TREATMENT OF BREAST CANCER

TREATMENT OF BREAST CANCER

Treatment of breast cancer include the following methods

 Control of local disease by
   
Surgery
  
In patients without systemic disease local surgery may be curative but most patients have occult micrometastases . a mobile tumour with or without axillary lymph nodes is generally operable . prospective trials indicate no difference in 5-10 year survival rate of patients undergoing mastectomy or breast conservation (lumpectomy , wide local excision , quadrantectomy) and radiotherapy , but the local recurrence rate in the latter group is slightly higher

. Mastectomy with axillary clearance results in 5 year recurrence rate of 4%and 8% in node- negative and node - positive patients respectively
It is not yet clear if there are difference in long term survival (10-25)years between radical surgery and conservation
Subcutaneous mastectomy is indicated for prophylactic mastectomy in women at high risk of breast cancer
palliative mastectomy with or without local adjuvant treatment may be necessary to control advanced local disease anxiety and depression accompany ,mastectomy in many women but breast conservation does not protect against this many women fearing the possibility of residual or recurrent disease

Management of the axilla 
 . 
Failure to treat the axilla does not confer a worse prognosis, node involvement being an expression of poor outcome rather than a determinant
Recently the technique of sentinel lymph node biopsy has gained popularity to avoid unnecessary axillary clearance in patients with node - negative disease at the procedure to remove the primary tumour the area is injected with a vital blue dye and a radicolloid (technetium 99 m sulphur colloid ) a small axillary incision is made and the first lymph  nodes to drain the tumour are identified by direct vision (stained blue) and a held gamma detector
 The nodes are excised and examined histologically , if this is clear of tumour no further axillary procedure is deemed necessary if the nodes are positive axillary clearance is undertaken    as a separate procedure 

The technique has high accuracy and low morbidity , in node positive patients level three axillary clearance (removal of all axillary nodes including apical nodes) has a long term local recurrence rate of under 2% arm swelling affects less than 5%of women providing the axilla is not irradiated . radical axillary irradiation effectively prevents node recurrence but brachial plexus neuropathy occurs in ..5-1%
 
 Radiotherapy 

. Radiotherapy is necessary after breast conserving surgery to reduce local recurrence rates overall survival is not improved but aggressive radiotherapy causes excess long term mortality from other tumours and ischaemic heart disease

Chest wall radiotherapy is unhelpful in patients undergoing modified radical mastectomy and axillary irradiation should not be performed if level three axillary clearance has been performed . chest wall and axillary radiotherapy are usually the treatment of choice in advanced inoperable tumours
 
 breast reconstruction 

Reconstruction probably does not interfere with the detection of tumour recurrence and restores appearance to near normal techniques include the placement of an implant with or without prior tissue expansion and  latissimus dorsi and rectus abdominis myocutaneous flaps which result in extensive scarring and possible complications as infection flap necrosis and  late capsule formation considerable asymmetery and nipple reconstruction is often unsatisfactory

 The reconstruction can be performed combined with the original mastectomy or as a secondary procedure at a later date
 
 Control of systemic disease

 Radiotherapy 

Provides excellent palliation of metastases particularly of bone
For more details see here

 Chemotherapy

 Reduce the 10-year probability of death by 10%in younger , premenopausal women with early breast cancer

cylcophosphamide methotrexate and fluoruracil (CMF) given for 6 months is a typical regimen
  
The benefit is independent of menopausal status oestrogrn receptor status or the use of tamoxifen  a short course of chemotherapy in a fit patient mat temporarily control advanced or inoperable disease
For more details see here
  
 Hormonal treatment

. Tamoxifen used for at least 2 years at a dose of 20 mg per day reduces the 10 year probability of death by 17% together with reduced local recurrence rates
For more details see here
 
This is benefit is most apparent in older women and seems independent of menopausal and oestrogen receptor status
For more details see here
Oophorectomy

 Ovarian irradiation LHRH agonists in women under 50 with early breast cancer ovarian ablation significantly improves long term survival it is useful in advanced metastatic disease to induce regression or delay spread 

If no response is obtained second line agents (aminoglutethamide . progestagens ) can be used 
4- pain relief and counselling oral apiates non steroidal agents , radiotherapy and steroids (for cerebral involvement) should be used liberally when the disease advances and symptoms develop drainage of effusion and ascitis may be beneficial

councelling and contact with o hospice are helpful in the late stages of disease

For cancer types symptomes and signs see here

For cancer risk factors see here
 

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