Breast cancer | Looking Back: The Evolution of Treatment Methodologies Over the Decades in Breast Cancer Care

Breast cancer is the most common form of cancer in women all over the world, including India. In fact, breast cancer accounts for a third of all cancers that affect women in the country. According to a study by the ICMR, the current age-standardized breast cancer rate is around 25.8 for a lakh woman and is expected to increase to 35 for a lakh woman by 2026. This is the The most common invasive cancer in women and the second leading cause of cancer-related deaths after lung cancer. Breast cancer forms in the lobules or ducts of the breast. It can also occur in fatty tissue or fibrous connective tissue of the breast. Cancer can spread outside the breast through blood vessels and lymph vessels. Breast cancer can be classified as “invasive”, “non-invasive” or “in situ”. While invasive breast cancer spreads from mammary ducts or glands to other parts of the body, non-invasive breast cancer does not spread from the original tissue.

Factors such as increased sedentary lifestyles, smoking, obesity, alcohol consumption and genetics have all contributed to the increased incidence of breast cancer. Unfortunately, the prevalence of taboos, myths and low awareness of the disease and its treatment results in late presentation and affects the success rate of treatment. Breast cancer is among the best-known research cancers in the medical ecosystem, and technological advancements in screening, diagnosis and subsequent treatment have helped dramatically improve patient outcomes. The evolution of breast cancer treatment over the past two decades has been phenomenal with the ability to detect cancers as small as 3 to 5 mm in the breast through various imaging techniques and to detect metastases from a distance with scans like PET-CT. Advances in imaging technology enable the acquisition of clinically important and actionable information about the disease in real time.

Evolution of treatment methodologies over the decades

1. Mastectomy, which was first performed around 1882, is the surgical removal of the entire breast. At the time, mastectomies were very invasive, requiring removal of the breast, lymph nodes, and underlying muscle. The drastic procedure caused pain and long-term disability in the patients. However, mastectomy has evolved over time and currently the procedure is less drastic and in appropriate cases there are even ways to preserve the skin (skin sparing mastectomy) as well as the nipple (nipple sparing mastectomy) in combination with reconstructive surgeries, to shape a new breast with tissue taken from other parts of the body or with silicone.

Benefits: Helps in local control of breast cancer in those with extensive local disease. It is also used as a risk reduction method in patients with a gene defect that increases their risk of breast cancer.

2. Lumpectomy, also known as breast-conserving surgery, was developed in the 1970s and was a less invasive surgical option than mastectomies. In 1985, research found that lumpectomy followed by radiation therapy gave women a chance of survival equal to the more invasive mastectomy. This procedure is currently used to remove the cancerous tumor and a small margin of healthy tissue around the tumor and provides the same benefits as before.

Benefits: Allows women to retain their breasts, with enormous psychological benefits.

3. Sentinel lymph node biopsy was a procedure that was developed in 1991 to identify, remove, and examine the first draining lymph nodes in the armpit (sentinel nodes) for cancer cells. In some patients, this procedure helps prevent more extensive armpit surgery. Saving lymph nodes that do not have cancer is not only oncologically safe, but also prevents the development of potentially serious side effects from the removal of all the glands that work to aid lymphatic drainage.

Benefits: Sentinel node biopsy is the standard of care and can help minimize damage to the lymphatic drainage in the arm by preserving the lymph nodes and lymph in the armpit.

4.axillary lymph node dissection, first advocated as part of the treatment of invasive breast cancer in the 18th century, involves the removal of several lymph nodes under the arm. The actual number of lymph nodes removed varies from person to person. Axillary lymph node dissection is only necessary for women with early stage breast cancer with small amounts of cancer in the sentinel nodes.

Benefits: This eliminates cancer cells from the armpit and the number of nodes involved is a marker of the aggressiveness of the tumor guide.

5. Radiotherapy developed in the 20th century to shrink cancerous tumors of all kinds involves the use of high-energy x-rays or other particles to destroy cancer cells. For breast cancer, radiation therapy is used to reduce the risk of the cancer coming back in the retained breast or in the chest wall after a mastectomy. There are several types of radiation therapy: external beam radiation therapy (given from a machine outside the body), intraoperative radiation therapy (given through a probe in the operating room) and brachytherapy ( administered by placing radioactive sources into the tumor). Recently, researchers developed a very high-throughput radiation therapy beam to treat cancer while reducing side effects.

Benefits: Reduce the risk of local recurrence. It can also be used to shrink and kill metastatic cancer cells that have spread from the breast to the bones or the brain.

6. Therapies using the drug can be classified into – chemotherapy, hormone therapy, targeted therapy and immunotherapy. While chemotherapy became an option after World War II, hormone therapy came into being in the 1960s and targeted therapy was discovered in the 1970s. Immunotherapy was developed in 1986 with the expansion of Immunotherapy drugs that took place in the early to mid-1990s. These can also help destroy cancer cells. Common ways of giving systemic therapy include an intravenous (IV) tube placed into a vein with a needle, an injection into a muscle or under the skin, or into a pill or capsule that is swallowed ( orally). It is used to shrink cancerous tumors before surgery, prevent recurrence after surgery, and treat cancer that has metastasized or has spread to other parts of the body. Highly specialized gene tests can be performed on tumor tissue to profile it and assess the need for chemotherapy more definitively, thus avoiding over or under treatment in large numbers of patients.

Benefits: These therapies are used to reduce the risk of the cancer spreading, to treat the cancer that has spread, and to reduce the risk of the disease coming back.

The bottom line

The treatment of breast cancer is constantly evolving. There are huge advances in everything from preventive measures to early detection and effective targeted treatments. This approach to individualizing care, tailored specifically to each woman, has led to phenomenally high cure rates. The most important message, however, is that the success of treatments depends on the stage of presentation. The bottom line is that early detection is always the key!

Disclaimer: The article was written by Dr Kanchan Kaur, Director of Breast Services, Cancer Institute, Medanta. The opinions expressed are personal.