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TREATMENT OF BREAST CANCER
The multimodality treatment consists of the following
With the multimodality approach early stage breast cancers
can be treated with success rates between 90 to 100 %. The team at the
center utilizes all this information to tailor the most effective treatment
for each individual.
The goal of our team is complete eradication of the breast cancer
when possible, our priorities are the following:
A. Compete eradication of breast cancer
B. Breast and lymph node preservation.
C. Titration of the treatment to the individual patient.
Our team utilizes the following treatment principles in achieving
the above goal.
1. Local and Regional Control (Surgery / Radiation)
2. Staging (Sentinel node Biopsy / Axillary node dissection)
3. Systemic Control (Chemotherapy or Hormonal therapy)
4. Prevention. (Surgery / Hormonal therapy)
The center utilizes a combination of the various treatment modalities
in its multidisciplinary approach for treatment of breast cancer.
A. SURGERY
Complete removal of the breast cancer is the most important step in
breast cancer treatment. The extent of the breast involvement is mapped
using the physical findings, size of the imaged abnormality of the breast
by mammography, ultrasound and when appropriate MRI. The size of the
tumor in relation to the size of the breast, location of the lesion
in the breast, and number of lesions in the breast are a few of the
factors which play a role in making a decision about which one of the
following surgical options is appropriate. Patient’s personal
fears, preferences are very important to us and are incorporated in
the decision making. The following are the surgical options we utilize
at the center.
1. Partial Mastectomy / Lumpectomy
2. Simple Mastectomy
3. Modified Radical Mastectomy
4. Sentinel Node Biopsy
5. Axillary Node Dissection.
6. Plastic Surgery and Reconstruction.
1. Partial Mastectomy /Lumpectomy
This involves removal of the cancer with an envelope of normal breast
tissue by our surgeon. The reminder of the breast tissue is preserved
and the normal shape of the breast is maintained. Small tumor size is
ideal for this treatment option. This is our treatment of choice in
small tumors at a single location in the breast.
2. Simple mastectomy
This involves removal of the entire breast tissue and nipple areola
complex. The center use this in situations when the tumor size is large,
tumor is scattered in different quadrants of the breast or located in
the center of the breast with involvement of the nipple. This is also
used in patients with high risk to prevent development of breast cancer
in the future. The lymph nodes, muscles and the skin overlying the breast
are not removed. Most of the patient will undergo reconstruction during
the same surgery.
3. Modified radical mastectomy
In addition to the simple mastectomy this involves removal of the
lymph glands from the armpit. This form of mastectomy is done when the
sentinel node shows involvement with breast cancer. As in simple mastectomy
there is no removal of any muscle, unless the cancer either involves
or is close to the muscle and the skin is spared for reconstruction
of the breast following mastectomy. The reconstruction is done at the
end of the procedure by our plastic surgeon.
4. Sentinel node biopsy
This refers to the first node in the armpit to be involved with breast
cancer. In many situations this is the only node involved with breast
cancer. Recent literature suggests that if the sentinel node does show
any cancer, the incidence of the involvement of other nodes in the axilla
is very low. Our physicians have been using this principle for the past
seven years. By using nuclear medicine and coloring dye the surgeon
identifies the sentinel node during the procedure. Our incidence of
sentinel node identification is between 95 to 100 %. Once the node is
identified, it is removed and tested by the pathologist while the patient
is under anaesthesia. If the node/s do not show any involvement with
breast cancer cells the remainder of the Axillary glands are not removed.
This reduces the risk of developing arm swelling (Lymphodema) and other
morbidities associated with the Axillary node dissection.
5. Axillary node dissection.
This is reserved for patients who have cancer in there sentinel node/s.
Since the incidence of other nodes been involved with breast cancer
is higher, they are removed at the time of surgery and tested. This
helps in removal of breast cancer and provides us the number of positive
glands. This information is valuable to our oncologists for staging
and planning chemotherapy.
6. Plastic surgery
Our patients are evaluated by a plastic surgeon prior to mastectomy.
The breast is reconstructed either by using tissue expanders and implant
or by tissue transfer flaps (TRAM, Latismus, DIEP). These options, possible
risks and outcomes are discussed with the patient. The procedure is
then carried out after the completion of mastectomy, by our plastic
surgeon. This saves the patient, surgery at a later date.
B. RADIATION
A radiation oncologist evaluates the patient for the appropriate treatment
recommendation. They use various radiation techniques to deliver radiation
to the breast, chest wall or axilla for the control of breast cancer.
Radiation is used commonly as an adjunct to partial mastectomy to decrease
the possibility of local recurrence and for prevention of a possible
new cancer in the treated breast. In patients with large breast cancer
or with several Axillary nodes involved with breast cancer, we use radiation
in addition to surgery and chemotherapy for local control.
New research has shown us that most of the patients with small breast
cancer can be treated with partial breast radiation by the use of a
single (Mammosite)
or multiple small catheters in the breast. Our center was one of the
first to implant these in an office setting. Unlike the whole breast
radiation that needs 6 weeks, partial breast radiation is completed
in 5 days. This is a significant convenience to the patient and also
maintains the normal texture and feel of the breast.
C. CHEMOTHERAPY/ HORMONAL THERAPY
An oncologist evaluates all breast cancer patients. Based on the available
statistics and our own data, patients with either advanced stage breast
cancer, a high grade breast cancer, or other risk factors including
age and family history are likely to have recurrence. They will need
to be treated with addition of either chemotherapy or hormone therapy.
Once all the staging is completed and the tumor data is available our
oncologist will recommend the most effective treatment plan and offer
our patient a choice of research protocol participation. In a select
number of patients the chemotherapy is given prior to the surgery. This
is done to shrink the size of the tumor and make it resectable with
preservation of the rest of the breast.
Some cancers are dependent upon the hormones for their progression
and growth. They can be controlled with medications that block the production
or effect of these hormones and hence arrest the growth of breast cancer.
Some breast cancers have a strong expression of HER 2 NEU. The treatment
of these cancers is targeted by using a specific antibody, which binds
to the cancer cells and helps in killing the cancer cell.
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