TREATMENT

SURGERY OF THE BREAST

We recommend that all choices of therapy should be discussed between the patient and her doctor so that best treatment plans can be made. No surgery should be done before doing a biopsy, or trying to get a biopsy, to confirm the diagnosis of cancer then do the appropriate surgery. In Early stages of breast cancer, i.e. stages I and II, the surgical treatment is usually a partial mastectomy which includes complete removal of the tu- mor and surrounding normal tissue in one bloc, followed by radiation therapy. In some cases the patient may need a total mastectomy, with or without breast reconstruction. The type and timing of reconstruction, which may be immediate or delayed, varies according to the characteristics of the tumor, plans of treatment, and patient

SURGERY OF THE AXILLARY LYMPH NODES

When the tumor is small, and there is no evidence of lymph nodes in the axilla, we do not recommend removal of all lymph nodes. The patient should rather have an examination of the First Lymph Node which we call Sentinel Lymph Node (SLN) that may be involved by tumor. SLN is detected by using a Blue Dye technique or radioactive method or both, and sent to pathology. If it does not contain tumor, then there is no need to have all lymph nodes removed and the patient is spared the usual complications of lymph nodes’ removal and arm edema.

If SLNB shows tumor, then patients should have Axillary Lymph Node Dissection; however in a situation where only one or two lymph nodes are involved, and in cases of partial mastectomy,new surgical research shows that we do not need to remove all lymph nodes in all cases and that women who are postmenopausal, have low grade tumors, strong hormone receptors positivity, and those who get radiation therapy that includes the lower parts of the axilla, may not need axillary lymph node dissection. These new issues should be discussed in details between the women and her doctors and at the hospital Tumor Boards.

NEO-ADJUVANT CHEMOTHERAPY BEFORE SURGERY

The patient may need chemotherapy, with or without targeted anti-HER2 therapy, before surgery to reduce the size of a large tumor, make surgery easier, and even transform surgery from total mastectomy to partial mastectomy.

NEO-ADJUVANT HORMONAL THERAPY BEFORE SURGERY

If the patient has a tumor that is strongly positive for estrogen receptors, especially if she is older, we may use hormonal therapy to reduce the size of the tumor before surgery If the patient has a tumor that is strongly positive for estrogen receptors, especially if she is older, we may use hormonal therapy to reduce the size of the tumor before surgery. New research using hormonal therapy and CDKi are ongoing.

CHEMOTHERAPY BEFORE SURGERY(NEOADJUVANT CHEMOTHERAPY):

The patient may need chemotherapy before surgery if she has a large tumor and the doctors need to decrease the size of the tumor to transform surgery from Total Mastectomy to Partial Mastectomy, or to make surgery easier. If the patient has a tumor that has HER2-positive (HER2: +++, or HER2: ++ with FISH, D-ISH test positive), then we add targeted therapy pertuzumab plus trastuzumab to the chemotherapy regimen (Example AC-TH/P or TCH/P. If we achieve a complete pathological response then the patient survival outcome will also be better.

ADJUVANT CHEMOTHERAPY,TARGETED THERAPY,AND HORMONAL THERAPY AFTER SURGERY

After surgery, and according to the characteristics of the tumor and involvement of axillary lymph nodes, the patient may need adjuvant therapy such as AC-T, CMF, AC, TC, without or with anti-HER2 trastuzumab, or trastuzumab with pertuzumab together, to be followed by hormonal therapy for 5 or usually 10 years. Anti-HER2 therapy is usually given for 12 months, however recent study showed that six months may be enough in many lower risk patients. Small tumors with negative lymph nodes do well with only one type of chemotherapy (weekly paclitaxel x12 doses, with trastuzumab for one year. Young patients who need chemotherapy and require hormonal therapy are advised to receive monthly injections of LHRHa medications to suppress ovarian function in addition to tamoxifen or Aromatase Inhibitor.

Recent research has shown that if the patient has a tumor that has low grade and estrogen receptor strongly positive, the patient may not need chemotherapy and can be given preventive hormonal therapy alone. The doctor usually depends on the results of the pathology, experienced breast pathologist who reviews the tumor, and may need new genomic profile tests to omit chemotherapy or to use it. Such genomic profiling tests available include Oncotype Dx, Mammaprint, Prosigna, and EndoPredict. Recently, the American Joint Commission on Cancer AJCC added Oncotype Dx in its new classification, and if it is low score then there is no need to give chemotherapy and the patient is given only hormonal therapy. Using those special Genomic Profiling tests may help doctors omit adjuvant chemotherapy in 50% of the patients.

RADIATION THERAPY

Radiation therapy is given always if the patient has a Partial Mastectomy, If the patient has lymph nodes under the axilla that are positive, or if the tumor is more than 5 cm in size. Radiation therapy is usually given after chemotherapy is completed. New radiotherapy protocols are given over 3-4 weeks instead of the usual 6 weeks. The radiotherapist will decide if shorter hypo-fractionated radiation therapy is suitable for the patient.

TREATMENT OF METASTATIC BREAST CANCER

When the patient has a tumor that has positive hormone receptors, she is usually treated with anti-hormonal therapy, unless she has a rapidly progressive cancer, severe symptoms and signs of disease, or hormonal resistance, in which cases she requires chemotherapy.

Hormonal therapy could be tamoxifen, aromatase inhibitor (anastrozole or letrozole or exemestene), or fulvestrant. New advances show that CDK4/6 inhibitors (palbociclib, ribociclib, or abemaciclib) are recommended in addition to aromatase inhibitors in first line, or in addition to fulvestrant in second line. Fulvestrant alone can be used in new patients with disease spread to bone only. Everolimus is another new drug that is used with exemestene for hormone resistant cases.

Chemotherapy includes drugs that may cause hair loss but there are others that do not cause hair loss. Oral medications. There are injections or tablets. The Oncologist usually discusses options of treatment with the patient.

If the patient has HER2-positive disease, then she gets chemotherapy with anti-HER2 therapy trastuzumab and pertuzumab.

If the tumor is spread to the bone, then we add zoledronic acid or denosumab to combat it and strengthen the bones. Patients should have their teeth checked and fixed before starting those bone strengthening drugs.

TUMOR BOARDS

Every hospital and every doctor who treats cancer patients should have Tumor Board meetings. These are multi-disciplinary meetings where doctors from various specialties (Medical Oncologists, Surgeons, Radiologists, Pathologists, Reconstructive Surgeons, Nurses, others) meet and discuss the cases of patients and make better collective decisions for more up-to-date better care.

SUPPORTIVE CARE

Supportive Care should be given from day one of diagnosis and treatment. Nausea and vomiting are prevented. Infections can be prevented and treated. Many drugs take care of pain if it happens. Psychological and moral support is essential from doctors, nurses, volunteers, friends and family members.