Breast CANCER-Treatments
The treatment of breast cancer requires close coordination between different medical and paramedical disciplines as it associates, according to needs, surgery, radiotherapy, chemotherapy, hormone therapy and new targeted treatments. These different treatments can be used alone or, more often, in combination.
The choice of a particular treatment depends on different factors, the most important of which are:
The type of breast cancer
Whether or not the lymph nodes are invaded;
The presence or not of hormonal receptors on the surface of cancerous cells;
The presence or not of metastases in other organs;
The age of the person and his or her general condition.
On the other hand, the therapeutic strategy is never established by a single doctor. Each patient in whom breast cancer is discovered is subject to multidisciplinary oncology (COM) consultation, where doctors from different disciplines meet. The choice of treatment is the result of this COM. Each treatment is therefore individualized.
The effects of breast cancer treatments are not confined strictly to cancer cells. Healthy tissues can also be affected, which explains the appearance of side effects whose intensity often varies from one person to another. Most side effects fade over time and disappear after treatment is stopped. In some cases it is necessary to use medication to control adverse effects. Side effects are supported by treatment.
1. Surgery
Surgery is often the first treatment applied in case of discovery of breast cancer. As much as possible, the surgeon will try to preserve the breast by a limited ablation. It is always supplemented by the removal of one or more lymph nodes located under the arm (at the armpit level). This process is called lymph node cleaning. For small tumors, one can spot and then remove the first (or first) ganglion that drains this area. This technique is called the "Sentinel ganglion". If the Sentinel ganglion is free from cancerous cells, then it is not necessary to remove the other deep-lying lymph nodes.
The presence of lymph nodes invaded by cancer cells largely affects complementary treatments. Depending on the characteristics of the tumor, different techniques are conceivable.
Radical mastectomy This surgical procedure, also called a mastectomy, corresponds to the complete removal of the breast. After a radical mastectomy, an external lightweight tissue prosthesis is offered to the patient at the time of return home to provide a balanced silhouette.
The lumpectomy
It is a surgical ablation of the tumor and some of the healthy tissues that surround it. If necessary, wider samples, called "surgical cuts", are made to remove a sufficient margin of safety around the tumor. This conservative surgery helps to conserve the breast.
The quadrantectomy (also called partial mastectomy) corresponds to a larger lumpectomy.
Side effects of surgery
The most common symptoms that result from surgery for breast cancer are, on the breast side operated:
A stiff feeling of the muscles of the neck, arm and shoulder;
Tingling at the hand level
The possibility of a hematoma or an infection of the wound;
Sensitivity disorders in the scar and breast (late sequelae).
The removal of the lymph nodes under the arm (Axillary Hollow) is responsible for some women for swelling of the arm and hand on the surgical side. This phenomenon is called "big arm" or "lymphedema ". The treatment mainly uses specialized physiotherapy (lymphatic drainage) since there is no effective medication to eliminate this problem. However, this risk can be greatly reduced when a small number of lymph nodes can be taken for microscopic examination (sentinel ganglion technique).
2. Radiation therapy
This type of breast cancer treatment uses very high energy rays capable of destroying cancer cells.
Objectives of radiation therapy
Like surgery, radiotherapy is a local treatment for breast cancer, that is, it allows you to act directly on the area affected by cancer cells. It is used, depending on the case, to:
Reduce the risk of local recurrence of the disease after surgery
Allow the preservation of the breast in the best conditions
Treat the tumor directly when an operation is not possible
Irradiate the different ganglion areas around the breast when the lymph node-by-surgery showed many invaded ganglia.
Irradiation techniques
The radiation therapy can be applied according to two techniques. Depending on the diagnosis, these two breast cancer treatments can be combined.
External radiation Therapy
The Rays are produced by a device located outside the body. It usually does not require hospitalization. The rays are administered 5 days a week, for several weeks in a row. In some specific cases, irradiation may be administered during surgery (Mobetron technique).
Internal radiation Therapy
The source of rays is placed in thin tubes temporarily implanted in the breast. This form of radiation therapy requires a few days of hospitalization.
Specific approaches
Some types of breast cancer require specific approaches. Thus, lobular carcinoma in situ only increases the risk of later developing invasive cancer. Most often, his discovery does not require radiotherapeutic treatment or even surgery, but careful surveillance.
Radiotherapy and prosthesis Ideally, the fitting of a breast prosthesis should be carried out one year after radiotherapy. In fact, changes in the structure of the skin are observed in the months or even years following the treatment by Rays. Radiotherapy is possible on a prosthesis already in place (in the case of a recurrence).
