"Medical tourism offers a unique opportunity for patients seeking high-quality breast cancer treatment at a fraction of the cost, while also gaining access to cutting-edge technologies and specialized care that may not be available in their home countries. With leading hospitals and internationally accredited oncologists, medical tourism provides patients with hope, advanced treatment options, and a supportive environment for recovery."
What is breast cancer?
Cancer is the uncontrolled growth of cells within the body. Usually, all of our cells have a specific lifespan of days to years that is genetically programmed in our DNA. When our DNA becomes damaged, either through the aging process, exposure to toxins such as radiation or chemicals or through inherited genes, some cells do not die a natural death but continue to grow. As they do, they form new cells with the same genetic misinformation. These extra cells may form masses or tumours that can be either malignant or benign. A benign tumour is a tumour that does not invade the surrounding tissue or spread around the body and stays in one place. A malignant tumour can invade the surrounding tissue or spread via the blood or lymph networks and affects other cells and organs.
Breast cancer is the second most common type of cancer in women but 1% of all cases are men. Invasive and non-invasive breast cancers are diagnosed in their hundreds of thousands every year, yet remission rates are consistently increasing due to advances in treatment, screening and more awareness of symptoms in the general population.
Most breast cancer is first diagnosed when high-risk women and men are screened at local clinics, or come to their general practitioner reporting a small, hard lump in the tissue of the breast. Furthermore, most women are now aware of the BRCA acronym that stands for ‘breast cancer gene’. The presence of variances of this gene can increase one’s chances of developing breast cancer and those with BRCA1 or BRCA2 are usually given the opportunity to visit their local hospital for regular screening by way of a mammogram.
As breast cancer is so common, research abounds, even in the field of screening methods. Only recently, twice-yearly MRI (magnetic resonance imaging) by experienced radiologists has been proposed as a better alternative than annual mammograms, especially in younger, higher-risk women.
Early diagnosis usually happens where breast cancer has run in families or a person has (and feels) a small, localised lump. Treatments for breast cancer are primarily aimed at tumour removal and preventing further growth. Some women at high risk of developing breast cancer may be considering a preventive bilateral mastectomy; however, this route is rarely advised. Whether you have been diagnosed with breast cancer or are in a high-risk group, Remedazo can put you in touch with expert oncologists for up to three free online consultations to discuss your considerable options.
Should you need to have one or both breasts removed, new techniques in reconstructive surgery can help you regain your pre-surgical silhouette; however, current breast surgery techniques look at the cell type and rate of growth of cancerous cells and try to limit the amount of tissue that is removed. A lumpectomy (removal of the tumour) can achieve complete remission in many cases.
Are there different types of breast cancer?
There are various forms of breast cancer and your medical notes may be difficult to understand. Most specific types are based upon the location and type of abnormal cells.
The breast is primarily composed of glandular (milk-producing) and fatty tissues. Each glandular section is divided into lobes, and these lobes are divided into smaller lobules. A lobule produces breast milk. This milk travels through ducts that meet at the nipple which is surrounded in darker tissue known as the areola. The breasts also contain connective tissue, nerves, ligaments, blood vessels, lymph vessels and lymph nodes. Men have no glandular tissue or ducts and their breasts contain primarily fatty deposits. Hormone imbalances in men can cause gynaecomastia or larger breast tissue in men.
The different tissue types and structures can lead to varying breast cancer types. Types are also categorised according to cell type and whether a tumour is invasive or non-invasive, for example. More recently, genomic research categorises breast cancers according to their gene and protein types. The majority are oestrogen-positive, 20% are HER2-positive, and the same percentage accounts for triple-negative breast cancers.
Naturally, it must be said that a great many lumps found in the breasts of women and men are benign. Cysts, fibrous noncancerous tumours, hyperplasia (excess growth of normal cells), papilloma, adenosis, fat necrosis and inflammation can cause similar symptoms and are not malignant. An experienced radiologist will be able to detect discernible differences; however, sometimes a biopsy is the only way of finding out whether a lump is benign or malignant.
Invasive breast cancer
Where breast cancer cells spread into other areas via the blood circulation or lymph, the term invasive breast cancer is used. If invasive breast cancer reaches organs such as the bones, lungs, liver or brain, the term metastatic breast cancer is used.
