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Breast cancer treatment by stage: resources

Breast Cancer Treatment by Stage

Treatment of Non-invasive (Stage 0, carcinoma in situ) breast cancer

Stage 0 breast cancer is known as carcinoma in situ. This type of breast cancer is confined to the limiting membranes and has not infiltrated in to the surrounding tissues. There are two types of carcinoma in situ ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS).......
Click on the above link to read more the treatment of stage 0 breast cancer


Stage I Breast cancer:

Stage I breast cancer is usually treated with lumpectomy followed by radiation therapy. Some patients may elect to have mastectomy, or sometimes the nature of the tumor may require a mastectomy. The surgery usually also involve exploration and removal of lymph nodes from the armpit area. In stage I breast cancer, radiation therapy is done only if the surgery was lumpectomy or the edge of the surgical resection was involved with cancer. Breast reconstruction can be done during the initial surgery or may be delayed until a later date. Sentinel lymph node biopsy is an option if your surgeon has expertise in this procedure. In stage I breast cancer the decision to initiate adjuvant chemotherapy is mainly made based on the size of the tumor. If the tumor is less than 1 cm (just less than half an inch), the relative benefits from chemotherapy may not match the potential side effects and chemotherapy is generally not recommended. Adjuvant chemotherapy is usually give if the tumor size is larger than 1 cm. Sentinel lymph node biopsy may. be used instead of standard axillary lymph node dissection. Some physicians may advise adjuvant therapy even if a cancer smaller than 1 cm based on some other unfavorable features. Hormonal therapy is recommended in almost all patients with stage I breast cancer if the tumor is hormone receptor positive. If chemotherapy and or radiation therapy is given, the hormonal therapy may be delayed until completion of chemotherapy and radiation therapy.


Stage II Breast cancer:

Like stage I breast cancer, stage II breast cancer in often treated with lumpectomy and radiation, and in some cases mastectomy may be a better surgical option or patients choice. Unlike stage I breast cancer, in stage II breast cancer, if the tumor size is more than 2 inches (5 cms) in size, or if cancer has spread to more than three lymph nodes, patient will benefit from radiation therapy even if the surgical choice was mastectomy. Adjuvant chemotherapy is recommended to all patients unless there is something that suggests that patient may not tolerate chemotherapy. If the tumor is found to be hormone receptor positive, adjuvant Hormonal therapy is almost always recommended. If the patient has a larger tumor, a good option would be to receive chemotherapy prior to surgery (called neoadjuvant chemotherapy). Sometimes the size of the tumor relative to women's breast size may make lumpectomy difficult or impossible. In these situations neoadjuvant chemotherapy is given with the idea of decreasing the tumor size so that a better surgery can be performed. Depending on the response to neoadjuvant chemotherapy, the surgeon may opt to do a lumpectomy or mastectomy. The patient may get further chemotherapy and radiation therapy after the surgery depending upon the type of surgery and the number of nodes involved as mentioned above. Hormonal therapy is advised to almost all the patients who has hormone receptor positive tumor.


Adjuvant Therapy for breast cancer

Adjuvant chemotherapy is offered to patients with stage I, II and III breast cancer after surgical removal of the tumor. In stage I breast cancer the decision to give chemotherapy is based on the tumor size, hormone receptor status, and menopausal status of the patient. In stage I breast cancer, if the tumor size is less than 1 cm (about half an inch) chemotherapy is not generally recommended, however your physician may sometimes recommend adjuvant chemotherapy even if the tumor was less than 1 cm based on some other poor outcome factors. Women with hormone receptor positive tumor are mostly recommended to take adjuvant Hormonal therapy. This adjuvant hormonal therapy is not effective in patients who have hormone receptor negative tumors. Pre-menopausal women are usually given tamoxifen for 5 years. Tamoxifen is appropriate for post-menopausal women as well. There is another hormonal drug option available for postmenopausal women. This is a drug from the class of aromatase inhibitors and is called anastrozole (Arimidex) and has been shown to be superior to tamoxifen in the breast cancer treatment. Some of the side effects of tamoxifen like the risk of uterus cancer and blood clots are much less with the use of anastrozole. The risk of osteoporosis and fracture are however higher with anastrozole compared to tamoxifen. Removal of all the post-menopausal estrogen may be responsible for the increased risk of osteoporosis and fracture. The experience with tamoxifen however spans to the last twenty years, whereas our experience with anastrozole is limited to the last few years. These are some of the factors we should consider before choosing between tamoxifen and anastrozole as the choice of adjuvant therapy. One new study has suggested that, at the end of five years of tamoxifen if another hormonal agent namely letrozole is given for another 5 years, that would further decrease the risk of breast cancer from coming back. Also one new study has suggested that if at the end of 2 to 3 years, if tamoxifen is switched to another hormonal agent namely exemestane, patient may get more benefit, Like anastrazole and letrozole, this drug is also a member of the aromatase inhibitors group. Other options include surgical removal of the ovaries or chemical suppression of ovarian hormone production. Most commonly used adjuvant chemotherapy regimens include n a combination of cyclophosphamide with doxorubicin or epirubicin with or without fluorouracil. See Hormonal therapy for breast cancer for more details on this topic.


Small size stage IIIA breast cancer:

In stage III breast cancer, if the tumor size is small the surgical treatment option may be lumpectomy followed by radiation similar to stage II breast cancer. Modified radical mastectomy is another option. A breast reconstruction surgery may be done at the time of surgery or may be delayed for several weeks. Surgery is usually followed by chemotherapy. Hormonal therapy is recommended if the tumor is hormone receptor positive. Radiation therapy is offered after lumpectomy, however if the choice of surgery was modified radical mastectomy, radiation therapy is not generally recommended unless there are some other bad features like more than 3 positive lymph nodes involved with cancer, or a close margin on the mastectomy specimen.


Larger stage IIIA, IIIB and IIIC

Large size IIIA breast cancer as well as stage IIIB and IIIC cancers may be treated with neoadjuvant chemotherapy with an idea to decrease the size of the tumor prior to surgery. After completion of neoadjuvant chemotherapy, a modified radical mastectomy is usually undertaken. As in the case of earlier stages of breast cancer, reconstruction surgery may be done during breast cancer surgery or several weeks after completion of surgery. In few patients, who had marked reduction in the tumor size, a lumpectomy may be an option. Your physician will usually ask you to come back for more chemotherapy after surgical wounds are healed. Most patients will get radiation therapy, after completion of chemotherapy even if the surgical procedure was lumpectomy. Hormonal drugs are invariable given if the tumor is hormone receptor positive unless the patient has some specific problem that would prevent its use.


Stage IV breast cancer

Local therapies like surgery and radiation therapy are not options for stage IV breast cancer patients unless there is a specific problem or symptoms that would require these local treatment modalities. Systemic treatment with chemotherapy drugs or hormonal drugs are the primary treatment for stage IV breast cancer. If the tumor expresses high level of Her2/neu protein then the option of immunotherapy using trastuzumab (Herceptin) alone or in combination with chemotherapy would be available. Herceptin generally is not given as an initial treatment for these women, but is initiated once standard hormone therapy and or chemotherapy is no longer effective. Patients who have metastatic disease to the bone may also be started on a bisphosphonate like pamidronate (Aredia ) or zolendronic acid (Zometa) to stengthen the bones. See the section on bisphosphonate for more details.


Breast cancer treatment

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