MD Anderson’s Nellie B. Connally Breast Center provides patients with truly multidisciplinary care. That means your medical oncologist, radiation oncologist, surgical oncologist, and reconstructive surgeon work together as a team to achieve the best possible outcome. They coordinate care and develop a comprehensive treatment plan that’s unique to each patient’s disease and needs.
Many patients undergo some form of surgery as part of their breast cancer treatment.
Some will receive chemotherapy or targeted therapy before surgery. The goal of these treatments is to shrink the tumor and affected lymph nodes to make the procedure and recovery easier on the patient. This also allows the treating team to assess how cancer has responded to treatment, which can be important for some breast cancer subtypes.
There are two categories of breast cancer surgery:
- Lumpectomy: In a typical lumpectomy surgery, the tumor and a small amount of surrounding normal tissue are removed. This procedure may be appropriate for early breast cancer cases where the tumor is still small. Lumpectomies are generally outpatient procedures and have shorter recovery times. These procedures are usually followed by radiation therapy.
- Mastectomy: In a typical mastectomy surgery, the tumor and the entire breast are removed. There are several different types of mastectomies, including procedures that spare the breast’s skin and nipple/areola. Often a mastectomy and breast reconstruction can be performed in the same procedure.
In some cases, both breasts are removed (double mastectomy). This can help prevent the development of new breast cancer. It is typically done for patients who have an elevated risk of developing breast cancer due to family history or their own genetic profile, such as a BRCA mutation.
In both lumpectomies and mastectomies, surgeons may also remove nearby lymph nodes. Breast cancer can spread through nearby lymph nodes. Doctors will study the ones that are removed to determine if there are cancer cells within the nodes. This information can help determine the risk of the disease spreading to distant organs, as well as the need for chemotherapy and radiation therapy.
Like all surgeries, breast cancer surgery is most successful when performed by a specialist with a great deal of experience in a particular procedure. MD Anderson’s breast cancer surgeons are among the most skilled and renowned in the world. They perform a large number of surgeries for breast cancer each year, using the least-invasive and most-effective techniques. At the start of treatment, care teams assess if the patient needs reconstructive surgery. If so, our breast cancer surgeons and reconstructive surgeons work together to plan procedures that minimize incision and possible scarring. Their goal is to achieve the most effective surgery and the best possible cosmetic outcome and symmetry.
Radiation therapy uses powerful beams of energy carefully designed to kill breast cancer cells.
For breast cancer patients, radiation therapy can be used before surgery to shrink large tumors and make the surgery easier on the patient. Radiation therapy can also be used after surgery to kill any remaining breast cancer cells that can’t be seen by the naked eye. After a lumpectomy, patients often receive three to four weeks of daily radiation therapy. In some cases, one to two weeks may be appropriate. When the lymph nodes are involved or a mastectomy was needed, patients usually need six weeks of daily radiation therapy.
In metastatic breast cancer cases, radiation therapy can also be used as a palliative treatment to reduce symptoms caused by cancer spreading to other parts of the body and improve the patient’s quality of life.
There are different techniques used in radiation therapy. Your doctors and radiation oncologist will collaborate to make sure you receive the most effective and precise dose of treatment. Radiation therapy treatments for breast cancer patients include:
- 3D conformal radiation therapy: This technique uses radiation beams that are shaped to the tumor’s dimension.
- Intensity-modulated radiation therapy: IMRT uses multiple beams of radiation with different intensities to deliver a precise, high dose of radiation to the tumor.
- Volumetric arc therapy: In this special type of IMRT, in VMAT therapy, the section of the machine that shoots out the beam of radiation rotates around the patient in an arc. This can irradiate the tumor more precisely and shorten procedure times.
- Accelerated partial breast irradiation: A form of brachytherapy, APBI uses radioactive pellets or seeds to kill cancer cells that may remain after a lumpectomy.
- Stereotactic body radiation therapy: Sterotactic body radiation therapy administers very high doses of radiation, using several beams of various intensities aimed at different angles to precisely target the tumor.
- Stereotactic radiosurgery: Stereotactic radiosurgery is most commonly used to treat breast cancer that has spread to the brain. Stereotactic radiosurgery uses dozens of tiny radiation beams to target tumors with a precise, high dose of radiation.
At most hospitals, the radiation oncologist developing these treatments works on several different types of cancer. At MD Anderson's Breast Center, radiation oncologists are dedicated exclusively to caring for patients with breast cancer. This gives them the incredibly deep experience to draw from when designing treatment plans. Each breast cancer radiation treatment plan is also reviewed by every breast radiation oncology faculty member, ensuring that patients receive the best possible treatment.
Our physicians are recognized as world leaders in their field. MD Anderson radiation oncologists have developed radiation therapy treatments shown to deliver the most effective radiation courses in the shortest amount of time and with the fewest side effects.
Proton therapy is similar to the radiation therapies described above, but it uses a different type of energy and is much more accurate at targeting tumors. It delivers high radiation doses directly into the tumor, sparing nearby healthy tissue and vital organs. For many patients, this results in better cancer control with fewer side effects.
Cancer cells rely on specific molecules (often in the form of proteins) to survive, multiply and spread. Targeted therapies stop or slow the growth of cancer by interfering with, or targeting, these molecules or the genes that produce them.
In recent years, targeted therapy has become a major weapon in the fight against breast cancer. Breast cancer subtypes that once had poor prognoses are now highly treatable.