Non-invasive breast cancer (in-situ breast cancer)
When breast cancer cells remain in a single location in the breast and do not spread beyond that location, either into other lobules or lobes, that cancer is said to be in-situ or non-invasive. Both invasive and non-invasive breast cancer types can also be categorised according to cell type. The following breast cancer types can be both invasive and non-invasive.
Ductal carcinoma
Starting in the linings of the milk ducts, ductal carcinoma is the most common type of breast cancer in both men and women. Ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) make up approximately 80% of all breast cancer types. There are various subtypes of ductal carcinoma.
Medullary carcinoma
Medullary carcinoma is invasive ductal carcinoma that looks soft and grey, just like the brain stem or medulla. This breast cancer type is slow-growing and does not often spread into lymph nodes. It is more common in Asian communities and is more likely to occur in women over 40 years of age with the BRCA1 mutation. Medullary carcinomas do not respond well to hormones and first-line treatment is lumpectomy or mastectomy. This may be enough to remove the cancer due to its slow growth and low likelihood of spreading. Your oncologist may prefer to additionally prescribe chemotherapy, radiation therapy or targeted therapy or a combination of two or all of these.
Tubular carcinoma
Another IDC subtype is the tubular carcinoma that is most likely to develop in women over 50 years of age but is easy to identify on medical imaging results and, in combination with its slow-growing characteristics, is easy to detect in early stages long before a lump forms. A positive prognosis is usually associated with tubular carcinoma after surgery and often radiation therapy. In addition, most tubular carcinomas respond to hormonal therapy. Chemotherapy is rarely used in breast cancer types that are unlikely to spread.
Mucinous or colloid carcinoma
This rare invasive ductal carcinoma subtype develops in mucus and usually occurs five to ten years after the menopause. It responds well to treatment and does not easily spread to other lymph nodes or organs. Mixed mucinous carcinoma forms are trickier to treat as they are composed of different cell types but when not mixed are relatively easy to treat when detected in early to mid stages.
Inflammatory breast cancer (IBC)
Extremely rare but also extremely aggressive, inflammatory breast cancer begins in the lymph vessels just under the skin. Cancerous tumours block off the flow of lymph and cause inflammation; the breast looks red and swollen. While IBC can be caused by ductal carcinomas that spread (IDC), this type has been given its own category. It is more common in obese, heavier-breasted younger women and rarely responds to hormone therapy. Typical symptoms are orange-peel type skin that is red and warm, rapidly growing breast, a burning sensation or an inwardly turning nipple. A lump is not always present. Treatment begins with at least 6 cycles of chemotherapy, then surgery (radical mastectomy), then radiation treatment. Additionally, IBC responds to targeted therapy in the form of trastuzumab.
Metaplastic breast carcinoma
Another rarer form of breast cancer is the metaplastic breast carcinoma (MpBC). MpBC is also aggressive and begins in immature breast cells. These immature cells, instead of becoming glandular cells, turn into connective tissue cells and form masses that often look benign. Because of this, early detection is difficult (but certainly possible). This type of cancer does not respond well to hormone therapy but can be fairly successfully treated with mastectomy and chemotherapy, especially in earlier stages. The tyrosine kinase inhibitor cetuximab also seems to make a difference in many cases.
Mammary Paget’s disease
Paget’s disease of the nipple is another rare form of breast cancer and, as its name suggests, begins in the cells that surround the nipple and form its ducts. The areola can become itchy and red in the presence of Paget’s disease.
If Paget’s disease is diagnosed, you will be sent for an MRI of both breasts, as it rarely occurs alone; a ductal carcinoma is usually detected in the same breast. The first-line treatment for Paget’s disease is usually breast-conserving surgery, although the location and size of the accompanying ductal carcinoma may require a radical mastectomy. Radiation therapy usually follows, especially in breast-conserving procedures. As the oncologist must deal with two cancer locations, a combination of chemotherapy, targeted therapy and perhaps hormonal therapy is recommended.
