Introduction to breast cancer

• Breast cancer arises from cells in the breast that have grown abnormally and multiplied to form a lump or tumour.
• The earliest stage of breast cancer is non-invasive disease (Stage 0), which is contained within the ducts or lobules of the breast and has not spread into the healthy breast tissue (also called in situ carcinoma). Invasive breast cancer has spread beyond the ducts or lobules into healthy breast tissue, or beyond the breast to lymph nodes or distant organs (Stages I IV).
• Breast cancer is the most common cause of cancer-related deaths in women and occurs most frequently in postmenopausal women over the age of Breast cancer also occurs in men but is very rare, making up around 1% of all breast cancer cases.

Diagnosis of breast cancer

• The most common symptoms of breast cancer are changes in the breasts such as the presence of a lump, changes to the nipple, discharge from the nipple or changes in the skin of the
• Initial investigations for breast cancer begin with a physical examination, mammography and ultrasound In some cases, breast magnetic resonance imaging (MRI) will also be performed. If a tumour is found, a biopsy will be taken to assess the cancer before any treatment is planned.

Treatment options for breast cancer

• The treatment of breast cancer depends on how far advanced the cancer is (Stage 0 IV) and what type of cancer is
• Surgery, radiotherapy, chemotherapy, endocrine therapy and targeted therapy are used in the treatment of breast
• Breast cancer is ‘staged’ according to tumour size, involvement of lymph nodes and whether it has spread outside the breast and lymph nodes to other parts of the body, according to the TNM system (T – tumour, N – nodes, M – metastases). This information is used to help decide the best
• The presence of biomarkers including hormone receptors and a receptor called HER2 also help to determine what type of therapy is

Early stage non-invasive breast cancer Biological testing of the tumour

• Patients with Stage 0 disease will usually have the tumour removed by breast-conserving surgery or mastectomy. Radiotherapy is given after breast-conserving surgery but is not usually needed after mastectomy. Most patients with oestrogen receptor (ER) positive cancer will be given endocrine therapy after surgery and radiotherapy. Endocrine therapy is given to decrease the risk of recurrence (the cancer coming back), as well as prevention of new cancers in both the remaining and contralateral

 

 

Early stage invasive breast cancer

• Patients with Stage I IIA disease will usually be treated with surgery to remove the tumour and any affected lymph nodes. Breast-conserving surgery is always followed by radiotherapy. Most patients will then receive adjuvant therapy with one or a combination of systemic treatments, depending on the type of cancer
• Some patients, particularly those with larger tumours, may receive preoperative neoadjuvant systemic therapy to shrink the tumour and improve the likelihood of successful surgical removal of the tumour, or to decrease the extent of surgery (which can also achieve a better cosmetic result).
• The standard chemotherapy regimens in early breast cancer usually contain anthracyclines (e.g.

epirubicin or doxorubicin) and/or taxanes (e.g. paclitaxel or docetaxel), given sequentially.

• Patients with ER positive disease will receive endocrine therapy. In premenopausal women this is usually tamoxifen alone or in combination with drugs that suppress the ovarian production of oestrogen (called gonadotropin-releasing hormone analogues). Suppression of ovarian function may also be used with aromatase inhibitors. In postmenopausal women, aromatase inhibitors or tamoxifen are used, either alone or sequentially.
• Patients with HER2 positive breast cancer will usually receive the anti-HER2 drug trastuzumab as well as chemotherapy. In some patients, this may also be combined with pertuzumab. Neratinib is a new anti- HER2 agent that may also be used to treat HER2 positive

Locally-advanced and metastatic breast cancer (also called advanced breast cancer)

• Most patients whose breast cancer has been classed as Stage IIB III will receive neoadjuvant therapy before surgery is Depending on the type of breast cancer, this can include one or a combination of chemotherapy, endocrine therapy, anti-HER2 therapy and radiotherapy.
• Patients with Stage IV breast cancer will not usually be treated with surgery, but it may be discussed in some
• ER positive advanced disease is usually treated with endocrine therapy using aromatase inhibitors, tamoxifen or fulvestrant. In some cases, these drugs are combined with targeted therapies such

as cyclin-dependent kinase 4/6 (CDK4/6) inhibitors (palbociclib, ribociclib and abemaciclib) or

mechanistic target of rapamycin (mTOR) inhibitors (everolimus) to improve outcomes.

• For ER negative tumours and for ER positive tumours that have stopped responding to endocrine therapy, chemotherapy with capecitabine, vinorelbine or eribulin is usually A taxane or an anthracycline may also be used in some patients.
• HER2-positive advanced disease is usually treated with trastuzumab and pertuzumab in combination with chemotherapy (docetaxel, paclitaxel, vinorelbine or capecitabine). Further-line treatments include trastuzumab emtansine (T-DM1), trastuzumab in combination with lapatinib, lapatinib in combination with capecitabine or trastuzumab in combination with other chemotherapy
• Bevacizumab can be combined with chemotherapy but provides only a small benefit with no impact on survival, and is therefore rarely Olaparib and talazoparib are new targeted therapies that may be used to treat BRCA-associated advanced breast cancer (i.e. hereditary advanced breast cancer).

 

 

Follow-up of early breast cancer after treatment

• You will usually be seen by your doctor every 3-4 months for the first two years after finishing treatment, every 6-8 months from years 3-5 and once a year

You will also have a mammography every year, and some patients will also have regular MRI or ultrasound scans. Patients taking endocrine therapy will have regular assessments to monitor the side effects of the treatment