Early Breast Cancer
Breast cancer occurs when normal breast cells start to change and grow in abnormal and uncontrolled ways. There are several types of breast cancer. In early breast cancer, the cancer is contained to the breast and possibly the surrounding lymph nodes but does not involve other parts of the body.
What is breast cancer?
Breast cancer is common, with 1 in 7 Australian women (and 1 in 700 men) expected to develop breast cancer in their lifetime. It occurs when normal cells in the breast change and start to grow in abnormal and uncontrolled ways.
Breast cancer is often discovered when a person feels a lump in one of their breasts. Other symptoms include changes in shape or size of the breast or nipple, changes in the skin, or persistent or unusual pain. Breast cancer may also be detected on routine screening mammography, for example, at Breastscreen.
What is early breast cancer?
We often talk about stages of breast cancer. Breast cancer staging reflects the size of the cancer within the breast, and the number of local lymph nodes involved. In early breast cancer, the cancer is contained to the breast – and may also have spread to surrounding lymph nodes – but not other parts of the body.
Stages of breast cancer
The staging system usually used for breast cancer is the TNM system. These letters and numbers used to describe how large the tumour is (T), the degree of nearby lymph node involvement (N) and whether the cancer has spread or 'metastasised' to other organs (M). This system is complex, but you can ask your treating doctors to explain this in more detail and how it applies to your management.
Usually, the stage is determined at the time of diagnosis using a combination of imaging (eg mammogram and ultrasound) and clinical examination. Sometimes your treating doctors will ask for further imaging to be done to clarify the stage.
Different types of breast cancer
Breast cancer is not just one disease. There a several different subtypes that are determined by the presence or absence of molecules called 'receptors' on breast cancer cells. Treatment options vary according to these different subtypes. The three receptors which determine these subtypes are the oestrogen receptor (ER), the progesterone receptor (PR) and the HER2 receptor.
The main subtypes of breast cancer are:
Hormone receptor positive, HER2 negative breast cancer (ER and/or PR positive, HER2 negative) – around 60-70% of breast cancers
HER2 positive breast cancer (HER2 positive and ER and/or PR positive (so-called ‘Luminal HER2 positive’) or HER2 positive and ER/PR negative) – around 15-20% of breast cancers
Triple negative breast cancer (ER, PR and HER2 negative) – around 10-15% of breast cancers
Breast cancers may also be defined by ‘histological’ subtype. This refers to the specific growth pattern and structure of the cells. Around 80 per cent of breast cancers are invasive ductal carcinomas, which means the cancer has spread to the surrounding breast tissues. A smaller proportion (around 10 per cent) are invasive lobular carcinomas, which begin in the milk-producing glands called the lobules. Less common histological subtypes include mucinous, tubular, metaplastic, medullary, micropapillary or papillary carcinomas.
Breast cancer is a common yet highly individual experience. Dr Forster can answer any questions about your diagnosis and what this means for your treatment at your consultation.
Management of early breast cancer
Treatment for breast cancer depends on many factors including the type of cancer, the grade and stage of the cancer, and a person’s individual health circumstances and preferences. Most people will have a combination of treatments with care managed by a team of specialised health professionals.
Breast cancer care and multi-disciplinary teams
When a person is diagnosed with breast cancer, it is best practice for a multi-disciplinary team of health professionals to work together to coordinate the best possible treatment and care.
Dr Forster is a member of the Mater Hospital Breast Cancer multidisciplinary team (MDT). The team includes breast surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, breast care nurses, clinical trials coordinators and other health professionals who meet to review each patient’s pathology, radiological and clinical history before making an individualised recommendation for care.
Treatments for early breast cancer
Most people with a diagnosis of breast cancer will be offered a combination of treatments. For example, surgery to remove the cancer, radiotherapy to kill cancer cells in the remaining breast and local area, and 'systemic' drug therapy to prevent cancer from coming back (or sometimes before surgery to shrink the cancer and make it easier to remove).
Breast & Axillary Surgery +
Breast surgery
Breast surgery to remove breast cancer usually involves either breast conserving surgery (also called a lumpectomy or wide local excision) to remove the cancer and a small area of normal breast tissue around it, or a mastectomy which is surgery to remove the whole breast. Breast surgeons take many factors into consideration when advising people on their options for breast surgery. If a mastectomy is recommended, options for breast reconstruction will also be discussed.
Axillary surgery
As breast cancer cells can spread through the lymphatic channels, surgery to remove lymph nodes from the axilla (armpit) is a routine part of the treatment of early breast cancer. This occurs at the same time as surgery for the breast. The type of lymph node surgery depends on whether lymph node involvement is detected on imaging on clinical examination.
