage or the Metastatic breast cancer: When the breast cancer has already spread to other organs in the body, which is most commonly the liver, lungs, bone and brain. It can also spread to other organs but these are the most common or vital organs. This is the final and the most advanced stage and also called the 4th stage of breast cancer.”
Talking about how does the treatment change with each stage, Dr Bellala Ravishankar, Managing Director at Omega Hospitals, insisted, “Before we talk about treatment, we should also know about the importance of staging. If breast cancer is diagnosed at an early stage, the amount of treatment required is very limited and the outcome from the treatment will be extraordinary, which is why we encourage people to come at an early stage, but unfortunately, in spite of all the awareness programs, we still see many people coming at an advanced stage. The problem with advanced stage is we need to use more modalities of treatment and in spite of all this, the outcomes are poor compared to early stage treatment.”
Breast cancer treatment at different stages:
Dr Bellala Ravishankar said, “Coming to stage 1 therapy, if it is confined to only one breast, then you don't have to remove the entire breast, you just have to remove a lump and you can also address the axilla (armpit) in what is called the sentinel biopsy. Sentinel node biopsy is whether to completely remove the nodes in the axilla or not, so that it will reduce morbidity in the axilla. The long term morbidity from the surgery is reduced if the patient is treated at stage 1. After surgery when we get the biopsy report, we ask for common clear studied receptors like estrogen receptor, progesterone receptor, HER 2 receptor and Ki 67. Based on the report received, we decide whether the patient requires further treatment like chemotherapy or any hormonal therapy but most of the times when the patient has undergone breast conservative surgery, which is only removal of a lump and when we address the axilla, we have to give radiation. So here the radiation becomes a component as far as treatment is concerned.”
He added, “Once you have the biopsy report, we can plan whether she requires chemotherapy or only hormonal therapy is good enough. If there is a spread to the axilla, then definitely there will be a need for chemotherapy. We don't have to worry today because there are drugs available to control the toxicity from the chemotherapeutic agents, but there are certain unavoidable toxicities like hairfall, nausea and vomiting which can be reduced by potent drugs.”
Talking about when the patients come with an advanced disease, he shared, “When the patient has come with an advanced disease, we do a biopsy immediately and see what is the receptor status, basing on that, if the patient requires any targeted therapy we start with the targeted therapy. If there are no targetable lesions, we start them on chemotherapy and try to shrink the lump as much as possible by completing the course of chemotherapy and then the patient will undergo surgery. When the patients come with an advanced disease we won't be able to offer what is known as breast conservation therapy. We have to go for mastectomy, which is complete removal of the breast. Once that is done, based on the report the patient will be subjected to radiation and if required hormonal therapy.”
On the other hand, when the patient has reached the metastatic disease, he said, “In the 4th stage of the disease, the breast cancer has spread to some other organs again and here the treatment is based on what is called receptor status which is the ERPR, Ki67 and HER 2, if there is any targetable lesions that we have seen then we can start them on targeted therapy.”
Bringing her expertise to the same, Dr Sushruta Mysore Shankar, said, “In early stage breast cancer, we treat it when it is localised predominantly only in the breast. In any cancer, we have 3 modalities of treatment - Surgery, Chemotherapy and Radiation therapy. All 3 modalities are usually used in combination in succession to treat any kind of cancer, which is also applied to breast cancer. In early stage breast cancer, we are able to select 1 or 2 modalities or maybe avoid one of these modalities thereby reducing the complications and side effects to any patient seeking breast cancer treatment. In early stage breast cancer, we only go for removal of cancer, which is also known as lumpectomy or breast conservation surgeries. Here, our main goal is to cure the patient of cancer and also preserve the breast.”
She asserted, “Breast is important for all women, not only for cosmetic reasons or its functional purpose but also it has a lot of psychological effects on women. We do a surgery to only remove the cancer and to also see the size of the cancer. Usually in India, we don't see patients with very small cancers because it is very difficult for women to identify breast cancer in early stages where it is less than 1 cm because the breast is a very fatty organ and to find a small lump of 1 cm inside the breast is very difficult. If the patients go to the clinician when the lump is 1 cm or 0.5 cm it is very difficult to identify. Usually, they are detected during screening. Patients who have been going to the doctors, breast surgeons, and do regular follow ups with yearly mammograms (which are now mandatory after the age of 40) there we pick up very tiny lumps of less than 1 cm. These patients can only be treated with surgery and we can totally avoid chemotherapy because as we all know, it has toxic side effects on all other functions of the body.”
