Once a diagnosis of breast cancer has been confirmed in one of your patients, it is important to refer them to a Specialist Breast Surgeon or Multidisciplinary Team for discussion of further staging and management.
Early Stage Breast Cancer
If a breast cancer is localised and does not involve lymph nodes or skin, then it is classified an early breast cancer. There are important prognostic factors that are considered following a wide local excision and sentinel lymph node biopsy, which make up a pathologist’s synoptic report.
It features (i) type of tumour, (ii) size ,(iii) tumour grade, (iv) margin status, (v) hormone receptor status – ER, PR and HER2, (vi) lymphovascular space invasion status, (vii) associated ductal carcinoma in situ status and (viii) whether the sentinel lymph node is involved or not.
These factors, along with the patient’s age, medical co-morbidities and menopausal status help Medical Oncologists determine whether the use of adjuvant chemotherapy, monoclonal antibody therapy and/or hormone therapy is warranted.
Radiotherapy is a standard component of breast conservation management following lumpectomy for early stage breast cancer. It helps reduce the risk of recurrence by two-thirds and is, usually, very well tolerated.
Locally Advanced Breast Cancer
A locally advanced breast cancer (LABC) is defined as a primary tumour greater than 5cm in size, involvement of the chest wall and/or skin or an inflammatory breast cancer. This is also the case if ipsilateral axillary lymph nodes are involved and clinically fixed/matted or if any ipsilateral infraclavicular or supraclavicular nodes are involved.
Usually, surgery is not possible in the first instance in patients with LABC. Therefore, patients are treated with neo-adjuvant chemotherapy (or hormone therapy alone if hormone receptor positive, elderly and frail). If a good response is seen, the patient usually progresses to a mastectomy and post-mastectomy radiotherapy to the affected chest wall and ipsilateral, supraclavicular lymph nodes.
Radiotherapy for Breast Cancer
Radiotherapy treatment of breast cancer usually consists of external-beam radiotherapy following either a lumpectomy (or a mastectomy if deemed necessary). It is conducted daily (excluding weekends) over a course of 6 weeks to the affected breast or chest wall. Treatment usually takes about five minutes.
There have not been significant changes regarding radiotherapy treatment of breast cancer in recent times, other than the introduction of IMRT, which improves the delivery of radiation dose to the target. Current trials are looking into accelerated partial breast irradiation, but it is not standard treatment. The use of surgical clips to “outline” the surgical bed is helpful to Radiation Oncologists in delineating the radiotherapy “boost” volume and therefore improve accuracy and clinical outcomes.
The common side effects of radiotherapy to the breast/chest wall usually appear in the 2nd or 3rd week. They include mild fatigue, a brisk skin reaction (a little like sunburn), breast swelling and mild discomfort. Moisturising with products such as Sorbolene, Viatmin E cream or Bio-oil during treatment will help prevent a severe skin reaction.
There is the phenomenon of late side effects, which can include permanent discolouration of the skin and breast firmness. There are also much rarer side effects such as effects on the lung (less than 1 in 100 patients). IMRT helps to avoid normal healthy tissue such as lung and heart tissue and prevent those associated side effects.