BREAST CANCER ADJUVANT THERAPY

& Multidisciplinary Care

A Team Approach

Multidisciplinary health professionals for best breast cancer and gender-affirming surgery approach by Dr Saam Tourani

Our success in curing breast cancer is largely owed to the availability of multidisciplinary therapies. These including adjuvant therapies (those given after the surgery) and neoadjuvant therapies (those given before the surgery). There are often multiple specialists involved in your cancer care who are brought in and coordinated by your surgeon. Breast cancer care is truly a teamwork and by selecting Dr Tourani as your surgeon you can rest assured that your care is the hands of skilled, knowledgeable and caring specialists all along the way!

Surgery is a very important part of any curative treatment plan for breast cancer; however, the survival rate is often increased by adding other treatment modalities. These additional treatments can be broadly divided into local and systemic therapy options. The main local therapy option for breast cancer other than surgery is radiotherapy. On the other hand there are increasing numbers of systematic therapy options available depending on the cancer subtype.

Breast cancer adjuvant therapy

Radiotherapy

Patient lying down in a breast cancer radiotherapy machine

Radiotherapy is the use of radiation, usually x-rays or gamma rays, to kill cancer cells or damage them so they cannot grow and multiply. Radiotherapy is often combined with lumpectomy as part of a standard breast conservative therapy. The idea is that it kills the small amount of cancer cells that may have been left in the breast following surgery. Sometime radiotherapy is also recommended for patients who undergo mastectomy especially those with large tumours (>5cm) or involved armpit lymph nodes. Again, the idea is to eradicate the cancer cells that may have been left in the skin lymphatics or on the chest wall. If the cancer has spread to the lymph nodes, radiotherapy may also include the lymph node basins around the breast.

When you are referred for radiation, you will first have a consultation with a radiation oncologist who will discuss the pros and cons of radiotherapy with you and plan your treatment. The treatment is often delivered everyday Monday to Friday for 3-5 weeks. You will be in the treatment room for about 20min where you will be lying still while the radiation machine will move and buzz around you.

Systemic therapies will be administered as injection, infusion, or oral medications that circulate in your blood stream affecting the cancer cells in the entire body. You will see a medical oncologist who will elaborate on the benefits and side effects of various treatments and details of treatment duration and frequency. The systematic therapy options available for breast cancer can generally be divided into four categories described below. In addition, bone absorption inhibitors such as Zometa (Zoledronic acid) are often prescribed both to prevent and treat osteoporosis resulted from other systemic therapies and as an adjuvant therapy to prevent recurrence of cancer.

Systemic Therapies

Endocrine therapy is the most common type of systemic therapy for breast cancer as 60% of breast cancers are hormone receptor (estrogen and/or progesterone receptor) positive. They come in tablet form that are usually administered for 5 years. They either block the estrogen receptor or stop estrogen production. If you are premenopausal, you may also be given a monthly injection to suppress your ovaries.

Endocrine (Hormone) Therapy

Patient sitting on a chair in the infusion centre for breast cancer chemotherapy

Not all women with breast cancer will need chemotherapy. When deciding on chemotherapy the most important determinant is the tumour subtype. Chemotherapy is often indicated in triple negative and Her2 positive tumours, which is often given in the neoadjuvant setting (before surgery). For hormone positive, Her2 negative cancers chemotherapy, if indicated, is usually administered in the adjuvant setting, before radiotherapy and endocrine therapy. A combination of multiple factors including age, lymph node status, tumour size, grade and proliferative index (Ki-67) is used to decide if chemotherapy is beneficial in hormone positive, Her2 negative cancers. In some borderline cases, genomic profiling of the tumour is requested for a more precise prediction of chemotherapy benefit.

Chemotherapy

Breast cancer genomics. Familial breast cancer genetic testing by leading breast surgeon Dr Saam Tourani

Cancer Genomics

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Cancer Genomics 〰️

Targeted therapies are increasing being used to treat breast cancer. These are not cytotoxic medications like chemotherapy drugs. They are designed to attack specific molecular agents or pathways involved in the development of cancer. Anti-Her2 medication Herceptin has been around the longest and is indicated in Her2 positive cancers which accounts for about 20% of cases. More anti-Her2 drugs have become available since including Perjeta, Kadcyla and Enhertu.

CDK 4/6 inhibitors, such as Abemaciclib, Palbociclib, and Ribociclib, are another category of targeted therapies that are used in hormone receptor positive cancers.

Targeted therapy

TImmunotherapy is a type of cancer treatment designed to boost the body’s natural defences to fight the cancer. Their use in triple negative cancers (for which we don’t have targeted therapy options) have been associated with improved response to treatment and survival.

Immunotherapy

Additional Resources