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.
Surgery for breast cancer
Like all surgeries, breast cancer surgery is most successful when performed by a specialist with a great deal of experience in the 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 asses 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 achieving the most effective surgery and the best possible cosmetic outcome and symmetry.
Some patients will receive chemotherapy or targeted therapy prior to surgery. The goal of these treatments is shrink the tumor and any involved lymph nodes in order to make the procedure and recovery as easy as possible on the patient. This also allows the treating team to assess how the cancer has responded to treatment, which can be important for some breast cancer subtypes.
The surgeries themselves fall into one of two categories: lumpectomies and mastectomies. Your surgeon will recommend the best option for you based on the size and location of tumors in the breast, the size of the breast itself and the need for radiation treatment.
In a typical lumpectomy surgery, the tumor and a small amount of surrounding normal tissue is removed. Lumpectomies are generally outpatient procedures and have shorter recovery times. These procedures are usually followed by radiation therapy.
In a typical mastectomy surgery, the tumor and the entire breast are removed. There are a number of 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. This can help prevent the development of a new breast cancer. It is typically done for patients are at high risk for 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. These are important parts of the lymphatic system, which helps the body fight disease. 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.
Radiation therapy uses powerful beams of energy carefully designed to kill breast cancer cells.
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 incredibly deep experience to draw from when designing treatment plans. In addition, each breast cancer radiation treatment plan is 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.
For breast cancer patients, radiation therapy can be used before surgery to shrink large tumors or after surgery in order to kill any remaining breast cancer cells that can’t be seen by the naked eye. It 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.
Radiation can be given to the breast tissue surrounding the area where the tumor was located, as well as to nearby lymph nodes and the chest wall. 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.
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: A 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 surgery: SBRT 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 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. Read more about stereotactic radiosurgery
Proton therapy 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, 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 recurrence. Patients with the metastatic form of this disease are also given endocrine therapy in order 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 prior to 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 prior to surgery to shrink the tumor and simplify the procedure. Breast cancer patients can receive chemotherapy either orally or intravenously. Learn more about chemotherapy.
Angiogenesis is the process of creating new blood vessels. Some cancerous tumors are very efficient at creating 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, which prohibits them from activating receptors on endothelial cells inside blood vessels. Other angiogenesis inhibitor drugs work on a different part of the process, by stopping VEGF receptors from sending signals to blood vessel cells.
Treatment at MD Anderson
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Although immunotherapy has been successful in treating some cancers like melanoma, colorectal cancer and non-small cell lung cancer, it hasn’t shown as wide success in treating breast cancer yet. “It's hard because breast cancer is very smart,” Lim says. There are many subtypes and even sub-subtypes, which make it hard to train the immune system to attack.
But some patients with triple-negative breast cancer (TNBC) are benefiting from immune checkpoint inhibitors, the most common type of immunotherapy. Here, Lim explains why it’s been challenging to treat breast cancer with immunotherapy, which patients may benefit and what’s ahead.
Why is it challenging to treat breast cancer with immunotherapy?
Immunotherapy works by waking up 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 fight.
PD-L1 is a protein on the surface of a T cell. It binds with a partner protein called PD-1 that’s on the surface of a cancer cell. But this bond turns off the T cell and allows the cancer cell to hide. Immune checkpoint inhibitors take off this brake to allow the T cells to finish their job.
In cancers where immunotherapy works well, T cells have easy access into the tumor. But that’s not always happening with breast cancer. “In some breast tumors, there are little to no immune cells inside,” Lim says. Those tumors are considered immunologically cold and are more common in breast cancer than in other cancers successfully being treated with immunotherapy.
Even if the T cells get inside the tumor, they can be stifled by “bad” immune cells, so immunotherapy isn’t effective.
However, more recent research has shown that some immune cells are inside when the cancer is at an early stage, but after several rounds of treatment and as the cancer advances, there are fewer. “So we’re now starting to use immunotherapy as a first-line treatment option in combination with chemotherapy,” Lim adds.
Do immune checkpoint inhibitors treat triple-negative breast cancer?
Currently, immunotherapy is mostly being used to treat triple-negative breast cancer. “It’s aggressive and there aren’t any good targeted treatment options unless you have certain genetic mutations like BRCA,” Lim explains. “So we’ve worked hard to prove that immunotherapy works for these patients."
Pembrolizumab (Keytruda) and atezolizumab (Tecentriq) are the two immune checkpoint inhibitors most commonly used to treat breast cancer. These drugs each target the binding of PD-1 and PD-L1 protein. For either of these drugs to be an option, a patient must have high levels of PD-L1 proteins, which is determined with a biopsy. Other similar drugs are being tested through clinical trials.
Immunotherapy side effects are manageable, but long lasting
Immunotherapy side effects aren’t unique to breast cancer patients, but they can have a lasting impact, Lim explains. So, patients and their doctors need to consider the potential long-term side effects when making treatment decisions. “This is an important thing to keep in mind when choosing between chemotherapy and immunotherapy,” Lim says.
Side effects can be managed with medications, but some can’t be reversed. “For example, if your thyroid is seriously affected, you’ll have to take hormone replacement medication for the rest of your life,” Lim says. “So we have to weigh that, especially if your cancer is in the early stages.”
Clinical trials expand to inflammatory breast cancer and HER2-positive breast cancer
Researchers are looking at whether immunotherapy may be effective in treating other aggressive breast cancers, such as inflammatory breast cancer and HER2-positive breast cancer.
“Anything that’s shown resistance to standard therapies is a great opportunity to explore the use of immunotherapy,” Lim says. “There is a lot of work to be done, but researchers, including me, are trying hard through clinical trials and analysis of tissue/blood.”
Other types of immunotherapies may offer promise for breast cancer treatment
Immune checkpoint inhibitors are the most established type of immunotherapy, but there are others. And Lim is excited for the possibility of using them to treat breast cancer.
“Personally, my biggest hope is with CAR T cell therapy,” says Lim. With CAR T cell therapy, T cells are removed from a patient, modified in a lab to better fight cancer and then returned to the patient. “Although it’s still early, I think this is an exciting area of research,” Lim says. “At MD Anderson, we’ve seen a lot of success treating some lymphomas and leukemias with CAR T, and I’m hopeful for its use in solid tumors like breast cancer.”
Even if an immunotherapy isn’t available for your type of breast cancer right now, Lim urges patients not to give up hope.
“With everything we’re learning from new research and clinical trials, it may change in two years,” says Lim. “Be patient, trust your doctor, and talk to your doctor often to see what options are out there.”
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