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Breast Cancer-9


Welcome to part 9 of educational series on breast cancer. In seventh and eighth part, we learned about evaluation of breast cancer, essential for proper staging and for making critical treatment decisions.

Question: Thank you Dr. Shah for a detailed guidance on pre treatment evaluation. It was interesting to know about role of FNA vs Trucut biopsy. How do you decide treatment?

Answer: Treatment decisions are of course fairly complicated. But I can give some general guidelines. As you may recall, in seventh part, we divided patients in 3 categories – early (stage 1,2), locally advanced (stage 3), and metastatic (stage 4).

For Early Stage i.e. stage 1 and 2 patients, traditionally surgery has been the initial treatment. There is a wide variation in these patients, however, with regard to tumor size, lymph node status, breast size and other parameters that go in to deciding treatment.

Que: Can you tell us what is the commonest way of dealing with this stage?

Ans:.Surgery is the commonest initial treatment. Most patients in India undergo MRM i.e. modified radical mastectomy. Whole affected breast is removed along with nipple-areola complex. Axillary dissection is routinely performed with MRM, to remove regional nodes in axilla. Later also allows accurate staging of locoregional spread of disease, which is an important aspect of deciding further treatment.

Those patients with truly early disease i.e. small tumor (<2 cm), no lymph nodes involved and no poor prognostic features do not require any further treatment. All others require some treatment after surgery, as their prognosis is not good with only surgery. For example, as a rough guide, chance of relapse after surgery is about 1% per 1 mm increase in size of tumor i.e. if tumor is 25 mm, there is 25% chance of recurrence after surgery. If tumor is 50 mm, there is 50% chance of recurrence. If lymph nodes are positive, there is an additional risk. This is a very high risk, and obviously additional treatment is required. Surgery alone is not enough. However, it is important to understand that a good surgery provides very important initial risk reduction. Complete tumor clearance with good margins, removal of at least 6 (preferably more) axillary nodes, removal of all residual breast tissue (especially in case of large tumor size) are critical.

Que: Are there any advances in surgery? Is something less radical possible?

Ans: Yes, there is something known as lumpectomy or “breast conserving surgery”, where only the tumor is removed with sufficient margins. Whole breast is not removed. In fact, about 50% of surgeries in USA are now BCS. Awareness and trained surgeons for this option are limited in India. Radiotherapy to remaining breast tissue after lumpectomy is must.

Preoperative chemotherapy is routinely used to make patients suitable for lumpectomy, but only if they fulfill certain criteria.

Sentinel lymph node biopsy is a technique which reduces amount of axillary dissection, in patients with very small tumors and clinically normal axillary nodes. Very few centers routinely offer this option. Its impact on clinically meaningful parameters is anyways questionable.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001