Namarak Hospital

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Breast Cancer Treatment Guidelines

When breast cancer has been diagnosed, treatment guidelines may vary depending on
the stage and type of the cancer. Breast cancer staging requires these three key factors:

· The extent of the tumor; measured from the largest mass.

· The spread to nearby lymph nodes

· The spread to distant organs.

Once all these factors have been determined, you will know the stages of the breast
cancer which is usually expressed as a number on a scale of 0-4. Treatments will be
administered based on the stages as follow:

Stage 0

Stage 0 breast cancer is a cancer that has not spread outside of the mammary glands
or from its origin site. The chances of it spreading to the lymph nodes are only 1-2%.
Thus, if proper treatment has been given at this stage, chances of being cured are more
than 98%. The main treatment for this stage of cancer are surgery and other treatments
which are as follow.

1. Breast surgery

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 There are two main types of surgery to remove breast cancer, which are Mastectomy,
the removal of the entire breast and Breast-conserving surgery (BCS). If you had BCS,
radiation is required on the breast where the cancer was removed to help prevent it from
coming back in that area and give an effectiveness as close as the removal of the entire
breast. For those who consider having a mastectomy may also have the option for breast
reconstruction at the same time to restore the breast’s appearance after surgery.

2. Axillary lymph node dissection (ALND)

Since the stage 0 of breast cancer is very early, the chances of it spreading to nearby
lymph nodes under the arm is only 1-2%, therefore extensive ALND is still not necessary.
During the breast cancer surgery, the surgeon finds and removes the first lymph node(s)
to which a tumor is likely to spread to avoid lymphedema, or the swelling of the arm.

3. Hormonal Therapy

Hormone therapy prevents and reduce the risk of cancer spreading to the opposite
breast. Research has shown that Tamoxifen and Anastrozole can reduce the risk of
breast cancer in women at high risk by up to 40%.

Early Stage Breast Cancer (Stage 1 and 2)

In early stage of breast cancer (stage 1 and 2), these breast cancers are still relatively
small, usually not larger than 5 cm and either have not spread to the lymph nodes or have
only a tiny area of cancer spread in the sentinel lymph node of not more than 3 glands.
Most importantly, it has not spread to other organs. Surgery is a key component in
treating breast cancer at this stage while other forms of treatments are secondary.

The doctor will use data derived from stages and variations of cancer to construct an
optimum treatment plan. Further diagnostics and classification include
immunohistochemistry staining, a special dyeing technique to the tissue sample to
identify Estrogen Receptors (ER), Progesterone Receptors (PgR), HER2 gene and Ki-67,
to measure the cancer cell division rate. These data will further be grouped again to
determine the variation of the cancer which could be Luminal A, Luminal B, HER2, or
Basal like (Triple Negative).

Treatment Guidelines to Early stage Breast Cancer

1. Surgery for breast cancer

Surgery for breast cancer is divided into two parts: breast surgery and sentinel lymph
node biopsy (SLNB) or axillary lymph node dissection. There are several ways to perform
a breast surgery, such as Breast-conserving surgery (BCS), total Mastectomy, Nipple-
sparing mastectomy with reconstructive breast surgery etc. As for SLNB, during the
breast cancer surgery, the surgeon finds and removes the first lymph node(s) to which a
tumor is likely to spread as necessary to avoid lymphedema, or the swelling of the arm.

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Due to its early stage, the likelihood of the cancer spreading to the lymph nodes is
approximately less than 20%. In lymphatic mapping, a surgeon injects a radioactive
substance called Iso sulfan blue, then make a small incision to trace the first lymph node
that are stained with the blue dye with the naked eye. Some institutions may also use
diagnostic radiopharmaceuticals to provide a more accurate detection. This technique
requires radioactive injections and tools to detect the lymph node(s) with radiation. At
present, there is a new technology that administers the Indocynine green radioactive
substance and uses a Near field Infrared Fluorescence imaging to detect the lymphatic
and lymph nodes, upon incision. This gives a high-accuracy detection and avoid wide
incisions.