Sarcoma
Breast sarcomas are very rare and begin in the connective tissue of the breast. They can develop on their own (de-novo), after radiation treatment (RT sarcoma) or where lymphedema or the arm or breast exists (therapy-related sarcoma). As with all types of breast cancer, first-line treatment is surgery and larger tumours will usually require complete breast removal or mastectomy. Additional radiation and chemotherapy is common. Angiosarcoma is a subtype that either occurs de-novo (usually women aged 30 – 50) or about 10 years after radiation treatment.
Phyllodes tumour
Phyllodes means leaf-like in Greek and relates to the leaf-like cells that form this rare but quickly-growing type of breast cancer. Phyllodes tumours can be benign, borderline or malignant and are removed surgically. They rarely spread to the lymph nodes but postoperative radiotherapy is possible. Borderline Phyllodes tumours rarely recur.
Oestrogen-positive breast cancer
Some types of mutated cells that cause breast cancer have receptors on their outer surfaces that some hormones or other substances can attach to. When these substances attach, they encourage the breast cancer cells to multiply at a faster rate. New scientific discoveries allow oncologists to block these receptors and slow down cancer growth.
Oestrogen-positive breast cancers grow more quickly in the presence of oestrogen. Women taking hormone replacement therapy during or after the menopause sometimes have a higher risk of developing breast cancer because the hormones they take contain oestrogen. This may also apply to the hormone progesterone. Approximately 70% of all breast cancers are oestrogen-positive and so respond to treatment that limits oestrogen and progesterone in the body.
Progesterone positive breast cancer
When breast cancer cells have progesteron receptors, either in combination with or without oestrogen and/or HER2 receptors, treatment is adjusted to tackle these cell types. Together, ER+ (oestrogen positive) and PR+ (progesterone positive) breast cancers make up the group of hormone receptor positive (HR+) cancers. Depending on the hormone receptors your breast cancer cells have, hormone therapy may or may not be added to your treatment plan. If a cancer cell has receptors for only one type of hormone receptor, such as ER negative and PR positive, it is still considered an HR+ type cancer but only hormone treatment with progesterone inhibition is given. This is a useful and cumulative addition to other treatment forms.
HER2-positive breast cancer
Some types of mutated cells that cause breast cancer have receptors on their outer surfaces that some hormones or other substances such as certain proteins can attach to. When these substances attach, they encourage the breast cancer cells to multiply at a faster rate. New scientific discoveries allow oncologists to block these receptors and slow down cancer growth.
One protein that encourages breast cancer growth is called HER2. Approximately 15% of breast cancers have HER2 receptors. If you are prescribed trastuzumab, your breast cancer is HER2-positive.
Triple negative breast cancer
Some types of mutated cells that cause breast cancer have receptors on their outer surfaces that some hormones or other substances such as certain proteins can attach to. When these substances attach, they encourage the breast cancer cells to multiply at a faster rate. New scientific discoveries allow oncologists to block these receptors and slow down cancer growth.
When breast cancer cells do not have receptors for either oestrogen, progesterone or the HER2 protein, they are known as triple-negative cancers. Perhaps 15% of women (usually younger women) with breast cancer have this type that does not respond to either hormone therapy or HER2 therapy. In this case, other treatments are used.
Alternatively, triple positive breast cancers can be treated with both hormones and HER2 targeted drugs.
Breast cancer stages
Your medical notes may have listed a number of codes concerning your diagnosis. Or perhaps you are waiting for further testing and prefer to be well-informed before receiving your results.
The majority of oncologists adhere to the universal TNM staging system. In short, this system uses a scoring system for tumour, (lymph) nodes and metastasis according to biopsy and imaging results.
