Understanding Newer Breast Cancer Treatment Strategies

A decade ago, cervical cancer was the most prevalent cancer in women in India, followed by breast cancer. Currently, breast cancer accounts for 28% of the cancers in women in India, followed by cervical cancer. Breast Cancer was also found to be the 2nd most common cause of death in women in 2021. Newer, less-invasive techniques are being developed that do not involve the complete breast removal and prevent recurrence as medical professionals continue to uncover the roots of breast cancer. 

MedPiper Technologies and JournoMed along with MGM Healthcare and IMA Chennai Villivakkam and Ayanavaram Branch had conducted a webinar on 12th February, 2022 titled “Modern Trends and Management in Breast Cancer” where expert speaker, Dr. Alex A. Prasad spoke about the newer techniques in managing breast cancer cases. Dr. Alex A Prasad is the Senior Consultant of Radiation Oncology and Chairman of the Chennai Cancer Care Hospital. He is also the Founder of Cancer Care Foundation in Chennai.

A full body metastatic workup via a whole body PET-CT Scan will determine the spread and staging of the cancer. An isotope bone scan can also be done to determine osseous or bone metastasis. However, Dr. Prasad states that the best tool for screening breast cancer is the mammogram. Any woman with a family history of breast cancer should start screening at 36 years and any woman above 40 can get annual mammograms done. 

Staging of Breast Cancer:

Managing breast cancer depends on the stage of progression. Dr. Prasad refers to the Manchester staging system which classifies the breast cancer progression into the following stages: 

1. Stage 1: The growth is confined to the breast with the tumour being less than 2cm in size with or without clusters in the 1-3 lymph nodes near the axilla or breastbone region. 
2. Stage 2: The growth is confined to the breast with the tumour being 2-5cm or slightly larger in size with or without clusters in 1-3 lymph nodes near the breastbone or axillary region. 
3. Stage 3: The tumour is more than 5 cm in size with or without cancer clusters circulating in 3-9 lymph nodes in the axillary or breastbone region. This stage can also present as inflammatory breast cancer with lesions and circulating tumour clusters in the lymph nodes near the collarbone region. 
4. Stage 4: The cancer has metastasized to all parts of the body i.e to the opposite breast, bones, the brain, the lung and/or the liver. 

Receptors like the Oestrogen Receptor (ER), the progesterone receptor (PR) and the human epidermal growth factor receptor (Her2neu) are often used for prognosis. If there is the presence of all three receptors, it is a triple positive breast cancer. If there is the absence of all three receptors, it is a triple negative breast cancer. 

Therapies to treat breast cancer

Breast Cancer is a systemic disease and needs to be treated with a multimodal approach of chemotherapy, surgery and radiation therapy. 

Chemotherapy

Chemotherapy is commonly used in treating stage 3 tumours, marginally resectable tumours and inflammatory breast cancer. Stage 3 and Stage 4 breast cancer treatment involve a more aggressive multimodal approach where the primary focus is placed on chemotherapy, specifically Neoadjuvant Chemotherapy. AC (Adriamycin-cyclophosphamide) regimen and the Palcli-Adri (Paclitaxel-Adriamycin) regimen are some of the commonly used Neoadjuvant Chemotherapies which help optimise surgical outcomes. 

Radiation therapy

Radiation therapy is done after a lumpectomy or a breast conservation surgery to prevent recurrence. Many radiologists opt for Brachytherapy after a lumpectomy, instead of going for radical mastectomy. In brachytherapy, an interstitial catheter is placed in the tumour area through which radiation is supplied. The catheter placement requires 3-D planning. Brachytherapy ensures isodose distribution and confines the radiation to the lumpectomy site and not to the surrounding healthy or vulnerable tissues. 

Mammosite brachytherapy is another kind of brachytherapy that is less invasive and ensures quick cosmesis. One end of the mammosite catheter is balloon-shaped and is placed inside the patient. This is blown up to fill the lumpectomy site and supplies the radiation. The other end is placed outside and is connected to a machine through which a high dose of radiation is passed through. The radiologists and technicians’ exposure to the radiation is reduced as they will standardise the radiation doses via the machine. A SAVI applicator is also used for delivering the radiation to the lumpectomy site. 

For stage 2 tumours, radical modified mastectomy is the preferred route. However, if the specialist opts for conservative breast surgeries, they have to consider the age of the patient and the breast morphology and how radiation can affect these factors. Intensity Modulated Radiation Therapy (IMRT) is where the radiation beam is segmented and manipulated only to treat the target area. RapidArc Technique or VMAT (Volumated Modulated Arc Therapy) is also used for the homogenous distribution of radiation across the target area. 

Hypofractionated Radiation Therapy is another form of therapy where the cancer is treated with fewer numbers of higher dose radiations (20 fractions over 4 weeks) where normal treatment involves 25-30 fractions over 5-6 weeks. 

Breast conversation is the most preferred form of treatment when it comes to treating breast cancer cases as it offers equivalent tumour control and survival over mastectomy. Along with radiation therapy, these techniques offer higher recovery rates, lesser damage to the surrounding tissues and enable faster cosmesis.

Author: Parvathi Nair