We recommend that all options for therapy be discussed between you and your doctor
so that the best treatment plan can be agreed upon. In the early ages of breast
cancer (stages I and II), the surgical treatment is usually a partial mastectomy,
which includes the complete removal of the tumor and surrounding normal tissue in
one bloc, followed by radiation therapy.
In some cases, you 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 you.
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. You 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 you can be spared the usual complications of
lymph nodes’ removal and arm edema. If SLNB shows tumor, then you should have Axillary
Lymph Node Dissection; however, even in this situation, 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
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 you and your doctors.
NEO-ADJUVANT CHEMOTHERAPY BEFORE SURGERY
You may need chemotherapy, with or without targeted anti-HER2 therapy, before surgery,
to reduce the size of the tumor, make surgery easier, and even transform surgery
from total mastectomy to partial mastectomy.
NEO-ADJUVANT HORMONAL THERAPY BEFORE SURGERY
If you have a tumor that is strongly positive for estrogen receptors, especially
if you are older, we may use hormonal therapy to reduce the size of the tumor before
ADJUVANT CHEMOTHERAPY, TARGETED THERAPY, AND HORMONAL THERAPY AFTER SURGERY
According to the stage of tumor and lymph nodes, tumor characteristics, and patient
status, you may need treatment by chemotherapy, targeted therapy, and/or hormonal
therapy after surgery to prevent the recurrence of cancer cells. Certain chemotherapy
drugs and trastuzumab can be given at the same time but hormonal therapy is usually
given after the completion of chemotherapy.
Radiation therapy is always given after partial mastectomy in order to achieve same
results as total mastectomy. Radiation therapy is always given after mastectomy,
if the tumor size is greater than 5cm or if you have more than 3 positive axillary
lymph nodes. However, there are studies that say that radiation should be given
to all patients with positive lymph nodes. You should discuss this issue with your
TREATMENT OF METASTATIC BREAST CANCER
If the disease has spread to other parts of the body, such as bones, liver, lungs
or others, then doctors may start with hormonal therapy, or chemotherapy with or
without modern targeted therapy. If you are still menstruating (pre-menopausal),
the disease has positive estrogen receptors, and the disease is slowly progressing,
involves only bone, lymph nodes and soft tissue, then doctors may treat you with
removing the ovaries or stopping them from working and add tamoxifen. Aromatase
inhibitors, such anastrozole, letrozole or exemestene can be used if you are post-menopausal.
If the tumor has positive HER2 receptors then doctors may use targeted therapy such
as trastuzumab and lapatinib. If the tumor does not contain estrogen or progesterone
receptors then the doctors use chemotherapy and/or targeted therapy. In the presence
of spread to the bones, or osteoporosis, the doctors also use bone-strengthening
agents such as zoledronic acid, pamidronate, or denosumab. If you have any pains
then you will need medication such as paracetamol, codeine, tramadol, morphine tablets,
or fentanyl patches. Pain may be treated with radiation therapy. With good treatment,
no patient should suffer from pain.
CLINICAL TRIALS AND RESEARCH
Advances in the diagnosis and treatment of breast cancer are achieved thanks to
research and clinical trials. Research and clinical studies have made finding a
cure a reality and are encouraged in Lebanon and all Arab countries, as well as
in major cancer centers worldwide.
A Tumor Board is a meeting between a group of physicians from all specialties that
treat patients with cancer. Cancer specialists, surgeons, radiologists, pathologists,
medical oncologists, radiation oncologists, reconstructive surgeons, psychologists,
and nurses meet and discuss their patients’ cases in order to reach an agreement
on the best treatment possible. Every hospital that treats cancer patients should
have a weekly Tumor Board meeting. If a hospital does not have all different specialists,
than a Mini-Tumor Board meeting with whoever is available should be held.