T stands for tumour. T plus a letter or number describes the size (in centimetres) and location of a tumour. T letter and number systems for breast tumours are:
TX: It is not possible to evaluate the tumour due to a lack of data
T0: No evidence of a primary tumour
Tis: Ductal carcinoma ‘in situ’ (DCIS)
T1: The tumour is local to the breast and:
T1mi: The tumour is less than 0.1 cm
T1a: The tumour is between 0.1 and 0.5 cm
T1b: The tumour is between 0.5 and 1 cm
T1c: The tumour is between 1 and 2 cm
T2: The tumour is between 2 and 5 cm
T3: The tumour is larger than 5 cm
T4: The tumour has spread to areas beyond the breast and surrounding tissues
T4a: The tumour has grown into the chest wall
T4b: The tumour has grown into the skin
T4c: The tumour has grown into the skin and chest wall
T4d: Inflammatory carcinoma
N stands for nodes or lymph nodes and the following codes apply:
NX: Regional (nearby) lymph nodes cannot be evaluated due to lack of data
N0: No spread to regional lymph nodes
N1: Tumour has spread to lymph nodes in the armpit or under the breast and is so small it is not visible
pN1mi: Small groups of more than 200 cancer cells
pN1a: Cancer cells in up to 3 lymph nodes with one larger than 2 mm
pN1b: Small groups of cancer cells under the breast (internal mammary nodes)
pN1c: Small groups of cancer cells in up to 3 lymph nodes in the armpit (axillary nodes) and also in the internal mammary nodes
N2: Tumour has spread to axillary lymph nodes and/or internal mammary nodes and is visible
N2a: Cancer cells in the armpit (axillary) lymph nodes that are fixed to other tissues
N2b: Cancer cells in the internal mammary nodes that can be felt
N3: Tumour has spread to non-regional lymph nodes
N3a: Spread to the collarbone area
N3b: Spread to the armpit and under the breastbone
N3c: Spread to above the collarbone
Finally, M stands for metastasis. The following codes apply:
M0: There is no spread to distant lymph nodes or other organs
cMo(i+): Cancer cells are found in blood, bone marrow of non-regional lymph nodes but not visible on medical imaging
M1: Distant metastasis is present in distant lymph nodes and/or to other organs.
Breast cancer metastasis is most likely to affect the bones, lungs, liver and/or brain. 13
Breast cancer is then further grouped according to TNM results in up to 5 stages. Stage 0 is a carcinoma in site and early cancer stage that sometimes does not require treatment. Stage I (IA or IB) is relatively early non-metastasized breast cancers with no lymph node spread and tumours of less than 2 cm in size. Stage II (IIA and IIB) indicates a tumour of between 2 and 5 cm that is limited to the breast and minimal lymph node spread. Stage III (IIIA and IIIB) indicates axillary and/or internal mammary lymph node involvement with a tumour size of over 5 cm. Some more advanced stage III breast cancers are inoperable. Stage IV indicates metastasis. It should also be mentioned that other prognostic factors are important in breast cancer staging and treatment. These include the presence of HER2 and ER+ (oestrogen positive) cancers, oncotype DX and other computerised tests that measure the risk of your particular type of breast cancer recurring after treatment, and KI 67 status according to an index that is a new, highly sensitive test for predicting how responsive your cancer may be to chemotherapy that can be carried out on biopsy samples.
Additionally, you may have been rediagnosed with recurrent breast cancer after being in remission for a time. Local recurrence refers to cancer reappearing in the same area as the previous cancer, regional recurrence to an area close to the previous cancer, and distant recurrence refers to metastatic breast cancer.
What are breast cancer symptoms?
If you are reading this page, you may have been diagnosed with breast cancer due to the presence of one or more symptoms.
The most common symptoms of breast cancer are:
Skin changes (swelling, redness)
Larger size or change in shape of one or both breasts
Changes in the appearance of one or both nipples
Nipple discharge
Generalised pain of the breast area
Lumps felt during a breast examination
Itchy breasts
Orange-peel type skin on one or both breasts
National screening programs for the detection of breast cancer in the general population are common. Most screenings are for women over 45 years of age, women with a family history of breast cancer, and women with the BRCA1 or BRCA2 gene. Screening involves a mammogram or breast X-ray, although MRI imaging is becoming a more popular option.
Can I prevent breast cancer?
Unfortunately, a number of cancer types run in families. If you are aware of a family member suffering from breast cancer, your risk of developing it is higher. If you have been tested for BRCA1 or BRCA2 genes, this is also the case. Today, many cancer-linked genes can be checked via a simple blood test. If your family history or genetic makeup shows an increased risk of breast cancer you should attend biannual screening and be very aware of the physical signs of this disease.
Non-familial risk factors include alcohol use (younger women who drink alcohol from a young age have increased risk of developing breast cancer), smoking, obesity, short or absent breast-feeding periods, long-term (more than 5 years) hormone replacement therapy and higher levels of radiation exposure.