If there is no evidence that the cancer involved the lymph nodes at diagnosis, then a procedure called a sentinel lymph node biopsy is performed. This procedure involves identifying the lymph nodes that the breast drains to first and removing these for pathological assessment. These lymph nodes are identified by a nuclear medical investigation called lymphoscintigraphy, as well as the injection of blue dye into the tumour. If cancer cells are detected within the lymph nodes on histopathological examination, then more local treatment may be required to treat the axilla. This may mean further surgery in the form of an axillary clearance (also called axillary lymph node dissection), or radiotherapy, or both.
If involvement of axillary lymph nodes is detected at diagnosis, then an axillary clearance is usually the standard management. This involves surgical removal of most or all of the lymph nodes from the armpit. This usually occurs at the same time as the breast surgery.
Your breast surgeon is best placed to discuss these procedures in more detail.
Radiotherapy +
Radiotherapy uses x-rays to kill cancer cells in the area it is aimed at. Radiotherapy is usually needed after breast conserving surgery, and sometimes after mastectomy too, depending on the specific cancer. If radiotherapy is recommended, a radiation oncologist will discuss the benefits and potential side effects of this treatment in detail.
Systemic drug therapy +
A range of systemic drug therapies are used in the treatment and management of breast cancers. These include chemotherapy, hormonal therapy, targeted therapy, bisphosphonates and immunotherapy. Cancer management with drug therapies is supervised by medical oncologists who are physicians specialising in cancer treatment.
Chemotherapy – adjuvant and neoadjuvant +
Chemotherapy is a type of medicine which attacks fast-growing cells in your body including cancer cells. In early breast cancer, the intent of chemotherapy is to cure the disease by killing any undetectable cancer cells that have escaped the breast and lymph nodes. It is usually administered using a cannula (drip) inserted into a vein in the hand or arm. A course of chemotherapy for early breast cancer can take between 3-6 months depending on the recommended drug combination or 'regimen'.
In the past, chemotherapy was mostly given after surgery. This is termed 'adjuvant' chemotherapy and is still common. However, today, chemotherapy is also often used prior to breast surgery to shrink the cancer and kill any cancer cells beyond the breast and lymph nodes. When chemotherapy is given prior to surgery it is termed 'neoadjuvant' chemotherapy.
Read more about adjuvant and neoadjuvant chemotherapy here.
Hormonal therapy +
Hormonal therapy or ‘endocrine therapy’ is medicine used to treat forms of breast cancer which grow in response to hormones (oestrogen (ER) and/or progesterone (PR) receptor positive breast cancer). Endocrine therapy is a tablet taken every day to prevent the body from making oestrogen and progesterone, or to stop hormones from stimulating the growth of cancer cells.
For premenopausal women, monthly injections of a medication called goserelin may also be used to stop the ovaries from making oestrogen. Having the ovaries surgically removed is an alternative option which may also be recommended to reduce the amount of hormone circulating in the body. Hormonal therapy for breast cancer is usually given for at least five years, and up to 10 years depending on the individual risk of cancer recurrence.
Read more about hormonal therapy here.
Targeted therapy for HER2 positive breast cancer +
Targeted therapy may be required for treatment of a type of early breast cancer called HER2 positive breast cancer. Targeted therapies are types of medicines designed to interfere with breast cancer growth signals by binding to receptors on the cancer cells to stop the cells growing and dividing. Herceptin (also called trastuzumab) is a type of targeted therapy given intravenously with chemotherapy in HER2 positive breast cancer. Other types of targeted therapy may also be used depending on the individual circumstances.
Bisphosphonates +
Bisphosphonates are a group of medicines usually used to treat bone problems such as osteoporosis. In postmenopausal women with early breast cancer who have required chemotherapy, these medicines have also been demonstrated to reduce the risk of recurrence of cancer in the bones, as well as improving overall survival outcomes.
The main benefit of using bisphosphonates in early breast cancer treatment is to reduce the risk of recurrence and improve survival. A secondary benefit for some women is to offset the effect of hormonal treatments on bone density.
Read more about bisphosphonates here.
Immunotherapy +
Immunotherapy is a type of medicine given to stimulate the body's own immune system to attack cancer cells. Immunotherapy in breast cancer treatment is usually given intravenously, in combination with chemotherapy. Immunotherapy has so far only been demonstrated to benefit a small number of people with a specific subtype of breast cancer called triple negative breast cancer.