TREATMENT

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 surgery.

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

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 doctor.

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.

TUMOR BOARDS

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.