If you have any of the above risk factors, screening should begin from an earlier age. Remedazo can arrange annual or biannual complete health checks for all ages to ensure peace of mind.
A healthy lifestyle is important in breast cancer prevention. Avoiding obesity or losing weight, not smoking or stopping smoking and not drinking or stopping drinking excessive amounts of alcohol can lower your risk of developing breast cancer. For women with babies, breast-feeding for longer than six months is not only healthy for the mother but also for the baby. Menopausal or post-menopausal women taking hormone replacement therapy should arrange regular breast cancer screening.
While CT scans and X-rays can detect a range of illnesses, they emit large amounts of radiation and can cause damage to cells. This damage can lead to cell mutations and cancer. MRI scans do not use radiation but electromagnetic energy and are therefore much safer; however, they are not as cost-efficient as radiation-emitting machines and hospitals tend to limit their use. A less expensive option is ultrasound that uses soundwaves to produce an image. Arranging your own MRI scan at a private hospital can be a good idea.
It is also important to mention that people who regularly travel on long-haul (high altitude) flights can be exposed to higher radiation levels and should opt for the MRI scan (or ultrasound) rather than a CT scan or X-ray whenever possible.
Learning how to check your own breasts for lumps is also important. Your general practitioner or gynaecologist can show you how to do this. Be aware of skin changes and itchy or warm sensations in and around the breasts and make an appointment with your general practitioner, oncologist or gynaecologist if you do notice anything unusual.
How is breast cancer diagnosed?
Most breast cancers start as very small groups of mutated cells. Those with heavier breasts or less sensitive fingertips (such as diabetics) may find it hard to detect tiny growths. This is why screening is so important.
Breast screening involves a mammogram. This is an X-ray of both breasts and is not a comfortable experience as the breast tissue must be flattened between plastic plates in order to get the best image. A mammogram is the first step to breast cancer detection. If the radiologist notices something unusual on the X-ray or if the breasts are particularly heavy and the X-ray image is difficult to view, he or she will request an ultrasound.
If the radiologist is still unsure of a diagnosis, the next step is a breast MRI. An MRI provides much more detailed images of the breast tissue and does not involve radiation. It is important to mention that many lumps and bumps in the breasts are benign, such as cysts. So if a lump is detected, this does not mean you have breast cancer. In fact, up to 80% of women who are sent for biopsy do not have breast cancer.
To see whether a group of unusual cells is cancerous or not, the next step is a breast biopsy. There are two ways in which biopsies are carried out on breast tissue – core-needle aspiration and surgery. The first of these involves inserting hollow needles into certain areas of one or both breasts using ultrasound and is performed under a local anaesthetic. Occasionally, a marker is placed into suspicious tissue so that the surgeon can locate the area if he or she needs to operate. The second biopsy type is a surgical procedure but is usually performed with a local anaesthetic and sedation. A small incision is necessary to access the breast tissue. Again, the doctor may place a marker to help the surgeon locate the area should you need an operation at a slightly later stage.
If your biopsy results are positive for breast cancer, you will be sent for a PET scan and possibly a bone density scan. As the breast is a gland, a Dotatate PET scan may be advised. This scan requires some medications to be stopped up to two months beforehand – your GP or our specialist physicians will be able to tell you if this applies to you. For this test, you will be administered a small quantity of radioactive tracer via an intravenous catheter then wait for 45 minutes until this tracer reaches the site of potential cancerous cells. The scan itself takes up to 30 minutes and is carried out in the same way as a regular PET scan.
A biopsy is important when determining breast cancer treatment. The pathologist can see if the tissue contains cancer cells and, if so, whether these may respond to hormonal or HER2 therapy. They also tell the surgeon how much tissue he or she should remove. When your biopsy tissue samples are sent for testing, your oncologist will also order specific tests that can determine which treatment pathways best suit your cancer’s specific cell type. For example, triple positive breast cancer (determined by an immunohistochemistry (IHC) test on biopsy samples) can be treated with supplementary HER2 targeted therapies and hormone therapies in combination with a standard breast cancer treatment plan. This ability to match treatment to individuals instead of treatment to a disease as a whole is called personalised medicine. Personalised medicine is making waves throughout the medical sector and especially in the field of cancer therapy. Because new studies are continuously providing newer, better ways to further personalise treatment plans, Remedazo insists its partner oncologists, haematologists and pathologists are well-read in current research and new diagnostic, prognostic and treatment techniques.
