SURGERY 

Wide Local Excision (Breast Conserving Surgery Procedure)

This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have this treatment-often followed by radiation therapy-instead of mastectomy, and in most cases survival rates for both operations are similar. But this treatment may not be an option if:

• A tumor is very large
• Deep within your breast
• Already had radiation therapy
• Have two or more widely separated areas of cancer in the same breast
• Have a connective tissue disease that makes you sensitive to radiation
• Have inflammatory breast cancer

If you have a large tumor but still want to consider the possibility of this treatment, chemotherapy before surgery may be an option to shrink the tumor and make you eligible for the procedure. 
After surgery, your breasts may not match in size and shape. This is because removing breast tissue during surgery usually makes the affected breast appear smaller; however, swelling in response to surgery may also make your breast appear bigger (not a permanent effect).

Mastectomy

Mastectomy involves removal of all of the breast tissue, sometimes along with other nearby tissues. Mastectomy may be right for you if:

• Cancer is found in more than one part of your breast.
• Your breast is small or is shaped so that a lumpectomy would leave you with very little breast tissue or a very deformed breast
• Radiation therapyafter surgery is not appropriate for you.
• You believe you would have greater peace of mind with a mastectomy.

The effect and risk of this treatment are:

• Pain and tightness discomfort (only up to 2 weeks after surgery- not permanent effect)
• Infection at the site of the operation ( in less than  3% of patient)
• Surgery scar

If you are having a mastectomy, your doctor will discuss more about breast reconstruction with you. Breast reconstruction is surgery to rebuild your breast shape. It cannot give a woman back her breast - a reconstructed breast does not have natural sensations. However, the surgery offers a result that looks like a breast. Breast reconstruction may take more than one surgery. Extra steps may include:

• Adding a nipple
• Changing the shape or size of the reconstructed breast
• Operating on the opposite breast for a better match

Axillary Lymph Nodes Dissection

A traditional axillary lymph node dissection usually removes nodes in levels I and II. For women with invasive breast cancer, this procedure accompanies a mastectomy or breast conserving surgery. It may be done at the same time as, or after, a lumpectomy (through a separate incision).

Based on the doctor's physical exam and other indicators about the likelihood that cancer has spread to your lymph nodes, the surgeon will generally remove between five and thirty nodes during a traditional axillary dissection. The total number of lymph nodes "involved" (showing evidence of cancer) is more important than the extent of cancer in any one node.
Your doctor will let you know if any lymph nodes were involved (and if so, how many), as well as the extent of tumor involvement in each nodes.

There are center which may offer sentinel nodes biopsy as alternative to axillary lymph nodes dissection however the surgery only offered for certain cases only.

THERAPY 

CHEMOTHERAPY

Chemotherapy is the use of cancer-killing drugs injected into a vein, given as a shot, or taken as a pill or liquid. These drugs enter the bloodstream and go throughout the body, making the treatment useful for cancers that have spread to distant organs. While these drugs kill cancer cells, they also damage some normal cells, which can lead to side effects.

The most common side effects of chemotherapy:

• Nausea, vomiting, and diarrhea
• Hair loss
• Fatigue and anemia
• Infections
• Mouth sores
• Taste and smell changes
• Menopause and fertility
• Memory loss
• Problems with hands and feet (neuropathy)

Three different chemotherapy strategies may be used:

1. Adjuvant chemotherapy - to people who have had curative treatment for their breast cancer, such as surgery and radiation. It is given to reduce the possibility that the cancer will return.
2. Neoadjuvant chemotherapy - to shrink a large tumor and/or to kill stray cancer cells. This increases the chances that surgery will get rid of the cancer completely.
3. Therapeutic chemotherapy - to women with breast cancer that has spread beyond the confines of the breast or local area.

Ports for Chemo
Your oncologist may recommend that you have a port or "port-a-cath" inserted in your upper chest wall (the space between your collarbone and your breast) to make chemotherapy easier and more comfortable for you. You will have a chest X-ray to confirm that the port is positioned correctly. When chemotherapy is over, the port can be removed quickly in another same-day procedure. The port is about the size of a quarter, only thicker, and will show only as a bump underneath the skin.

There are several benefits to having a port:

• No need to find a vein every time you receive chemo.
• A port may be especially valuable for women who might be experiencing some swelling of the arm on the side of their surgery.
• The medication goes right into the main blood supply entering the heart, so it can be sent quickly and efficiently to all parts of the body.
• Some types of chemotherapy can be very uncomfortable if injected into a vein just under your skin. The port avoids this potential discomfort.
• Getting blood for blood tests can usually be done through the port, decreasing the number of times you need to have a vein "stuck."

RADIOTHERAPY

Radiation therapy is used to kill tumor cells if there are any left after surgery. It is a local treatment and therefore works only on tumor cells that are directly in its beam. It is used most often in people who have undergone conservative surgery such as lumpectomy. Conservative surgery is designed to leave as much of the breast tissue in place as possible. Radiation therapy is usually given five days a week over five to six weeks. Each treatment takes only a few minutes. It is painless and has relatively few side effects.

Side Effects of radiotherapy:

• Radiation will not make you lose your hair, unless radiation is given to your head.
• Your skin can turn pink, red and may be sensitive and irritated.
• During your treatment course, you may feel tired.

Most radiation side effects are temporary.

HORMONAL THERAPY

Hormone therapy is often used to treat women whose cancers are sensitive to hormones estrogen and progesterone receptor positive cancers. Similar to chemotherapy, this form of therapy can be used to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.

Two classes of medications are used in hormone therapy:

1. Selective estrogen receptor modulators (SERMs)
2. Aromatase inhibitors.

Selective Estrogen Receptor Modulators (SERMs)

SERMs act by:

• Blocking any estrogen present in the body from attaching to the estrogen receptor on the cancer cells
• Slowing the growth of tumors
• Killing tumor cells

SERMs can be used in both pre- and postmenopausal women. The most common SERM prescribed for hormone therapy is tamoxifen (Nolvadex). Tamoxifen is used to reduce the risk of breast cancer for women who:

• are at high risk of breast cancer but have no personal history of the disease, or
• have non-invasive, hormone-receptor-positive breast cancer, or DCIS (ductal carcinoma in situ), or
• have hormone-receptor-positive invasive breast cancer at any stage..

You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anti-cancer drugs. But tamoxifen isn't trouble-free. Women taking tamoxifen may experience menopausal symptoms such as:

• night sweats
• hot flashes, and vaginal itching
• discharge or dryness

More serious side effects including blood clots and endometrial cancer occur infrequently. Older women, especially those with other medical conditions, may be at greater risk of more serious side effects than are younger women.

Aromatase inhibitors

This class of drugs, which includes:

• anastrozole (Arimidex)
• letrozole (Femara)
• exemestane (Aromasin)

It blocks the conversion of a hormonal substance (androstenedione) into estrogen. This effectively stops estrogen production in cells other than the ovaries. Fat cells, the adrenal gland and other normal cells all make small amounts of estrogen.

These drugs are only effective in postmenopausal women.

Updated:: 13/03/2019 []