2. Chemotherapy

Chemotherapy is an adjuvant therapy which is indicated to patients in the event of

detecting the spread of cancer to the lymph node after surgery, and or in cases with no
detection to the lymph node but the tumor is greater than 1 cm. Breast cancer groups
such as Luminal B, HER2 and Basal-like (Triple negative), which can be known from the
special dyeing technique of Estrogen Receptors (ER), Progesterone Receptors (PgR),
HER2 gene and Ki-67, are likely to benefit from chemotherapy and prevent the
recurrence of cancer rather than depending on the surgery alone. The optimal time for
chemotherapy is 4-8 weeks after surgery. The chemotherapy regimen varies, usually 4, 6,
or 8 times and is administered every 3 weeks.

3. Radiotherapy

Adjuvant radiotherapy is administered to those patients who have undergone breast-

conserving surgery and postmastectomy patients with tumor greater than 5 cm, or the
cancer has spread to the lymph nodes, or margin close to normal tissue such as the
muscle behind the breast. Radio therapy should be administered six months after surgery
with the session lasting for 4-6 weeks.

In addition to the external beam radiation, today, in modern technology, intrabeam or

the intraoperative radiotherapy takes about 30 minutes. This single definitive treatment is
suitable for patients who undergone breast-conserving surgery with tumor less than 3 cm,
have Estrogen Receptors (ER), and an age of 45 years and older. This revolutionary form
of radiotherapy has given another option offering more room of convenience to patient.

4. Targeted therapy

Targeted therapy are treatments that target specific characteristics of cancer cells, for
instance, a HER2 cancer type should be treated with HER2 targeted therapy, injected
every three weeks for a year. In current treatment standards, Trastuzumab will be use in
inhibiting at a single location, suitable for cases where no cancer has spread to the lymph
nodes. In high-risk cases, where cancer has already spread to the lymph nodes, double
targeting with two agent inhibitors such as Trastuzumab in combination with Pertuzumab,
will be provided to maximize the effectiveness of the treatment.

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5. Hormonal therapy

Hormone therapy is recommended to tumors that are hormone receptor-positive.

Drugs like Tamoxifen should be considered as an adjuvant hormone treatment for cancer
with Estrogen Receptors (ER), and Progesterone Receptors (PgR), which is applicable to
both premenopausal and postmenopausal women. Aromatase inhibitors such as
Letrozole, Anastrozole, and Exemestane are also available for postmenopausal women
where these drugs inhibit the production of estrogen, such as stopping ovarian function in
menstruation. The most commonly used hormone therapy such as Tamoxifen and
Aromatase inhibitors should be taken one tablet every day for 5 years and an extended
day up to 10 years for high-risk patient such as those whose cancer has spread to the
lymph node.

Locally Advanced Breast Cancer (Stage 3)

In this stage of breast cancer, treatment is similar to the early stage breast cancer,
however, surgery may not be the primary or the initial option of treatment as these tumors
are larger or attached to nearby vital organs, such as a larger lymph node attaching to
nerves and blood vessels. Surgery may not remove all cancers or may cause injury to
nearby organs. Thus, most often, these cancers are treated with neoadjuvant
chemotherapy (chemo before surgery) prior to surgery to shrink the tumor and making it
easier to remove later in the surgery. Whereas other treatment such as radio therapy,
targeted therapy and hormonal therapy follows similar indications with the early stage
breast cancer.

Metastatic Breast Cancer (Stage 4)

The general aim of stage 4 cancer treatment is to alleviate symptoms with palliative
care, stabilizing the metastatic disease, and prolong the patient’s life as much as
possible. The main treatments for stage 4 breast cancer would be systemic therapies, or
the use of drugs which may include chemotherapy, HER2 targeted therapy, or hormonal
therapy. Each case will be treated differently based on the characteristics and types of
cancer, metastasized organ, and patient’s physical and mental health condition. Currently,
there are several new groups of drugs available; targeted therapy drugs such as CDK4/6
inhibitors, MTOR inhibitors, PI3K inhibitors or immunotherapy etc. Surgery and
radiotherapy are not necessary in these group of patients unless under specific
circumstances such as patient having a ruptured wound or have had initial aching pain.
Besides cancer treatment, these cases also need to treat complications caused from
breast cancer metastasizing to nearly any organ of the body. For example, if cancer has
spread to the bone, symptoms may include aching in the bone, fractures, or even high
calcium content in the blood.

By Assoc. Prof. Dr. Youwanush Kongdan

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Remark:: There's no guarantee for fixed result and outcome was uncertainty depend on
individual

Video

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