In addition to hormone and HER2 receptor tests, your oncologist will also order prognostic tests such as the KI-67 biomarker test (or mitotic index test) that, in early-stage hormone-responsive breast cancer types, can show how rapidly your cancer is growing. The Ki-67 measures the presence of proteins that are released only during the multiplication phase of cells. If your diagnostic report shows a Ki-67 result of 2%, only 2 in every 100 cells are dividing. Results of over 20% indicates rapid growth and may mean that your oncologist recommends high-dose chemotherapy in combination with other treatment methods.
How is breast cancer treated?
The most common and recommended treatment for non-metastasized breast cancer is surgery. Extremely small tumours in older patients may be treated with active surveillance. Active surveillance does not treat the cancer but relies on regular diagnostic tests. If the tumour then begins to show signs of growth or activity, systemic therapies or surgery can be planned.
As with many types of cancer, surgery alone can be curative. However, breast cancer is usually treated with a combination of surgery, hormonal therapy, chemotherapy, and radiotherapy to lower the risk of recurrence. Immunotherapy and targeted therapies can also be used to slow down the progression of cancer that does not adequately respond to other treatment methods or to target certain cell types on a personalised basis. These treatment methods will be discussed in more detail further on.
Why do I need breast cancer treatment?
Treatment is necessary for any type of cancer to try to prevent cancerous cells from travelling to other organs via the surrounding blood and lymph vessels. When treated at an early to mid-stage, breast cancer can be cured; even advanced breast cancer can be kept under control for long periods of time with rapidly increasing treatment options. New therapies and procedures are continuously increasing longer-term breast cancer survival rates.
How do I prepare for breast cancer treatment? What can I expect?
Approximately 2 to 4 weeks before surgical cancer treatment or other therapy pathways you will be asked to supply the results of your blood tests and copies of any diagnostic and imaging results (ultrasound, CT, MRI, biopsy and/or PET). This means we can see how your breast cancer is progressing and will help us to advise the best treatment options. We will also need any information regarding medication use, other illnesses or disorders and your overall state of health.
You will need to undergo an MRI, PET or CT scan and possibly a bone scan – if these have not yet taken place - which will help us to see if cancer has spread to other organs.
Approximately 2 weeks before your treatment you will need to ask your home doctor to take blood for a preoperative or pre-treatment blood test. Remedazo will inform you well beforehand which tests your doctor will need to take blood for. For some procedures, blood-thinning and other medications will need to be temporarily stopped, others do not. Our or your own doctor will advise you what to do.
Breast cancer treatment
The information below covers all available treatments for breast cancer at Remedazo. If you would like information on any therapy not covered in this section, please do not hesitate to contact us.
Surgical breast cancer treatment
When the results of a biopsy are positive for breast cancer and this cancer has not spread to areas far from the original tumour, surgical removal is the first-line treatment. While surgeons used to remove the entire breast to ‘be sure’ of removing all the cancer, this is no longer the recommended procedure; the majority of surgeons will remove the lump and any affected lymph nodes. They will also send tissue samples for immediate testing while you are still asleep to check that they have removed all detectable cancer cells. This is why breast cancer surgery can sometimes take 2 to 3 hours, as each time a sample is sent to the pathologist the surgeon must wait for 30 to 45 minutes for the results.
Lumpectomy Surgery
Also known as breast-conserving surgery, this procedure involves the removal of a lump and its surrounding tissue rather than the entire breast. A number of lymph nodes may also be removed and tested. Removal of one or more regional lymph nodes is known as a sentinel lymph node biopsy. This surgery requires a lighter general anaesthetic that does not paralyse the muscles; this means your time in the recovery ward after surgery will probably not exceed 1 hour. Similarly, hospital stays rarely exceed 48 hours. Remedazo goes above and beyond standard aftercare protocols by providing strict monitoring for at least 24 hours after every breast cancer surgery. This is rarely considered necessary by many medical institutions but Remedazo chooses to exceed, rather than meet, current standards at all times. For small, easily accessible breast tumours, this procedure may be carried out under a local anaesthetic. You can discuss your options during your free Second Opinion.
