Treatment Plans for Breast Cancer Patients
Cancer is the uncontrolled proliferation of abnormal cells in parts of the body. Breast cancer develops once breast cells begin to proliferate and grow at a very fast rate. Usually, the cells clump together to form a lump which can be seen in an x-ray. Once the cancer spreads into adjacent organs or in distal organs in the body, it is considered malignant. Not all breast cancers originate from the same part of the breast. However, majority of breast cancers develop in the ducts where milk is carried to the nipple or in the glands that produce breast milk. Most breast cancers are classified as carcinomas which are cancers that arise in the epithelial tissue or lining of the organs.
Apart from skin cancer, breast cancer is the most commonly diagnosed cancer among women living in the United States. According to The American Cancer Society (ACS), breast cancer death rates are the highest compared to death rates for any other cancer, besides lung cancer. It is estimated that 1 in 8 women in the United States will develop breast cancer in her lifetime; that means about 12% of U.S. women will develop breast cancer. In spite of the fact that these statistics are alarming, there are various treatment alternatives accessible for those that are diagnosed with breast cancer.
First and foremost, the most ideal approach to treat any disease would be to prevent it. However, due to the lack of information about breast cancer, there are no settled guidelines for prevention. Thus, it is recommended that monthly breast self-exams are conducted to check for lumps, discharge and difference in skin, as well as yearly mammograms for women ages 40 years or older. Cancer staging can be used for various things, but it is mainly used for to determine patient prognosis as well as treatment planning. A patient’s staging also determines which type of treatment would work best. Stage 0 defines noninvasive breast cancer which have not grown into stroma or supporting tissue. Stages I-III are invasive breast cancers which have integrated in stroma or skin. During these stages, the cancer has spread to proximal sites but not distal sites. Stage IV cancer is a metastatic cancer present at the time of diagnosis which has spread to distal sites. As time progresses, all stages could possibly metastasize. (Susman, 14)
Treatments accessible for those with breast cancer can be either local or systemic treatments. Local treatments treat the tumor without affecting the rest of the body, which is why this treatment type is most common. On the other hand, systemic treatments target cancer cells almost anywhere in the body. For systemic treatments, drugs are administered by mouth or put directly into the bloodstream.
The most common local treatment for breast cancer is surgery. Surgery is a primary treatment that can be part of a multidisciplinary treatment plan. However, not all patients are candidates for surgery. Surgery for breast cancer is the removal of the entire tumor and any microscopic spread. During this treatment, lymph nodes that are affected may also be removed as well as surrounding normal tissue. The more normal tissue removed, the riskier the procedure is. In some cases, surgery is the only treatment modality necessary when the entire tumor is removed. One type of surgery is a mastectomy, which is the removal of the whole breast. Types of a mastectomy include simple and total mastectomy, radical mastectomy, modified radical mastectomy, subcutaneous mastectomy and partial mastectomy. Because of the side effects and invasive nature of a total mastectomy, physicians suggest reconstructive surgery after this procedure.
Unfortunately, when compared to other types of surgeries, a total mastectomy followed by reconstruction has a higher relative risk of treatment-related complications (Sheu, 17). Breast-conserving surgeries (BCS) such as a lumpectomy, partial mastectomy, quadrantectomy, or segmental mastectomy involve the removal of only part of the breast effected by the disease. The goal is to remove the cancer as well as some surrounding normal tissue. The size and location of the tumor determines how much of the breast is removed. Obviously, no single treatment method can be appropriate for patients within different stages; thus, the success of BCS depends on appropriate patient selection. When compared to mastectomy, it was found that BCS is not only oncologically safe but also has a positive impact on the aesthetic outcome and psychological well-being of patients with breast cancer (Murugappan, 2018).
