breast cancer management breast cancer management breast cancer management takes different approaches depending on physical and biological characteristics of the disease, as well as the age, over-all health and personal preferences of the patient. treatment types can be classified into local therapy (surgery and radiotherapy) and systemic treatment (chemo-, endocrine, and targeted therapies). local therapy is most efficacious in early stage breast cancer, while systemic therapy is generally justified in advanced and metastatic disease, or in diseases with specific phenotypes. historically, breast cancer was treated with radical surgery alone. advances in the understanding of the natural course of breast cancer as well as the development of systemic therapies allowed for the use of breast-conserving surgeries, however, the nomenclature of viewing non-surgical management from the viewpoint of the definitive surgery lends to two adjectives connected with treatment timelines: adjuvant (after surgery) and neoadjuvant (before surgery). the mainstay of breast cancer management is surgery for the local and regional tumor, followed (or preceded) by a combination of chemotherapy, radiotherapy, endocrine (hormone) therapy, and targeted therapy. research is ongoing for the use of immunotherapy in breast cancer management. management of breast cancer is undertaken by a multidisciplinary team, including medical-, radiation-, and surgical- oncologists, and is guided by national and international guidelines. factors such as treatment, oncologist, hospital and stage of your breast cancer decides the cost of breast cancer one must pay. staging staging breast cancer is the initial step to help physicians determine the most appropriate course of treatment. as of 2016, guidelines incorporated biologic factors, such as tumor grade, cellular proliferation rate, estrogen and progesterone receptor expression, human epidermal growth factor 2 (her2) expression, and gene expression profiling into the staging system. cancer that has spread beyond the breast and the lymph nodes is classified as stage iv, or metastatic cancer, and requires mostly systemic treatment. the tnm staging system of a cancer is a measurement of the physical extent of the tumor and its spread, where: t stands for the main (primary) tumor (range of t0-t4) n stands for spread to nearby lymph nodes (range of n0-n3) m stands for metastasis (spread to distant parts of the body; either m0 or m1) if the stage is based on removal of the cancer with surgery and review by the pathologist, the letter p (for pathologic) or yp (pathologic after neoadjuvant therapy) may appear before the t and n letters. if the stage is based on clinical assessment using physical exam and imaging, the letter c (for clinical) may appear. the tnm information is then combined to give the cancer an overall stage. stages are expressed in roman numerals from stage i (the least advanced stage) to stage iv (the most advanced stage). non-invasive cancer (carcinoma in situ) is listed as stage 0. tnm staging, in combination with histopathology, grade and genomic profiling, is used for the purpose of prognosis, and to determine whether additional treatment is warranted. classification main article: breast cancer classification breast cancer is classified into three major subtypes for the purpose of predicting response to treatment. these are determined by the presence or absence of receptors on the cells of the tumor. the three major subgroups are: luminal-type, which are tumors positive for hormone receptors (estrogen or progesterone receptor). this subtype suggests a response to endocrine therapy. her2-type, which are positive for over-expression of the her2 receptor. er and pr can be positive or negative. this subtype receives targeted therapy. basal-type, or triple negative (tn), which are negative for all three major receptor types additional classification schema are used for prognosis and include histopathology, grade, stage, and genomic profiling. surgery excised breast tissue showing a stellate, pale area of cancer measuring 2 cm across. the tumor could be felt as a hard, mobile lump before the surgical excision. surgery is the primary management for breast cancer. depending on staging and biologic characteristics of the tumor, surgery can be a lumpectomy (removal of the lump only), a mastectomy, or a modified radical mastectomy. lymph nodes are often included in the scope of breast tumor removal. surgery can be performed before or after receiving systemic therapy. women who test positive for faulty brca1 or brca2 genes can choose to have risk-reducing surgery before the cancer appears. lumpectomy techniques are increasingly utilized for breast-conservation cancer surgery. studies indicate that for patients with a single tumor smaller than 4 cm, a lumpectomy with negative surgical margins may be as effective as a mastectomy. prior to a lumpectomy, a needle-localization of the lesion with placement of a guidewire may be performed, sometimes by an interventional radiologist if the area being removed was detected by mammography or ultrasound, and sometimes by the surgeon if the lesion can be directly palpated. however, mastectomy may be the preferred treatment in certain instances: two or more tumors exist in different areas of the breast (a "multifocal" cancer) the breast has previously received radiotherapy the tumor is large relative to the size of the breast the patient has had scleroderma or another disease of the connective tissue, which can complicate radiotherapy the patient lives in an area where radiotherapy is inaccessible the patient wishes to avoid systemic therapy the patient is apprehensive about the risk of local recurrence after lumpectomy specific types of mastectomy can also include: skin-sparing, nipple-sparing, subcutaneous, and prophylactic. standard practice requires the surgeon to establish that the tissue removed in the operation has margins clear of cancer, indicating that the cancer has been completely excised. additional surgery may be necessary if the removed tissue does not have clear margins, sometimes requiring removal of part of the pectoralis major muscle, which is the main muscle of the anterior chest wall. during the operation, the lymph nodes in the axilla are also considered for removal. in the past, large axillary operations took out 10 to 40 nodes to establish whether cancer had spread. this had the unfortunate side effect of frequently causing lymphedema of the arm on the same side, as the removal of this many lymph nodes affected lymphatic drainage. more recently, the technique of sentinel lymph node (sln) dissection has