Most lumpectomy procedures for breast cancer (not benign cysts) require postoperative radiation therapy after you have recovered from the surgery. Sessions usually begin within 1 to 2 weeks after the lumpectomy procedure and radiation treatments are given over the course of the next 6 weeks. Lumpectomy and subsequent radiation therapy provides comparable results to mastectomy and often avoids later considerations for reconstructive breast surgery.
Mastectomy surgery
Mastectomy is the removal of the entire breast and usually one or more axillary lymph nodes. This procedure is performed under a general anaesthetic. In a small number of cases, reconstructive breast surgery can be carried out at the same time but significantly lengthens the operation time. In general, a mastectomy procedure takes between 1 to 3 hours depending on how many lymph nodes need to be removed. Recovery times from this type of surgery are rapid; you will be able to leave the hospital within 1 to 2 days. If you are able to combine reconstructive breast surgery with mastectomy, expect a procedure to last between 3 and 8 hours, 1 night in a medium care ward and a further 2 to 3 days in hospital.
Mastectomy procedures are only carried out when radiation therapy is not possible (due to pregnancy or earlier radiation therapy on the same breast), when multiple tumours are present or if a patient requests mastectomy as a preventive measure (a prophylactic mastectomy). However, it is still possible that your oncologist will recommend a full course of radiotherapy after mastectomy.
Nipple-sparing mastectomy, total mastectomy or radical mastectomy are subcategories of breast removal surgery. As the name suggests, the nipple-sparing mastectomy preserves the nipple but removes all of the breast tissue. Either during the same procedure (immediate) or at a later stage (delayed), a breast implant can be inserted to preserve your natural silhouette. The total mastectomy procedure removes the breast and nipple and sometimes lymph nodes very close to the breast tissue. No muscle tissue is removed. This is the operation of choice for women who opt for prophylactic mastectomy. The radical mastectomy removes all breast tissue and axillary lymph nodes. While the muscles under the breast used to be removed, this is no longer considered necessary.
When speaking with your selected surgeon for the first time, he or she may discuss different lymph node removal techniques. The most common lymph nodes affected by breast cancer are the internal mammary nodes and the axillary nodes. Some patients prefer to have more lymph nodes removed than may be necessary but many surgeons prefer to remove only the sentinel nodes. These are the lymph nodes that lie closest to the area of cancer and the ones most likely to be affected by travelling cancer cells. During surgery, these lymph nodes are removed and sent immediately to the pathology department. If they are free of cancer cells, there is no need to remove more lymph nodes during this single operation. If they do contain cancer cells, the surgeon can remove the next closest-lying group and test those. This happens during a single operation. Removing too many lymph nodes can mean that fluids do not drain well and lymphedema can occur. This may lead to swelling of the arm on the side of the operated breast as the lymph fluids have less channels to travel through.
You can also talk to expert plastic surgeons during a free Second Opinion online appointment to discover whether immediate or delayed breast reconstruction surgery is the best option for you.
Peri-operative breast cancer surgery care
You will be admitted to your chosen clinic on the day of the procedure. Certain people such as those with a very high BMI, breathing difficulties, diabetes or other chronic illnesses usually benefit from spending the night before the operation in a hospital setting.
From midnight of the day before your surgery, you will be asked to refrain from eating. Undigested stomach contents can create serious complications during general anaesthesia. Smokers should stop smoking at least one week before surgery; stopping smoking beforehand improves oxygen levels throughout the body. Between midnight and six hours before anaesthesia you may only drink water or clear liquids. You are not permitted to eat, drink or smoke in the six hours preceding anaesthesia. Failure to comply may mean the anaesthesiologist and surgeon will be forced to postpone your procedure. This is purely for your own safety. It is possible to brush your teeth during this period but no water may be swallowed. In certain circumstances, medical staff will administer oral medications with a little water. This is administered under the advice of the anaesthesiologist and is therefore permitted. If your lumpectomy is planned to proceed under local anaesthetic, you might still be asked to refrain from eating or drinking before surgery. This means that if you find the surgery or situation too uncomfortable, the anaesthetist has the option to use a light form of general anaesthesia to increase your comfort.