Radiation Therapy is another local treatment for breast cancer. It is the use of ionizing radiation to cure abnormal cells like cancerous tumors. It uses high energy radiation like X rays, gamma rays and charged particles to injure or destroy most nearby cells indiscriminately. The goal of radiation therapy is to destroy as many abnormal cells as possible, while also limiting the damage to healthy and normal surrounding cells. Two main types of radiation therapy can be used to treat breast cancer. The first and most common type is external beam radiation which delivers radiation to the outside of the body with the use of a linear accelerator. The other type is internal radiation which is also known as brachytherapy. This procedure involves the use of a radioactive source which is put inside the body for a short time. Radiation Therapy for breast cancer patients is often used as an adjuvant treatment in a multidisciplinary plan. This means it is given in addition to the primary treatment to maximize its effectiveness. It can be used after a mastectomy when the tumor is bigger than 5cm or if there is lymph node involvement; if the cancer metastasized to the bones or brain; and after BCS to reduce the possibility of recurrent cancer in the breast or nearby lymph nodes.
Multiple studies have shown that radiation therapy used as an adjuvant treatment after a lumpectomy was far more beneficial than a lumpectomy alone. Fisher et al conducted a study in which “818 women with localized DCIS were randomly assigned to a lumpectomy or a lumpectomy plus 50 Gy of radiation. Tissue was removed so that resected specimen margins were histologically tumor free. Results showed that the women who underwent a lumpectomy preceding ipsilateral breast irradiation had a significantly better event-free survival at 8 years of follow-up than women treated by lumpectomy alone. Furthermore, the results concluded a 43% reduction in the average annual incidence rate for all first events as a result of radiation therapy” (Fisher et al, 1999). For patients who underwent BCS, radiation is delivered to the entire breast followed by a boost of radiation to the area where the cancerous tissue was removed, to prevent the cancer from reoccurring in that area. Although not as common, brachytherapy can be used concurrently with external beam radiation as an extra boost to the tumor site for patients who had BCS. Earlier studies show promising results but with more complications including poor cosmetic results. Thus, further research and follow up is being conducted for this treatment option.
Systematic treatments available to breast patients include chemotherapy, immunotherapy and hormone therapy. Chemotherapy is the use of drugs given intravenously or by mouth. It works by disrupting the cell cycle and some chemo drugs work in any cycle. Chemotherapy can be used as a neoadjuvant treatment, adjuvant treatment or for advanced breast cancer which has metastasized. Neoadjuvant chemotherapy is used before surgery to shrink tumors when the tumor at diagnosis is too big to remove surgically. Because it is a systemic treatment and travels through the patient’s bloodstream, it can also kill cancer cells that have spread elsewhere but aren’t actually visible. Adjuvant chemotherapy is used after surgery to damage or kill surrounding cancer cells left behind or microscopic cells that weren’t visible. The outcome of adjuvant chemotherapy astonished researchers when Bonadonna et al. combined treatment techniques by using CMF, which is cyclophosphamide, methotrexate and 5-fluorouracil.
Results showed a significant increase in survival rates for patients diagnosed with positive lymph node breast cancer. Bonadonna et al. findings made clear that chemotherapy can eradicate micro-metastatic disease visible at the time of diagnosis. “A systematic overview of over 100 randomized clinical trials revealed that adjuvant chemotherapy improves disease free survival (DFS) and overall survival (OS) in patients with early-stage breast cancer. At 10 years, the risk of recurrence was reduced by 22%-37% and the risk of death by 14%-27%” (Esteva, 302). Like adjuvant chemotherapy, the main goal of neoadjuvant chemotherapy for breast cancer is to improve local control as well as survival rates. Multiple studies have found several other advantages to neoadjuvant chemotherapy. Researchers have found that tumors too large to be operated on or removed by lumpectomy can be effectively shrunken or down sized through neoadjuvant chemotherapy. Fisher et al. also found that the use of chemotherapy, tamoxifen, or radiation prior to surgery prevented kinetic alterations triggered by excision of the primary tumor. Both adjuvant and neoadjuvant chemotherapy have shown to play a role in the reduction of reoccurring breast cancer. Chemotherapy can also be used as a primary treatment for breast cancer patients with metastasizes beyond the breast and axillary area. The length of treatment varies based on the effectiveness of the chemotherapy and the patient’s tolerance to it.