Side effects of radiation therapy
During treatment against breast cancer, irradiation irritates the healthy tissues located in the treated area and causes:
Skin damage (similar to a mild burn);
itching;
Dry skin (the most superficial cells of the skin are detached);
Pigments.
In the course of many radiotherapy sessions, patients may experience a general fatigue that gradually settles. Other side effects include swelling of the breast or the appearance, after several years, of a network of small, enlarged superficial blood vessels (telangiectasia). Redness of the Skin (erythema) at the folds may also occur, especially when the breast is large and collapsed.
These reactions can be aggravated by pre-existing skin lesions (fungal infections) or when applying cosmetic products, especially if they contain alcohol.
Some practical tips to limit these disadvantages:
Wash the area treated by rays in clear, lukewarm, soap-free water.
Avoid deodorants, skin products, plasters on the area to be treated.
Apply talcum powder to the axillary trough (under the arms) and under the breast to dry out those areas that naturally transpire.
Wear loose clothing and avoid wearing a bra.
Protect the skin with a cotton shirt.
After the end of radiotherapy, use cosmetic creams to treat redness, tickling, dryness, and skin pigmentation.
3. Chemotherapy
Unlike surgery or radiotherapy that are local treatments, chemotherapy uses one or more medications that will be disseminated throughout the body. Depending on the situation, it is administered before or, most often, after surgery.
When administered after surgery, doctors talk about adjuvant chemotherapy. This term means that chemotherapy is intended to destroy cancer cells present in possible undetectable micro-metastasis, or in proven metastases, and which are not affected by local treatments. Chemotherapy therapy usually begins in the first month after surgery.
It happens more rarely that the chemo precedes the surgery in order to reduce the tumor volume and allow a less intrusive operation. In this case, we're talking about neoadjuvant chemotherapy.
Side effects of chemotherapy
Drugs used against breast cancer destroy cancer cells but also a number of healthy cells that have the property to multiply rapidly. This is the case mainly of bone marrow cells (bone marrow produces red blood cells, white blood cells and platelets), cells that line the walls of the digestive tract and cells that ensure hair growth.
The main side effects of chemotherapy are therefore:
General fatigue, often associated with a decrease in the number of red blood cells (anemia);
Greater susceptibility to infections, due to a decrease in the number of white blood cells, which may require the taking of antibiotics;
A risk of bleeding and the appearance of Hematomas, linked to the decrease in platelet count;
Nausea, vomiting, loss of appetite, related to digestive tract cell damage (medications help alleviate these symptoms);
A fall of the hair (one can try to prevent it by wearing a refrigerant helmet).
4. Hormone therapy
Like chemotherapy, hormone therapy is an adjuvant treatment for breast cancer that supplements the surgical treatment. It aims to reduce the risk of metastasis and also decreases the subsequent risk of new breast cancer. Hormone therapy blocks the production or action of certain hormones in order to slow down or stop the growth of cancer cells.
A hormone tumor
Not all breast cancers respond to hormone therapy. This treatment is only useful if the cancer is "hormone". This is the case when cancer cells present hormone receptors on their surface (which allow hormones to bind to the surface of the cells). These receptors are assimilated to locks whose opening by the appropriate key (in this case an estrogen-class hormone) stimulates the multiplication of cancer cells. Laboratory tests are used to detect the presence of hormonal receptors on the surface of cancer cells.
Hormone therapy Medications
Hormone therapy consists of administering medications (in tablet and/or injection form) that prevent the action of hormones, in order to suppress their influence on cell multiplication. It is a technique used in particular against breast cancer.
These medicines include two main categories:
The SERM (of the English "selective Estrogen Receptor Modulators")
They compete with estrogens by taking their place in hormone receptors, thus preventing the hormone from exerting its effect on cancer cells. The main drug in this category is tamoxifen, which is taken in the form of tablets. Although it gives rise to relatively few side effects, some patients mention nausea, hot flashes, irregularities in the rules. A slightly increased risk of endometrial cancer (uterus) has also been established. This risk could be more pronounced in the case of prolonged administration. Annual gynecological surveillance by ultrasound is recommended.
AI (aromatase inhibitors) anti-aromatases prevent the action of an enzyme called "aromatase", which contributes to the production of estrogens (hormones favouring the multiplication of certain cancerous cells). These medications are used to block the production of estrogen in different tissues (fat, liver, muscle, breast) after menopause.
Finally, another technique is to remove the organs that produce the hormones (ovaries and adrenal glands) by external surgery or radiotherapy. In the medical language, this procedure is named "Castration ".
Side effects of hormone therapy
Anti-estrogens cause a young woman to have symptoms characteristic of menopause:
Hot flashes sweating abundant sudden changes in insomnia mood
...
