Multidisciplinary Treatment

Highlights

Multidisciplinary Treatment

The following is a brief contribution from Amanda Kong, MD, Medical College of Wisconsin surgeon and Tina Yen, MD, MS, Medical College of Wisconsin surgeon. Dr. Kong joined the Medical College in 2008 and Dr. Yen joined the Medical College in 2004. Both believe care of each patient should be individualized, while emphasizing a multidisciplinary approach and use of the most recent advances in care. To make an appointment with Drs. Kong, Yen or their colleagues in the Clinical Cancer Center, please call 414-805-0505 or 866-680-0505.

Breast Cancer

The breast is composed of lobules (milk producing glands), ducts (the passages from the glands to the nipple), fatty tissue, blood vessels and lymphatics. Breast cancer develops in the lining of either the ducts or the lobules. Carcinoma in situ is very early stage breast cancer which is still confined to the ducts and lobules from which it originated. Carcinoma in situ may start in the lobules (LCIS) or ducts (DCIS). LCIS is not thought to turn into cancer itself but serves as a risk factor for developing invasive breast cancer in either breast. DCIS is the most common form of non-invasive breast cancer. Breast cancer is considered to be invasive when it has grown and spread beyond the duct or lobule. About 80 percent of all invasive breast cancers are invasive ductal carcinomas and 10 percent to 15 percent are invasive lobular carcinomas.

Treatment

The treatment of breast cancer is constantly changing and requires a multidisciplinary approach to provide optimal care of the patient. Patients are given a tumor stage based on physical examination, radiology studies, and surgery results. Treatment is based on tumor size, lymph node involvement and the involvement of other organs as well as individual patient characteristics. Treatment may consist of receiving chemotherapy first followed by surgery or surgery first followed by either radiation or chemotherapy/hormonal therapy or both. The American Joint Commission on Cancer (AJCC) staging system for breast cancer is available on the National Cancer Institute Web site.

Surgical Options

Breast conserving therapy (BCT) consists of a lumpectomy also known as a segmental or partial mastectomy. This operation involves removing the cancer with a rim of normal breast tissue around it. If the breast lesion is palpable, the surgeon may remove it through a small incision in the breast. If the lesion is not palpable, the lesion will be localized by mammogram or ultrasound before the surgery and a wire will be placed in the breast to provide the surgeon with a roadmap for the operation. After BCT, a patient will require radiation therapy to the remaining breast tissue. Typically, early stage breast cancers (stage 0, I and II) are treated with BCT. A total mastectomy consists of removing the entire breast. For patients who desire reconstruction, a skin-sparing mastectomy is performed where the breast and nipple are removed through an incision around the areola, leaving most of the breast skin intact.

Both of these operations are performed by a breast surgeon.

If a patient desires immediate reconstruction (reconstruction at the time of the cancer operation), the patient will be referred to the Plastic Surgery Center team at Froedtert & The Medical College of Wisconsin to discuss surgical options. These include using a tissue expander/implant or the patient’s own tissue to reconstruct the breast. A tissue expander serves as a temporary implant that sits within the skin of the skin-sparing mastectomy. It is slowly enlarged over time with fluid by the plastic surgeon until it reaches its final size. At this time, it is switched out for a permanent implant. If the patients is a candidate to use their own tissue, a DIEP (deep inferior epigastic perforator) flap may be performed which uses the abdominal fat, blood vessels and skin to create a new breast mound while sparing the abdominal muscles. Other reconstructive options are also available.

For patients with invasive cancer who do not have documented lymph node involvement, evaluation of the lymph nodes under the armpit is essential. We perform a sentinel node biopsy at the time of the breast surgery. The idea of the sentinel node biopsy is that if the cancer has spread to this first node(s) in the armpit, it may have spread to other nodes. We send the sentinel node(s) for evaluation for tumor cells while the patient is under anesthesia at the time of the breast surgery. If it is positive for tumor cells, then we proceed with an axillary lymph node dissection, where we remove all of the lymph nodes under the armpit. If it does not have tumor cells, we leave the remaining lymph nodes in place.

Other Treatments

Patients who undergo a lumpectomy will require post-operative radiation therapy. The purpose of radiation therapy is that it reduces the chance of recurrent tumor in the remaining breast by more than 50 percent. Sometimes patients will require radiation after a mastectomy if they have a larger tumor or lymph nodes involved with cancer under the arm.

Chemotherapy is recommended if lymph nodes are involved with cancer or is dependent on the size of the tumor and other tumor characteristics. Each decision on whether a patient should receive chemotherapy is based on the individual. In certain cases, a 21-gene test, oncotypeDx, is used to see if the patient should receive chemotherapy in addition to hormonal therapy.

Hormonal therapy, consisting of Tamoxifen or an aromatase inhibitor, should be considered in any patient with a hormone receptor positive breast cancer, especially if the tumor is ≥1cm in size. Hormone therapy decreases the risk of recurrence and prevents new breast cancers. Tamoxifen is given to premenopausal patients. Aromatase inhibitors or Tamoxifen are offered to postmenopausal patients.

Other novel agents such as Herceptin (trastuzamab) are also available for tumors which are Her-2 Neu positive, which is another tumor marker. Herceptin, when given with chemotherapy, has been shown to reduce recurrence rates by 50 percent.

Follow-up

After you receive surgical treatment, you will be referred to one of our physicians in Medical Oncology or Radiation Oncology if necessary. Our cancer patients will be monitored carefully at least every six months for the first five years after their diagnosis and then yearly thereafter. Women treated by BCT will undergo a new baseline mammogram of the treated breast six months after surgery. Women treated by mastectomy, with or without reconstruction, no longer require mammogram studies of the side that underwent mastectomy. Women will continue to receive their yearly mammograms.

Conclusion

Breast cancer therapy is a constantly evolving process. Froedtert & The Medical College of Wisconsin are committed to providing up-to-date multidisciplinary treatment for our patients. Through weekly meetings at our tumor board consisting of surgeons, medical oncologists, radiation oncologists, pathologists, plastic and reconstructive surgeons and radiologists, we formulate individualized treatment plans for all of our breast cancer patients. In addition, we are committed to developing improved treatments for our patients and participate in several national clinical trials. The cornerstone to providing care to breast cancer patients is finding the best combination of surgery, medical therapy and radiation to optimize outcomes along with finding a plan that suits the needs of the patient.

Drs. Kong and Yen are part of the exceptional staff of physicians of the Breast Cancer Program.

Author: Amanda Kong, MD, and Tina Yen, MD, MS