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Breast Cancer-10


Welcome to part 10 of educational series on breast cancer. In ninth part, we learned about surgery for early stage breast cancer i.e. stage 1 and 2 cancers, and when do we need additional therapy e.g. chemotherapy.

Question: Thank you Dr. Shah. In fact, it was for the first time that I got some clarity on what is the recurrence rate of breast cancer and why we need additional therapy after surgery. It was really an eye opener. If time permits, I would really love to hear from you about prognostic features which help you in deciding treatment plan.

Answer: I am glad. It is really important for doctors and patients to realize that removing a cancer if often not enough. Since cancer is a systemic disease in many cases, from the time diagnosis is made. Do you know that by the time a cancer is visible by scan or palpable, it already has millions of cells, and several have frequently spread to other parts of the body but are just too small for detection. Circulating cancer cells have been found in blood in patients with very early stage breast cancer.

Que: This means that we have to try very hard to make early diagnosis. Isn’t it?

Ans:. Yes, of course and that is going to give us the best results. Unfortunately the reality in India is different today. And a large number of patients are diagnosed in stage 3 i.e. locally advanced breast cancer (LABC).

These are patients with either large primary tumors more than 5 cm in size or invading local structures, OR those with matted or fixed axillary nodes or nonaxillary nodal involvement.

Primary surgery in LABC is often incomplete and risk of leaving disease is high. Therefore, preoperative chemotherapy is strongly indicated. Same regimens used for postoperative chemotherapy are reasonable. Responses are seen in majority of patients, allowing complete proper surgery. In about 50% patients, response is dramatic and in about 25% patients no tumor may be found at surgery, known as pathologic CR.

If patient has Her-2 positive disease, a drug called Trastuzumab (Herceptin) should be added. When Herceptin is added, response rate improves remarkably.

Elderly patients with hormone receptor positive disease can be treated with preoperative hormonal therapy e.g. aromatase inhibitors.

Que: Do these patients need more radical surgery?

Ans: Standard surgery for these patients is same as others i.e. modified radical mastectomy and axillary dissection. However, since chemotherapy responses are so much better nowadays that some patients become eligible for only lumpectomy.

All these patients need adjuvant radiotherapy. Radiotherapy should be done after completion of chemotherapy.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001