become popular, as it requires the removal of far fewer lymph nodes, resulting in fewer side effects while achieving the same 10-year survival as its predecessor. the sentinel lymph node is the first node that drains the tumor, and subsequent sln mapping can save 65–70% of patients with breast cancer from having a complete lymph node dissection for what could turn out to be a negative nodal basin. advances in sln mapping over the past decade have increased the accuracy of detecting sentinel lymph node from 80% using blue dye alone to between 92% and 98% using combined modalities. sln biopsy is indicated for patients with t1 and t2 lesions (<5 cm) and carries a number of recommendations for use on patient subgroups. recent trends continue to favor less radical axillar node resection even in the presence of some metastases in the sentinel node. a meta-analysis has found that in people with operable primary breast cancer, compared to being treated with axillary lymph node dissection, being treated with lesser axillary surgery (such as axillary sampling or sentinel lymph node biopsy) does not lessen the chance of survival. overall survival is slightly reduced by receiving radiotherapy alone when compared to axillary lymph node dissection. in the management of primary breast cancer, having no axillary lymph nodes removed is linked to increased risk of regrowth of cancer. treatment with axillary lymph node dissection has been found to give an increased risk of lymphoedema, pain, reduced arm movement and numbness when compared to those treated with sentinel lymph node dissection or no axillary surgery. ovary removal prophylactic oophorectomy may be prudent in women who are at a high risk for recurrence or are seeking an alternative to endocrine therapy as it removes the primary source of estrogen production in pre-menopausal women. women who are carriers of a brca mutation have an increased risk of both breast and ovarian cancers and may choose to have their ovaries removed prophylactically as well. breast reconstruction main article: breast reconstruction breast reconstruction surgery is the rebuilding of the breast after breast cancer surgery, and is included in holistic approaches to cancer management to address identity and emotional aspects of the disease. reconstruction can take place at the same time as cancer-removing surgery, or months to years later. some women decide not to have reconstruction or opt for a prosthesis instead. investigational surgical management cryoablation is an experimental therapy available for women with small or early-stage breast cancer. the treatment freezes, then defrosts tumors using small needles so that only the harmful tissue is damaged and ultimately dies. this technique may provide an alternative to more invasive surgeries, potentially limiting side effects. radiation therapy radiation therapy is an adjuvant treatment for most women who have undergone lumpectomy and for some women who have mastectomy surgery. in these cases the purpose of radiation is to reduce the chance that the cancer will recur locally (within the breast or axilla). radiation therapy involves using high-energy x-rays or gamma rays that target a tumor or post surgery tumor site. this radiation is very effective in killing cancer cells that may remain after surgery or recur where the tumor was removed. radiation therapy can be delivered by external beam radiotherapy, brachytherapy (internal radiotherapy), or by intra-operative radiotherapy (iort). in the case of external beam radiotherapy, x-rays are delivered from outside the body by a machine called a linear accelerator or linac. in contrast, brachytherapy involves the precise placement of radiation source(s) directly at the treatment site. iort includes a one-time dose of radiation administered with breast surgery. radiation therapy is important in the use of breast-conserving therapy because it reduces the risk of local recurrence. radiation therapy eliminates the microscopic cancer cells that may remain near the area where the tumor was surgically removed. the dose of radiation must be strong enough to ensure the elimination of cancer cells. however, radiation affects normal cells and cancer cells alike, causing some damage to the normal tissue around where the tumor was. healthy tissue can repair itself, while cancer cells do not repair themselves as well as normal cells. for this reason, radiation treatments are given over an extended period, enabling the healthy tissue to heal. treatments using external beam radiotherapy are typically given over a period of five to seven weeks, performed five days a week. recent large trials (uk start and canadian) have confirmed that shorter treatment courses, typically over three to four weeks, result in equivalent cancer control and side effects as the more protracted treatment schedules. each treatment takes about 15 minutes. a newer approach, called 'accelerated partial breast irradiation' (apbi), uses brachytherapy to deliver the radiation in a much shorter period of time. apbi delivers radiation to only the immediate region surrounding the original tumor and can typically be completed over the course of one week. indications for radiation radiation treatment is mainly effective in reducing the risk of local relapse in the affected breast. therefore, it is recommended in most cases of breast conserving surgeries and less frequently after mastectomy. indications for radiation treatment are constantly evolving. patients treated in europe have been more likely in the past to be recommended adjuvant radiation after breast cancer surgery as compared to patients in north america. radiation therapy is usually recommended for all patients who had lumpectomy, quadrant-resection. radiation therapy is usually not indicated in patients with advanced (stage iv disease) except for palliation of symptoms like bone pain or fungating lesions. in general recommendations would include radiation: as part of breast conserving therapy. after mastectomy for patients with higher risk of recurrence because of conditions such as a large primary tumor or substantial involvement of the lymph nodes. other factors which may influence adding adjuvant radiation therapy: tumor close to or involving the margins on pathology specimen multiple areas of tumor (multicentric disease) microscopic invasion of lymphatic or vascular tissues microcopic invasion of the skin, nipple/areola, or underlying pectoralis major muscle patients with extension out of the substance of a ln inadequate numbers of axillary ln sampled types of radiotherapy the savi applicator is a multiple catheter breast brachytherapy device.