I HAVE BEEN DIAGNOSED WITH BREAST CANCER - WHAT ARE THE NEXT STEPS?
The treating surgeon or oncologist will request further investigations to get all of this information. He/she will use the information already gained from the imaging and the biopsies and may request further tests to establish if there is any spread of the cancer. You may be required to have further blood tests, a chest x-ray, and an ultrasound of your liver. If you have any other symptoms or if any of these further tests show any suspicious areas your doctor may request a Bone Scan or a PET CT scan. If the results show that there is no obvious distant spread then the treating surgeon and oncologist will take into account your age, your chronic medical conditions and the extent of the cancer to formulate a management plan which is tailored specifically to you.
Surgery and oncology have come leaps and bounds and as the treating team we have a few ‘weapons’ in our arsenal to manage and hopefully defeat Breast Cancer. The treatment modalities include surgery, reconstruction, chemotherapy, radiotherapy, and hormone therapy. The management plan may include all of these components or a select few depending on your individual requirements and the stage. In simple terms breast cancer stages can be divided into the following categories:
- Very early stage cancer – the cancer cells have not yet become invasive
- Early stage cancer – the cancerous cells or cancerous tumour involving an area of the breast smaller than 5 centimetres
- Locally advanced cancer – the cancerous cells or cancerous tumour involves an area bigger than 5cm, the skin of the breast is affected by cancer, there are many large glands affected by cancer in the armpit or axilla
- Metastatic or Stage 4 cancer – the cancerous cells have spread and formed tumours distant from the breast, most commonly affecting bones, lung, liver or brain
- To start planning the correct treatment the stage of the cancer will need to be established:
- Very Early Stage – Surgical Excision with or without a biopsy of the gland (sentinel node) in the axilla or armpit
- Early Stage – Neoadjuvant chemotherapy or Surgical Excision with a biopsy of the gland (sentinel node) in the axilla or armpit
- Locally advanced cancer – lump bigger than 5 cm, skin involvement, nipple involvement – Neoadjuvant chemotherapy to help downstage the cancer before surgery
- Stage 4 or Metastatic Breast Cancer – Palliative Chemotherapy
In this stage the cancer cells have not become invasive (usually referred to as Ductal Carcinoma In-Situ – DCIS) and are confined to a very small area of the breast, usually smaller than one centimetre. Patients are usually diagnosed with this form of Breast Cancer when it is found on imaging such as a mammogram or ultrasound done for screening purposes. If there are no other areas of the breast affected and if there are no other worrying factors, then you may only require an excision of this area with a smaller surrounding area of normal breast tissue. The procedure can be done under local or general anaesthesia and the tissue that is removed from the breast will be sent to the pathology laboratory for final testing.
If the final pathology assessment of the tissue is still favourable, then this is all you may need in terms of management. You may be referred to an oncologist to assess your further risk and you may need hormone therapy to reduce the risk of a recurrence, but you should not require chemotherapy or radiotherapy.
Please note that the final testing may reveal more extensive cancerous cells than previously noted or may show a wider area of tissue that is affected by cancer in which case you will need to move on to more extensive surgery and further treatment which could involve chemotherapy and radiotherapy.
The first step at this stage is usually surgery. The type of surgery will depend on the size of the lump and overall size of your breast and if there is any cancer involvement of the glands in the underarm or axilla.
Surgery may be a wide local excision of the lump or a mastectomy. If there are no glands, then the sentinel (First possible affected gland) node will be biopsied and if this is positive all the glands will be removed under the arm. This is referred to as a Sentinel Lymph Node Biopsy – SNLB. If there are glands affected by cancer at the outset, then all the glands will be removed.
You will also be counselled as to the reconstructive options that are feasible in your specific situation and the decision to do a prophylactic mastectomy on the non-affected side will be assessed based on your individual risk profile.
There are many surgical options, and your treating surgeon will discuss all of the viable options based on your individual case.
Following surgery the tissue removed is sent to the pathologist for microscopic examination and your further management will be dependent on these results. Further management may include radiotherapy – which is an essential component if you choose to have Breast Conserving Surgery or wide local excision, chemotherapy and hormone therapy.
Cancerous tumours that are larger than 5 cm, involvement of the overlying skin of the affected breast or if there are numerous affected glands in the underarm may require chemotherapy to shrink or reduce the Breast Cancer so as to make surgery possible or easier. The term we use for this is Neoadjuvant treatment.
Once completed and depending on the response of the Breast Cancer you will then be reassessed, and your surgical options will be discussed.
Sometimes patients with lumps smaller than 5cm will require Neoadjuvant treatment because they have very small breasts.
Oncology treatments are advancing at a rapid pace and surgery is reserved for patients who have very large cancers which are very painful or causing other local problems. The mainstay of treating patients in this category is trying to reduce the burden of cancer by using appropriate chemotherapy and hormone regimes.