If it has not reached the axilla (armpit), Dr Sushruta Mysore Shankar revealed, “We can do a sentinel lymph node biopsy, where we are trying to avoid the complications of the axillary surgeries for the patient. If this is negative, we are going to avoid axillary dissection as well. When it is locally advanced, we are not going to have an option of skipping chemotherapy. Chemotherapy becomes an essential part of the treatment and this also could also require a pre-surgery chemotherapy where is called as Neoadjuvant. All the treatments given after surgery are labelled as adjuvant treatments. If the tumour is very large and the breast cannot be saved, if there is a large tumour in a small breast or if there is heavy volume of the disease in the armpit, then we recommend Neoadjuvant chemotherapy to reduce the volume of the disease and the burden of the disease in the body.”
She concluded, “As we go to the last stage, stage 4, also known as Metastatic breast cancer, surgery plays a very small role. Surgery is always done with a curative intent and if the disease has already spread to other organs, all we do is give chemotherapy or other advanced treatment like targeted therapy and hormonal therapy. If the patient is having metastasis to the bones which is causing a lot of pain or difficulty in mobilisation, then we give radiation therapy which is palliative. We give treatment to improve the quality of life.”
Avoiding chemotherapy in early stages:
Dr Bellala Ravishankar highlighted, “Another key advancement now is when the patient has got an early stage disease, we could also avoid chemotherapy by doing a special test called CanAssist Breast test. By doing this test, it will help us know if she requires chemotherapy or not. This will help us avoid subjecting all the patients who come to us with an early stage breast cancer to chemotherapy because chemo has long term acute toxicity which may not be tolerated by patients. There are certain genes which are studied and they give us a score whether the patient falls into a low risk, intermediate or a high risk.”
He pointed out, “If the patient falls into a low risk group, we don't offer any chemotherapy, we straight away put them on follow up,and if the estrogen receptor and progesterone receptor are positive, then they're put on hormonal therapy. This test avoids unnecessarily treating a patient with chemotherapy even when they don't require it. Previously we used to do this but now it's changed. This test is validated on Indian patients and it’s quite affordable for Indian patients. Due to advances in science, we can now personalise treatment for patients based on their estrogen, progesterone receptor and HER2 and information from tests like CanAssistBreast. We can always personalize our treatment so that we can avoid the unnecessary toxicity on patients who do not require chemotherapy.”
Dr Sushruta Mysore Shankar explained how the treatment changed over the last 15 years:
- Moving from Mastectomy to Breast conservation surgery: With respect to surgery, earlier when cancer was detected in the breast, the only solution was to remove the breast (mastectomy). When this procedure is done, the patient goes for a flat chest and the breast is removed. Apart from the side effects of the treatments, diagnosis, distress management of the whole cancer management, the patient also suffers from psychological deterioration due to loss of a breast, identity crisis and much more.
- Now from Mutilating surgeries, we have moved to Breast Conservation Surgeries, where we don't have to remove the whole breast. 90% of the time we try to save the breast, only 10 % time, when it is multifocal and we are not left with any other option, then we have to go with mastectomy.
- Sentinel Node Biopsy: All the time when mastectomy was done, patients used to come up to us after 2-3 years with a swollen arm and no mobility to the arm, a lot of restrictions in movements, pain, heaviness, etc. Now we have moved to Sentinel lymph Node Biopsy which avoids all complications of axillary dissections.
- Chemotherapy: Hormonal therapy has been used for decades. Apart from protocol based treatment, just like appendix, we used to treat all breast cancer patients according to the protocol of stages (stage 1, stage 2 etc). Now, we are customizing treatment for each patient and this is a very huge feat achieved in this field. Every patient gets a tailored and customised treatment. Not all patients are subjected to the same drugs.
- Earlier if breast cancer was diagnosed, they used to receive a set of therapy irrespective of the response or the benefit they would achieve from that. Now we do ImmunoHistoChemistry (IHC) to see if the patients are hormone receptor positive and usually look for ER and PR receptors. Only if they are positive, the patient gets hormonal treatment. If the patient is negative, then it means the patient is not going to get any benefit or response from the treatment even though they are put on it and they will get all the side effects. Now we are able to treat only those patients with the drugs who we know are going to respond to this disease and are going to gain benefit from it
- For HER2/Neu receptors, we add targeted therapies. We have monoclonal antibodies where the drug is added only if they are positive for that specific mutation.
- Insights on prognostic tests - Prognostic tests are suitable for patients in the early stages because most of the advanced stage we know what should be done. It is recommended for patients falling in the border line and in their early stage with lymph nodes who are negative, we don't have to put them through the chemotherapy stress. When we are doing this test, we are going to get a score (less than 11, more than 11) patients have to go on hormonal therapy if ER, PR positive. They are going to score the patient depending on their risk score and depending on this scoring system, we will be able to prognosticate the patient’s further treatment response. We will be able to explain to them very precisely as to how much benefit they are going to receive from the treatment and what are the risks that we are going to undo with the treatment and risk of recurrence.