Tumors in the breast are common in women who are of menopausal age. They may be benign or malignant. But when a woman feels a lump, it is advisable to see that as the first sign to see a gynecologist. Upon provisional examination, diagnosis, and taking the gynecological history of the woman if the gynecologist feels the need to further investigate based on the size of the lump and the duration of its presence as per the patient.
Further investigations warranted are mammograms, and CT scans to know the size of the tumor. If the tumor is generally small, less than 0.5 cm in size, it is generally benign. Then a Fine needle aspiration assay can be conducted to understand if there is any malignancy. A biopsy could be preferable to understand the nature of the tumor and malignancy (if it is localized DCIS or invasive Ductal carcinoma). The biopsy also helps in understanding if the tumor is hormone receptor-positive for estrogen 0or progesterone receptors. In case the tumor is small and is estrogen or progesterone receptor positive, then hormonal therapy with Tamoxifen, letrozole, or anastrozole is recommended to treat this benign tumor.
case the tumor is larger than 3-5 cm, then to understand its responsiveness and
decrease its size before surgery, neoadjuvant chemotherapy is recommended. In case it is Herceptin neu receptor-positive
breast cancer, then it could be treated with targeted chemotherapy such as
Trastuzumab (the monoclonal antibody). In case the tumor is in early stages and is around 2 cm in size, then to check if there are any metastases, diagnostic investigations such as a bone scan (that thoroughly investigates the presence of any metastases in the entire body) and Ultrasound of the abdomen. After all these investigations, irrespective of the presence or absence of metastases, surgery is the first step toward treating breast cancer.
Treatment – Surgery
Starting from stage 1 breast cancer (small tumor), surgery is recommended. Surgery could be the removal of entire breast tissue (Mastectomy) or could be partial breast-conserving surgery (BCS) that is aimed at the removal of only the tumor and not the breast tissue. However, in case the patient takes the choice of BCS, then post-surgery the patient has to mandatorily undergo radiation therapy. But in the case of mastectomy, such radiation therapy can be avoided unless the patient’s malignancy is reported with metastases.
Post-surgery the patient is observed for any complications for about a day or two. In most cases, since the surgery is uncomplicated the patient may be discharged within a day. Further to which the patient is advised to rest for 2-3 weeks, only after which the treatment protocol for chemotherapy is initiated. Chemotherapy generally is to be initiated within 8 weeks post-surgery.
Treatment – Adjuvant Chemotherapy
In case, the hormone receptor involvement was not measured during the initial biopsy investigation, before starting chemotherapy in case of mastectomy, the involvement of nodes and metastases was observed through SLNB (Sentinel Lymph node biopsy). In case there is the involvement of nodes, then radiation therapy is recommended. In case there is no nodal involvement, then there is ER, PR, HER neu receptor involvement and KI 67 value to assess the risk of recurrence.
ER & PR positive breast cancers involve hormonal therapies such as Tamoxifen or aromatase inhibitors such as Letrozole or Anastrozole. Her neu-positive breast cancers indicate involvement of Her neu receptor hence warrants a targeted therapy with Trastuzumab. The dangerous kinds of breast cancers are triple-negative breast cancers which are of high risk of recurrence. This is indicated by abnormal KI 67 values (> 20%). Breast cancers with KI 67 values <10% are of low risk. Once it is decided that a chemotherapy regimen is recommended then before starting the cycle, the patient is assessed for her body surface area (based on height and body weight before the cycle), assess blood counts at baseline through CBP (hemogram), assess kidney function through measuring serum creatinine levels and assess liver function through serum bilirubin. Once these investigations are done, then the patient is assessed for a 2D echo investigation to ensure her CV health is ok to start the chemotherapeutic regimen.
The triple-negative breast cancer (TNBC) or axillary node-positive breast cancers are treated with adjuvant intensive chemotherapy region initiated by anthracycline derivatives such as doxorubicin (gold standard first-line treatment) along with Cyclophosphamide. The dosages of doxorubicin (60mg/m2 of body surface area) and Cyclophosphamide (600mg/m2 of body surface area) given intravenously differ for individuals based on their body surface area calculated by height (constant) and body weight (variable) before starting each cycle.
For such high-risk node-negative breast cancers or axillary node-positive breast cancers, in which an intensive chemotherapy regimen is recommended, each cycle is separated by a 21-day chemotherapy-free period. This 21-day interval is to observe the effect of the chemotherapy regimen on its side effects. Some of the side effects involve heart-related complications, infections, nausea and vomiting, etc., but are not necessarily seen in all patients.
How many chemotherapy treatment cycles
For high-risk breast cancers such as TNBC, 4 cycles (21-day length) of doxorubicin-cyclophosphamide cycles are recommended followed by the weekly cycle of taxol compounds such as Paclitaxel injections for 12 cycles.
Diet recommendations post the chemotherapy
High protein foods such as protein beverages (4 scoops X 4 times a day), fresh fruits, dry fruits boiled in water to remove the outer coat, and boiled or cooked vegetables, are recommended diets for patients post-chemotherapy.
What happens after first chemotherapy – Handling side effects
Intensive regimens involving doxorubicin decreased blood cell count, especially leukocyte count, absolute neutrophil count, etc. that are responsible for the body’s natural defense. Hence adequate care is taken during chemotherapy for the hygiene of living conditions, and to minimize the patient’s exposure to the outside environment so as to prevent the possibility of any infections post-chemotherapy cycle.
To regain the body’s natural immunity, pegylated G-CSF (PEG-Filgrastim 6mg) is recommended as a subcutaneous injection at least 24 hours post-chemotherapy to recover white blood cells in the next 21 days before the next cycle. However, intermittently a week after the first chemotherapy cycle, a complete blood picture is taken and assessed for the boost of blood count. If not adequately boosted the patient is recommended for a Filgrastim 300mcg subcutaneous injection for two consecutive days and allow the patient to recover full immunity and WBC count.
Since the G-CSF injection boosts bone marrow the patient undergoes back pain which can be managed by a pain killer. To avoid any gastric distress due to pain killers, add a tablet of a combination of rabeprazole and domperidone. Nausea and vomiting is the common side effect that can be treated with ondansetron tablets. The patient undergoes sleep problems at times, hence recommended with anxiolytic-like alprazolam only to be taken based on the recommendation of the medical oncologist.
How successful is chemotherapy
Survival rates at 5, 10, and 15 years are generally predicted by the NHS predict tool by doctors, and generally, the survival rates depend on various factors such as nodal involvement, risk of breast cancer, tumor grade, kind of breast cancer such as ER+ve or PR+ve or Her neu-positive or triple negative. However the survival rates of a woman with breast cancer without nodal involvement and a high risk of breast cancer because of being triple negative grade can typically be as follows –
67% without chemotherapy, 71% with chemotherapy
57% survival without chemotherapy, 61% with chemotherapy
47% survival without chemotherapy, 51% with chemotherapy.
So, as per tools and doctors, the number of patients whose survival increases are 4-6% with chemotherapy. It might be a paradox that the doctors and patients only count on that 4-6% for their own reasons but don’t count on the remaining 50% or more patients who survive.
In effect, one side of the coin is the burden of chemotherapy is a hope to be in that 4-6% with a lot of side effects and suffering during the treatment, instead of counting amongst the survivors just giving an inkling that the entire chemotherapy is started based on the fact that the patient will not be in that survivor’s percentage.
The flip side is that given the possibility of side effects but not necessarily in all patients and the benefit of treatment, even a 4-6% increase in survivors is indeed a great achievement to the medical fraternity and also the patients who enjoy long disease-free survival post-chemotherapy.