Breast cancer, Part 2: Issues in treatment

Issue: BCMJ, vol. 60 , No. 2 , March 2018 , Pages 90-91 Editorials

Breast cancer treatment has evolved over the past 50 years to become increasingly multimodal and multidisciplinary.


Dr Rona Cheifetz Dr Elaine McKevitt

BC statistics from 2016 show an age-adjusted net survival rate for breast cancer of 88%,[1] while an American source notes that patients with stage I disease are currently felt to have a life expectancy similar to age-matched peers.[2] Improved survival is attributed to a combination of screening and treatment.[3,4] An increasing range of treatment options are available now when a patient is diagnosed with breast cancer, and progress has been made in the areas of surgery, systemic therapy, and radiotherapy, all of which have led to more individualization of treatment plans. In BC most breast cancer treatment begins with surgery at one of 46 hospitals in the province providing this service.

Since randomized control trials in the 1970s demonstrated the safety of a breast conserving approach, many women have had the choice of surgical treatment with either mastectomy or breast conserving surgery. For women needing a mastectomy, advances in breast reconstruction have made this procedure more widely available and given women a greater range of reconstructive options. Axillary lymph node surgery has also evolved, with sentinel lymph node biopsy being recommended for most patients with a clinically negative axilla and fewer indications for axillary lymph node dissection.

Just as breast surgery has evolved, so has adjuvant therapy. In addition to the traditional considerations of age and stage of disease, decisions for optimal systemic treatment are being guided by the biology of the tumor. Chemotherapy is being used more often before surgery (neoadjuvant) in patients with operable breast cancer to shrink the tumor and allow for less-invasive breast conserving surgery. For selected patients this approach can also permit preoperative genetic testing or additional treatment through clinical trials, and can provide prognostic information from their response to chemotherapy.

Radiation therapy has also evolved and there are more postmastectomy indications for radiotherapy. Trials have demonstrated benefit with radiation for medial tumors and axillary metastasis, while other trials are underway to determine the safety of omitting radiation in older women with small, estrogen-receptor-positive breast cancers.

The increase in therapeutic options means that multidisciplinary case conferences are being used more often to optimize treatment and to sequence therapy. As advances continue and treatment becomes more individualized, a larger number of women will be managed in this way.

With more coordinated and targeted therapy, it may also be possible to reduce treatment sequelae. Already women can be reassured that physical activity following axillary surgery presents no increased risk to the treated arm, and new evidence has shown there is no need to avoid medical procedures on the treated arm following axillary surgery. As well, strategies are being developed to optimize function and to minimize posttreatment pain, which is reported to affect between 25% and 60% of patients.[5]

Addressing many of these concerns and complementing Part 1 of this theme issue, which dealt with diagnosis, Part 2 focuses on initial breast cancer treatment. In the first article, Dr Rebecca Warburton and colleagues review the current surgical management of breast cancer. This works stems from a provincial initiative to update surgical recommendations for breast cancer that was facilitated by the BC Cancer Surgical Oncology Network.

In the second article, Drs Michelle Sutter and Alison Ye present current recommendations for radiotherapy in initial treatment of breast cancer and discuss the impact of opening the BC Cancer Centre for the North in Prince George in 2012. The authors report that travel time for patients in the north needing radiotherapy has decreased and the number of women treated with breast conserving therapy in the region has increased.

In the third article, Dr Christine Simmons discusses patient selection for neoadjuvant chemotherapy. She also reviews the experience of patients receiving neoadjuvant therapy at the BC Cancer Vancouver Centre since 2013.

In the final article, Drs Connie Chiu, Brenda Lau, and Alan Nichol use their experience in Fraser Health and the Provincial Health Services Authority to address some of the physical concerns breast cancer patients may face after treatment, including lymphedema, cosmetic changes to the breast that affect self-image, and chronic pain.

We have been fortunate to witness an improvement in outcomes for breast cancer over the past 20 years with more individualized and multimodal treatment options. As our understanding of optimal treatment progresses, we anticipate an increasing need for multidisciplinary consultation and management, and better coordination in developing treatment plans. We also anticipate that the evolution of treatment will require a system that provides timely access to care in all areas of BC. 
—Rona Cheifetz, MD, MEd, FRCSC, FACS
Surgical Oncologist and Medical Lead, High-Risk Clinic, Hereditary Cancer Program, BC Cancer 
Associate Professor, Department of Surgery, UBC 
Head, Continuing Medical Education, Department of Surgery, UBC
—Elaine McKevitt, MD, MEd, FRCSC, FACS
Surgeon, Mount Saint Joseph Hospital
Chair, Continuing Medical Education and Knowledge Transfer, Surgical Oncology Network, BC Cancer 
Chair, Surgical Breast Tumour Group, Surgical Oncology Network, BC Cancer 
Clinical Associate Professor, Department of Surgery, UBC
 
Competing interests
None declared.
 

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This article has been peer reviewed.


References

1.    Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2016. Toronto, ON: Canadian Cancer Society. Accessed 15 March 2017. www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Can...
2.    American Cancer Society. Understanding a breast cancer diagnosis: Breast cancer survival rates, by stage. Accessed 19 October 2017. www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagno...
3.    Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: An overview of the randomised trials. Lancet 2005;365(9472):1687-1717.
4.    Olivotto IA, Mates D, Kan L, et al. Prognosis, treatment, and recurrence of breast cancer for women attending or not attending the Screening Mammography Program of British Columbia. Breast Cancer Res Treat 1999;54:73-81.
5.    Mejdahl MK, Andersen KG, Gartner R, et al. Persistent pain and sensory disturbances after treatment for breast cancer: Six year nationwide follow-up study. BMJ 2013;346:f1865.

Rona E. Cheifetz, MD, MEd, FRCSC, FACS, Elaine McKevitt, MD, MEd, FRCSC, FACS. Breast cancer, Part 2: Issues in treatment. BCMJ, Vol. 60, No. 2, March, 2018, Page(s) 90-91 - Editorials.



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