If you or a family member or friend have recently been diagnosed with early breast cancer, you may be wondering what happens now and how your cancer specialist decides the next steps in your treatment plan regarding chemotherapy. Oxford medical oncologist Dr Mark Tuthill explains more.
How is the stage of breast cancer determined?
If you have unfortunately had to have a breast biopsy or undergone surgery to remove a breast cancer, the tissues that have been removed are sent to a specialist histopathological laboratory for examining under a microscope. Special molecular tests are performed to determine the molecular type of the cancer which are then used by your team to plan your subsequent treatment. The tests usually take around five working days to complete as some testing processes require 24 hours to complete. Additional time may be required to resolve any uncertainties which arise during the analysis.
The tests will determine the type and size of the breast cancer, the grade (the appearance of the breast cancer), the amount and number of involved lymph nodes under the armpit (axilla) will also be calculated. The analysis will also determine if the breast cancer is sensitive to drugs which block the female hormone oestrogen, such as tamoxifen or letrozole or drugs which target HER-2 (a marker of aggressive breast cancer) such as Herceptin and pertuzumab.
The majority of patients will present with early breast cancer with no signs of spread around the body. Occasionally, investigations, referred to as ‘staging investigations’, will be performed that look for the spread of cancer around your body, such as:
- CT scan
- Bone scan
- MRI scan of your bones
- PET scan - a glucose scan that is sensitive at picking up breast cancers which have spread around the body.
Once these results are known, your cancer specialist let you know the stage of the breast cancer, and will plan the next phase of your treatment with you.
How do you decide who has chemotherapy? What are the risk factors?
The indications for chemotherapy will be determined based around the results from your operation or tumour biopsy. Some groups of women with breast cancer will have a high chance of receiving chemotherapy if their tumours express a molecule called HER-2 on their surface. This means that chemotherapy in combination with Herceptin and pertuzumab will have a good chance of reducing their breast cancer and prevent it from coming back and increasing their chances of being cured of breast cancer.
Other groups of women with so-called triple negative breast cancer, defined as breast cancer that is not sensitive to hormonal therapies or HER-2 targeted therapies, have a higher chance of receiving chemotherapy after surgery for early breast cancer.
The grade of cancer (breast cancers are graded from stages 1-3) gives an indication of how quickly the cancer is growing and the likely benefits of chemotherapy. A higher grade increases the likelihood of benefit from chemotherapy and lower grade reduces the chances of benefit. The size of breast cancer and the amount of lymph nodes involved under the armpit gives an indication of the likely benefit of chemotherapy.
Your cancer specialist will use a specialist computer program to predict your chances of benefits from chemotherapy and will discuss the results with you when you come to your appointment to discuss your treatment plan. There are a number of different programmes which are used the in the UK. The commonest is call NHS Predict 2.1 (https://breast.predict.nhs.uk/index.html). Your specialist can use the programme and discuss the potential benefits of chemotherapy.
What are the treatment options available?
There are lots of different chemotherapy regimens for early breast cancer and these differ around the world.
There are essentially two types of chemotherapy for early breast cancer. There is chemotherapy given before surgery, which is commonly referred to as neoadjuvant chemotherapy, or there is adjuvant chemotherapy, which is given after an operation.
Neoadjuvant chemotherapy is usually given to women with HER-2 positive breast cancer and to those with larger early breast cancers. The aim is to shrink the tumour down in order to preserve the breast tissue at the time of surgery.
There are lots of different chemotherapies for early breast cancer. Most are given either in combination, such as FEC chemotherapy followed by a single chemotherapy drug like Paclitaxel. Chemotherapy drugs will often be given in combination with other treatments such as Herceptin and Pertuzumab.
At what point would a patient need chemotherapy?
If you have HER-2 positive breast cancer then it is likely that you will be offered chemotherapy before you have surgery to remove the breast cancer. If you have other forms of breast cancer, it is most likely that you will be offered chemotherapy after surgery and once the results of the tumour tests are known.
How does the oncologist know whether chemotherapy would or would not be helpful?
Your cancer specialist will use a specialised computer algorithm called NHS Predict 2.1. This will give you a detailed summary of the likely benefits of chemotherapy for a woman of your age, with a tumour of similar characteristics to your cells.
For women with early breast cancer, your oncologist will usually recommend chemotherapy if there is a chance of helping at least 3 to 5 women out of 100 from developing recurrent breast cancer in the future. Even if chemotherapy is recommended, after a specialist discussion about your care at a Multi-Disciplinary Team (MDT) meeting, your specialist will go through the risks and benefits with you to make sure that the treatment is right for you.
There are several new molecular tests such as Oncotype DX and Prosigna Breast Cancer Prognostic Gene Signature Assay, which can be used to predict which women with oestrogen-receptive positive breast cancer should have chemotherapy. These tests have led to the first personalised treatment recommendations and can be used to determine if chemotherapy is likely to be of benefit to you.
Your cancer specialist team will arrange the test after you have had breast surgery. The tests are performed and number is generated using a molecular test, which can be used to guide your treatment. If the test scores come back showing that the benefits of chemotherapy are low and that chemotherapy is not indicated, you can be reassured that your outcome will be the same as for women that received chemotherapy with your type of breast cancer.
Both Oncotype DX and Prosigna Breast Cancer Prognostic Gene Signature Assay are available for both NHS and private patients in the UK.
Visit Dr Mark Tuthill's profile to book a consultation with him.