One type of targeted therapy is endocrine therapy (also known as hormone therapy), which is given to patients with hormone receptor-positive breast cancer. This can be given before surgery to shrink the tumor. It is also given after surgery for five to 10 years to prevent a recurrence. Patients with the metastatic form of this disease are also given endocrine therapy to prevent disease progression.
Patients with HER2-positive breast cancer also receive targeted therapies. These patients may receive a different set of targeted therapy drugs both before and after surgery. Since about half of patients with HER2-positive breast cancer also have hormone receptor-positive tumors, they are also given endocrine therapy.
While there are no targeted therapies for triple-negative breast cancer, researchers are studying the disease to identify possible drug targets.
Chemotherapy uses powerful drugs to directly kill cancer cells, control their growth or relieve pain. It is often given to patients before surgery to shrink the tumor and simplify the procedure. Breast cancer patients can receive chemotherapy either orally or intravenously.
Angiogenesis is the process of creating new blood vessels. Vascular endothelial growth factor (VEGF) is one of the main molecules that control the process. Some cancerous tumors are very efficient at using these molecules to create new blood vessels, which increases blood supply to the tumor and allows it to grow rapidly.
Researchers developed drugs called angiogenesis inhibitors, or anti-angiogenic therapy, to disrupt the growth process. These drugs search out and bind themselves to VEGF molecules, These drugs search out and bind themselves to VEGF molecules or receptor proteins, prohibiting them from activating angiogenesis.
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Can immunotherapy treat breast cancer? For certain patients, the answer is yes.
Two immunotherapy drugs — atezolizumab and pembrolizumab — are approved by the Food and Drug Administration (FDA) for patients with metastatic triple-negative breast cancer. Both of these are immune checkpoint inhibitors, the most common type of immunotherapy.
To understand how these drugs work, which breast cancer patients are benefiting and what’s ahead with research, we spoke with Clinton Yam, M.D.
How does immunotherapy work to treat triple-negative breast cancer?
Immunotherapy treats cancers by waking the immune system’s natural ability to defend the body from infection and disease, including cancer. T cells are a type of immune cell that help lead the immune system’s response to an illness.
PD-L1 is a protein that can be found on the surface of cancer cells and/or immune cells. It binds with a partner protein called PD-1 that’s on the surface of a T cell. But this bond turns off the T cell and allows the cancer cell to hide from the T cell. Immune checkpoint inhibitors take off this brake, which increases the likelihood that the T cells will attack and destroy the cancer cells.
Is immunotherapy an option for all patients with triple-negative
Unfortunately, no. Because atezolizumab and pembrolizumab interfere with the bond between PD-1 and PD-L1, immune checkpoint inhibitors are currently only used to treat patients with triple-negative breast cancer where the PD-L1 protein is found on the cancer and/or immune cells within the tumor. We determine if a patient has a high expression of PD-L1 through an immunohistochemistry test. This is performed on tissue that’s removed during biopsy. If the PD-L1 protein is not found on the cancer cells and/or immune cells within the tumor, PD-L1 immune checkpoint inhibitors won’t be effective.
Secondly, these drugs are currently only approved for use in patients with advanced disease. The cancer must have returned after initial treatment and not eligible for surgery, or it must have spread to other parts of the body. This is known as metastatic disease.
Lastly, immunotherapy may worsen symptoms of autoimmune disorders like lupus and rheumatoid arthritis, so these drugs aren’t typically used in women with these chronic illnesses.
What are the side effects of immunotherapy in patients with breast cancer?
Immunotherapy side effects are the same, regardless of the type of cancer being treated.
Immunotherapy increases the ability of the immune system to attack cancer cells, but it also increases the chances that the immune system will affect normal cells. This can cause inflammation throughout the body, which can lead to side effects, such as skin changes, cough, chest pain and diarrhea. In some cases, these side effects can be debilitating, depending on the organ(s) involved.
For example, if the thyroid gland is affected, the patient may develop a condition called hypothyroidism (low thyroid hormone) and may need thyroid hormone replacement in the future. In rare but extreme cases, liver or kidney failure can develop.
When treating breast cancer, is immunotherapy used alone or in combination with other therapies?
Right now, immune checkpoint inhibitors are used in combination with chemotherapy to treat metastatic triple-negative breast cancer.
However, there are ongoing clinical trials studying other combinations. For example, researchers are trying to find out if immunotherapy is more effective when combined with targeted therapies, such as PARP inhibitors. One challenge with treating breast cancer with immunotherapy is that immune cells have a harder time infiltrating the tumors. By combing immune checkpoint inhibitors with targeted therapies, we hope to help the immune cells better enter the tumor and, therefore, make these drugs an effective treatment option for more patients.
There is also hope that we may be able to use therapeutic vaccines to train the immune system to fight cancer.
Lastly, we know that radiation therapy helps jump-start the immune system. Through clinical trials, researchers are exploring how we might optimize immunotherapy by combining it with radiation therapy.
What are the immunotherapy options for patients with other breast cancer subtypes?
Clinical trials are working to expand the use of immunotherapy to more patients, including those with other stages of triple-negative breast cancer, as well as other breast cancer subtypes.
If you’re interested in immunotherapy options for breast cancer treatment, I encourage you to talk with your care team about clinical trial options. You may find a clinical trial opportunity that can give you access to immunotherapy and also enable you to pay it forward for future cancer patients.
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