The diagnosis of your breast cancer can only be confirmed by taking a sample of tissue from the concerning area in the breast be it a lump or an area that has been seen as worrying on the mammogram.
Stood the test of time : triple assessment
The gold standard today is the triple assessment and while not new is still not used by certain clinicians. All patients should have an ultrasound and mammogram depending on their age and wherever possible a needle biopsy; preferably a core needle biopsy. Incision and excision biopsies of breast masses for diagnostic purposes should not be done unless a failed needle biopsy in terms of pathological information is obtained.
The pathological information (tissue sample) is important because it gives us information about the personality of the cancer.
Please remember that a detailed insight into the personality of the cancer is confirmed after the final cancer surgery with the final histology result.
You need to know the following:
Is the cancer ductal (arising from the breast ducts) or lobular (arising from the breast lobules).
Lobular cancer are harder to pick up on mammogram and spread in single file (like ants marching across a wall) because they are more difficult to see your doctor may advise further investigations (MRI) and possibly a mastectomy as a surgical option.
Ductal cancers are further described as well differentiated (well behaved), moderately differentiated, and poorly differentiated (naughty, usually faster growing); further information about the personality is seen by features such as:
Angio-lymphatic invasion (trying to sniff out blood vessels).
Tumour necrosis (cancer killing a few of it’s own cells because it is disorganized).
Cancers bigger than 1,5cm with ugly personality features are usually best managed with some form of chemotherapy.
The next bit of information is finding out whether the cancer is in the lymph nodes.
If it is in more than 4 lymph nodes you need radiation.
Cancers of the breast are often sensitive to certain receptors and targets (this is an ever growing and changing field which you must know about and ask your doctor about these.)
Know whether your cancer is sensitive to estrogen (ER) and or progesterone (PR).
Know whether your cancer is sensitive to certain targets such as HER 2 neu.
Chemotherapy
The role of systemic chemotherapy has been confirmed in a recent meta-analysis of most subsets of patients with breast cancer with anthracycline-containing regemins are superior to non-anthracycline containing regimens.
The addition of the taxanes seems to improve overall survival in node positive disease and in ER/PR negative breast cancers.
Primary chemotherapy is the gold standard for all patients with locally advanced breast cancer and can be used to facilitate cosmesis and make breast conservation feasible in some patients.
Amplification of the Her2/neu is associated with increased aggressiveness of breast cancers. Trastuzumab should be utilised in these patients.
Radiation
All patients with invasive carcinoma should receive radiation therapy as part of breast conservation therapy.
Patients undergoing intra-operative radiation should be part of a trial.
Patients with implants, collagen vascular disease, very large breasts, locally advanced breast cancers or who have had primary chemotherapy should all see the radiation oncologist as part of the multi-disciplinary team prior to having surgery.
Post –operative radiation to the nodal basins and chest wall is appropriate in all stage 3 , stage 2 with 4 or more positive nodes (1-3 nodes positive conflicting data).
Endocrine therapy
All patients with hormone receptor – positive tumours are candidates for endocrine therapy which reduces the risk of recurrence and improves overall survival.
Patients with ER/PR negative tumours should not get hormonal therapy.
Hormonal therapy should be started once chemotherapy is completed.
Concurrent use of Tamoxifen and radiation therapy is not recommended due to potential risk of lung toxicity.
Aromatase inhibitors can be used in post menopausal patients either alone or in sequence with tamoxifen.
Certain subgroups (ER+/PR-; HER2+) seem to have a more marked benefit with aromatase inhibitors.
The use of hormonal medications are essential in preventing the breast cancer coming back.
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