5. Targeted Therapies
Targeted therapies are part of adjuvant treatments, just like chemo-or hormone therapy. They are used in addition to the surgery. They are intended to attack cancer cells that have detached themselves from the original tumor (metastatic cells).
In the case of breast cancer, the molecules most commonly used in the targeted therapies are trastuzumab (Herceptin), pertuzumab (Pertoss), and bevacizumab (Avastin).
About 1 in 5 breast cancer is ' HER2 positive '. This means that the cancer cells present on their surface HER2/neu proteins. The Herceptin generally works well on these patients, unlike the others.
Click here to learn more about targeted therapies in general.
Reconstruction after breast cancer treatments
Reconstructive Surgery
Who is reconstructive surgery for?
The improvement and safety of surgical reconstruction techniques as well as the potential physical and psychological benefits make this form of surgery available to all patients treated with mastectomy. Any woman, regardless of her age or the degree of advancement of her breast cancer, may, if she wishes, be a candidate for reconstruction.
When should it be considered?
Generally, a period of several months after the initial operation (mastectomy) is met before a reconstruction is performed. However, it is possible to rebuild the breast at the same time as the mastectomy. Most often, the breast is rebuilt after the end of chemotherapy or radiation therapy. In some cases, the choice of the later reconstruction technique is done before the mastectomy, which allows the surgeon to adapt the course of his incisions during the procedure.
Remember that breast self-monitoring should be continued, even in the case of breast reconstruction, as a recurrence of breast cancer is not impossible. Ask your doctor what type of surveillance is indicated according to the reconstruction practiced.
Prosthesis reconstruction
The primary condition for choosing this type of reconstruction is the quality of the skin. It must be adequate in quantity and flexibility. Too thin a skin will lead this reconstruction to failure in more or less short term. A good quality skin is therefore indispensable to accommodate the prosthesis safely and give the breast a sufficient curve.
Several types of prostheses currently exist on the market, including those with silicone gel or saline in the silicone casing.
Simple prosthesis
It is slid under the large pectoral muscle and the large serrated muscle so as to avoid as much as possible the formation of a rigid capsule (shell) giving the breast a frozen appearance. The fixed volume of these prostheses is a disadvantage because it does not adapt to weight loss or gain.
Tissue expansion Prosthesis
Tissue expansion consists of implanting a balloon under the skin or under a muscle and gradually inflating it for several weeks until sufficient volume and adequate breast curve are obtained. This type of reconstruction can only be used if the skin is healthy and has all the elasticity properties, i.e. breast cancer has not been treated by rays.
The main advantage of this technique is that it is a much lighter operation than necessary for a muscular-cutaneous shred reconstruction.
The main drawbacks of this technique:
The expansion procedure is long and sometimes unpleasant.
The rebuilt breast is little or no mobile.
The breast does not follow the natural progression of sagging of the chest with age.
Living tissue reconstruction
Muscle flap reconstruction of the abdomen
The surgeon may decide to transfer one of the belly muscles called the "great Right", as well as skin and fat, to rebuild the breast. This is the so-called "TRAM" technique. Patients are often seduced by this technique because in one operation they benefit from breast reconstruction and a flat belly. However, this is not a "small" operation and the risk of hernia at the belly level should not be neglected.
The skin flap reconstruction of the dorsal spine the technique is to use the hide at the armpit level. This is the so-called "Fleur de lys" technique. This skin area is cut in 3 "Petals " vascularized by the large dorsal muscle. After cancer treatments, the breast is reconstituted thanks to this tissue.
Free flap reconstruction
There are other areas where tissue can be collected for the reconstruction of a breast. For information, the large dorsal muscle opposite the surgery or the large buttock. These different shreds have been imagined to limit the muscular withdrawal on the belly wall.
Benefits of living tissue reconstruction:
The reconstruction is final.
The breast is supple, natural in its shape and in its consistency.
The amount of fat it is made of naturally changes depending on the catch or weight loss.
The reconstructed breast grows old with the body and the symmetry is much more stable in time than with a prosthesis.
Mirroring and rebuilding the nipple
Symmetrical breasts
The mirroring consists of a reduction or an increase of the opposite breast. When it is necessary or chosen by the patient, it is realized at least three months after the reconstruction to allow the reconstructed breast to take its final curve and volume. At the same time the reconstruction of the reconstructed breast nipple is to be practised.
The Nipple
The rebuilding of the nipple is usually carried out several weeks or even months after the breast reconstruction. This delay is necessary for new fabrics to be put in place, which prevents the nipple to be positioned too early.
The rebuilding of the nipple is carried out either:
Thanks to the tattoo technique (most frequent case);
Using tissue taken (on the inner side of the thighs, at the back of the ears or even at the vulva).
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