Errors of breast oncologists contributing to reduction of the patients’ life:
The erroneous orientation of the patient to preserving the breast without taking into account the condition stage and without the objective prerequisites to do so. The contribution of this factor is approximately 10% in the total mortality from mammary cancer.
A false negative diagnosis, when a comprehensive initial examination was completed and a preliminary diagnosis was established, but the biopsy was falsely performed on a healthy zone and/or the histological study had an inadequate quality. This tragic mistake contributes 2–5% to the total mortality.
Erroneous underestimation of the surgery scope, when instead of the subcutaneous mastectomy, a sectoral resection is performed, or instead of the radical mastectomy, any other surgical intervention is performed.
False negative postoperative biopsy, when a histological and/or immunohistochemical study of the material removed from a woman erroneously does not reveal cancerous cells at the resection margins. As a result, there is a relapse and a repeated resection, contributing 2–5% to the total mortality
An inadequately selected chemotherapy, given that the ideal basis for any complex immune, hormonal, and polychemotherapy is ensured by comprehensive genetic testing based on both the definition of point mutations specific to mammary cancer and the determination of the entire tumor genotype. It is accountable for about 50% of premature deaths
A short polychemotherapy, most often it happens that 2–4 cycles are performed instead of 3 sets of 7 cycles required by the NCCN recommendation, for a total of 21 cycles. This factor gives about 30% of all cases of premature death from mammary cancer.
Mammary cancer treatment methods
Surgical mammary cancer therapy
Only surgery guarantees women a cure for cancer. Clinical studies have convincingly proved that, according to the forecast, a partial removal of breast tissue with subsequent irradiation is not worse compared to complete breast removal, that is, resection and mastectomy are equivalent in terms of the result expressed as life expectancy without any tumor signs. Surgical approach depends on the tumor size and the degree of its aggressiveness. With a neoplasm, beginning at stage 0 and even at stage 3 of an initially operable process, an organ-preserving surgery is possible, of course, if the volume of the mammary gland itself allows. The larger is the reproductive organ, the greater is the surgical capability to preserve it.
Organ-preserving operative interventions include sectoral or segmental resection, also known as lumpectomy or quadrantectomy, when the tumor and at least 3 centimeters of surrounding healthy tissue are excised. Healthiness is crucially important, as there should be no cancer cells at the margins, which is checked by an urgent histological examination in the course of surgery. If at least one cancer cell is found under a microscope on the edges of the removed tissue, the surgeon will perform an additional excision called «re-resection», and send the tissue for histology. Radiation therapy is always performed after resection and wound healing and, if necessary, after several cycles of chemotherapy.
Mastectomy means complete removal of the gland together with adipose tissue from under the scapula and armpit, various modifications also entail removal of some pectoral muscles. Current standards also regard as absolutely radical the subcutaneous mastectomy, when all of the above is removed in a single block leaving a skin «pouch» for implant installation. A subcutaneous or skin-preserving surgery is possible only in the absence of cancer cells in the skin. The implant can be installed at once or after a while, and the process of artificial breast recreation is called reparative surgery. After completing special treatment, some women are offered corrective surgery on a healthy gland for symmetry.
With metastases to the axillary lymph nodes, they are completely removed along with cellular tissue (lymphadenectomy) in addition to a radical resection or mastectomy. The presence of metastases is detected during surgery with a biopsy of the sentinel lymph node, the one closest to the breast.
After surgery, chemotherapy is not performed with a cancer nodule less than 5 millimeters in the absence of metastases in the lymphatic basin ascertained by histological study, because additional medication will not change a woman’s life for the better.
In all other clinical situations, the issue of additional drug exposure is necessarily resolved after surgery. Preventive chemotherapy should preclude relapse and metastases, or postpone their appearance for as long as possible.
Chemotherapy treatment is necessarily based on the molecular biological subtype of the malignant tumor. It is possible to refrain from preventive chemotherapy with a high hormone dependence of the cancer, and a long-term hormone therapy is prescribed instead in such cases.
With an initially inoperable cancer, antitumor treatment starts with chemotherapy, prior to which a piece of tumor is taken for study of its cellular structure. The effect of the use of cytostatic drugs before surgery is expected in the absence of signs of hormonal dependence in the tumor, its high aggressiveness, and a triple negative type of cancer. Schemes with the most active cytostatics are applied, and treatment takes about six months, even with a significant decrease in the tumor after initial cycles. The benefits of treatment are undoubted if it was possible to completely or maximally reduce the cancer node, creating the technical conditions to performing radical surgery.
At stage 4 of mammary cancer, drug therapy is the leading method of treatment that begins with chemotherapy, then, in the presence of hormone receptors in tumor cells, perennial hormone therapy is performed. In very elderly women with a number of serious conditions and signs of hormonal sensitivity, hormonal drugs are applied at the first stage.
Chemotherapy is a difficult treatment and is always associated with complications that can and should be minimized. To improve tolerability and apply truly optimal concentrations of cytostatic drugs, an individual program is developed for each patient at the Clinic Medicine 24/7, it is also possible to elaborate a scheme by the sensitivity of cancer cells to drugs.
Given the unconditional dependence of cancer on the activity of the endocrine glands, it is far from always that the tumor responds to hormonal drugs. The efficacy of therapeutic hormones is predicted by the level of sex hormone receptors, estrogens and progestins. In principle, a positive result is possible with one percent of estrogen-dependent tumor cells, but the higher is their level, the greater is the benefit.
Hormone therapy is performed after the operation or instead of it in case of a metastatic condition. Currently, hormonal drugs are used even at cancer stage 0, the goal being not to prevent the appearance of metastases, but to prevent cancer development in another gland.
Preventive or adjuvant hormone treatment at any stage takes at least 5 years, if metastases occur during this time, then chemotherapy is performed and the hormonal drug is changed. With a metastatic process, hormonal agents are applied before progression.
Choice of the hormonal drug depends on the state of the menstrual function, accordingly only Tamoxifen is prescribed to menstruating women, while aromatase inhibitors and Tamoxifen are prescribed after menopause (the last menstruation in life).
Clinical studies did not help to choose the best endocrine drug, as both groups of drugs showed high efficacy and similar complications, but with different frequency of occurrence.
Radiation mammary cancer therapy
At the present stage, radiation therapy is a high-tech method that requires a CT scan and an X-ray simulator for optimal calculation of irradiation fields, this is 3D treatment on electron or proton accelerators.
The goal of irradiation is to kill all cancer cells and preserve the viability of normal tissues adjoining the tumor. The task of radiation therapy for mammary cancer is to prevent a relapse in the surgery area, therefore, at any stage irradiation complements radical resection.
At stage 2–3, irradiation is also performed after mastectomy, in some cases it is intensified by a ‘boost’ that makes it possible to bring more radiation power to the local area of the cicatrix. Radiation therapy begins after wound healing, that is, not earlier than 4 weeks after surgery.
If the patient requires chemotherapy, the necessary number of cycles is first performed, and irradiation is started after a couple of weeks in order to avoid severe radiation reactions. The period for radiation therapy commencement after surgery is quite broad, ranging from one to three months.
With an inoperable process, radiation therapy also starts 2–4 weeks after a full course of chemotherapy and can be performed together with hormone therapy. To improve the effect, it can be supplemented by local hyperthermia.
Radiation therapy always starts on Monday and ends on Friday leaving the weekend free, which allows normal tissues to recover. The number of sessions is determined by the goal — preventive treatment takes at least 25 days, while curative therapy of a non-removed tumor requires 30–35 procedures.
Radiation therapy does not affect life expectancy, but protects the woman from cancer recurrence.