Immunotherapy is a treatment technique that stimulates one’s immune system through the use of medicine to attack cancer cells. Since this treatment modality is not effective for every type of breast cancer, there are ongoing clinical trials and research on immunotherapy. Two immunotherapy drugs have been approved for the treatment of breast cancer within this year. Atezolizumab is the first approved which targets a protein located in tumor cells as well as immune cells. It is only approved for the treatment of breast cancers PD-L1 protein positive. The second approved is protein-bound paclitaxel. Paclitaxel has been successful in treatment for locally advanced triple-negative breast cancer which is inoperable, in addition to triple-negative metastatic breast cancer. The clinical trial conducted by Schmid et al compared the combination of atezolizumab and nab-paclitaxel with the combination of a placebo and nab-paclitaxel as the primary treatment of triple-negative breast cancer patients. The participants were 902 individuals diagnosed with either metastatic triple-negative breast cancer or locally advanced breast cancer. These patients didn’t undergo any prior treatment for metastatic disease. For the patients diagnosed with PD-L1 positive tumors and treated with atezolizumab in addition to chemotherapy, it was found that median time the patient would live without the cancer getting worse was 7.4 months. For those who were administered the placebo in addition to chemotherapy, the median time was 4.8 months (Schmid et al., 2018). The FDA’s approval of Atezolizumab and Paclitaxel for breast cancer treatment were based on these findings.
The last systemic treatment is hormone therapy. Hormone therapy is the use of drugs to delay or prevent tumors that are hormone receptor positive from proliferating, by depriving the cancer cells from the hormones they need to grow. Tamoxifen is a hormone therapy drug which blocks estrogen receptors on cancerous breast cells. It works by breaking the signal estrogen receptors send to help the cells grow and divide. “The later Early Breast Cancer Trialists Collaborative Group conducted a meta-analysis of 194 randomized trials employing adjuvant chemotherapy and endocrine therapy which demonstrated the 15-year breast cancer recurrence rate was reduced from 45% to 33% with use of tamoxifen, and also showed a 41% reduction in annual recurrence rate and reduction of breast cancer mortality by 35%. This meta-analysis determined that the risk reduction with tamoxifen was significant in both pre- and postmenopausal women and was independent of the receipt of chemotherapy” (Puhalla et al., 2012). Earlier studies assessed the use of tamoxifen compared to treatments with no additional use of an adjuvant therapy and discovered significant improvements in outcome with tamoxifen as adjuvant therapy without regards to the patient’s menopausal status (Fisher et al. 1989). Tamoxifen is now a standard of care with or without chemotherapy.
Knowing which treatment plan is most successful depends on the cancer staging as well as how the patient reacts to different treatment modalities. Although one treatment modality cannot be ruled out as the most successful treatment for breast cancer, various studies have shown that multidisciplinary treatment plans are the most successful. Majority of breast cancer patients with undergo surgery as a primary treatment if they are a candidate. Each patient is different and depending on the tumor size and location, the patient can receive chemotherapy, hormone therapy, radiation therapy or immunotherapy before surgery, after surgery or concurrently.
To lessen the effects of treatment, women may participate in integrative medicine techniques. Integrative medicine is palliative care which incorporates alternative medicine and conventional medicine methods and treatments. For this practice, you are treating the entire patient not just the disease. Examples include yoga, nutrition, fitness, meditation, massage therapy, herbal medicine, acupuncture and stress reduction. Yoga is thought to be very beneficial for cancer patients because it targets not only psychological but also physical and spiritual aspects of quality of life. A common complaint for breast cancer patients is sleep disturbances. This could be a cause of the treatment process or the cancer itself. Sleep disturbances have also been linked to impaired quality of life among cancer patients even when other symptoms such as fatigue or depression are controlled. However, studies have found that yoga helps improve sleep disturbances in cancer patients. Ratcliff et al. conducted a study where women treated by radiation therapy for six weeks were randomized to a yoga, stretching or a waitlist control group. Symptoms of depression and sleep disturbances were measured prior to the study. Findings showed “yoga was especially helpful for those women with disturbed sleep and depressive symptoms at the start of radiotherapy. In fact, the women in the yoga group who had sleep disturbances at study entry had mental health scores at 3 and 6 months after radiotherapy equivalent to those of women who did not have sleep disturbances at study entry” (Ratcliff et al., 2015). Findings were similar for the benefits of yoga for women with high depression symptoms. Thus, yoga and other alternative medicines help boost overall sense of well-being as well as help with pain management when undergoing the process of breast cancer and its treatment.
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