Approximately thirty minutes before the planned procedure time you will be collected from your room and brought to the surgical department either in your bed, on a gurney, in a wheelchair or on foot.
Preoperative breast cancer surgery preparation requires:
An intravenous line
A blood pressure cuff placed on the upper arm
The completely painless placement of electrodes to the chest to measure heart activity
A finger or ear sensor to measure oxygen levels in the blood
A general anaesthetic (perhaps a local anaesthetic for small, easily accessible tumours)
If breast reconstructive surgery is planned to coincide with mastectomy surgery, additional monitoring is required. This will include an arterial catheter and a second intravenous line, a thermometer and a urinary catheter.
At the surgeon’s signal, you will be anaesthetised.
What happens after breast cancer surgery? What can I expect?
You will be woken by the anaesthesiologist immediately after surgery and transported from the operating theatre to the recovery room. Here you will be carefully monitored. All patients remain in the recovery ward until they are fully responsive and any pain is well under control. If you have undergone a lumpectomy under local anaesthetic, you can return to a general ward immediately and return to your chosen accommodation the same day.
When the anaesthesiologist is satisfied you are fully awake and comfortable you will be brought to a surgical ward. Pain medication is given as standard but breast surgery pain, even for radical mastectomy procedures, is easy to control.
Your intravenous catheter will continue to administer fluids for up to 24 hours and your drain will be removed by a trained nurse or doctor within 2 days.
The majority of breast cancer patients are out of bed within 8 hours of exiting the recovery room. Average hospital stays range from 1 to 2 days. Upon discharge from hospital you will be transported to your accommodation and supported by your personal Remedazo team until you have safely and comfortably returned home or have completed further treatment. You will be able to travel within 2 days after discharge. We advise you to wear compression stockings when travelling.
Long-term postoperative care includes the removal of stitches after 5 to 8 days. This can be done by your general practitioner at home if you are not attending further treatment sessions. Full recovery from breast surgery only requires a few days to 2 weeks. Further radiotherapy is prescribed after most lumpectomy and some mastectomy procedures.
Non-surgical breast cancer treatment
While many surgical procedures cure breast cancer, most oncologists recommend courses of non-surgical therapies to lower the risk of recurrence or kill cancer cells that may have been left behind. The most common non-surgical treatment for invasive and non-invasive breast cancer is radiotherapy.
Nonsurgical treatments are also offered to those unable to undergo surgery due to low overall levels of health or those who need to keep metastatic or potentially recurring breast cancer under control. These treatments include radiofrequency ablation of very localised non-invasive and small breast tumours that destroys cancer cells using electrical current and is an outpatient procedure that may need to be repeated. Another option is cryotherapy where, instead of electricity, low temperatures are applied directly to a tumour to freeze and kill the cancerous cells.
Breast cancer radiation therapy
Radiotherapy may be given before breast cancer surgery to shrink a larger, early-stage tumour (neo-adjuvant radiotherapy) or after surgery to reduce the risk of the cancer recurring (adjuvant radiotherapy).
Radiotherapy as a stand-alone cancer therapy was only previously considered in the treatment of inoperable breast cancer. Today, new chemo-radiotherapy combinations of approximately 25 radiotherapy treatments given over the course of 5 weeks with 2 cycles of chemotherapy at 3 week intervals has been known to cure invasive breast cancer, significantly shrink tumours and decelerate tumour growth.
Fractionated external beam radiation therapy (EBRT) is usually prescribed to prevent the growth of potentially remaining cancer cells after surgery. This therapy is given over the course of 3 to 7 weeks in low doses. More recently, stereotactic body radiation therapy (SBRT) has provided patients with a higher dose, shorter course of radiation therapy. If cancer has spread to the bone tissue (bone metastasis), patients may be offered radiopharmaceuticals. These are injected drugs that contain radioactive substances that settle in areas of damaged bone. Here, they emit radiation that kills cancer cells. These drugs also relieve bone pain caused by metastasis and can extend life.
External beam radiation therapy focuses beams of radiation into the affected area of breast tissue and requires short (10 to 30 minute) visits to the hospital 5 times a week for several weeks. Long-term stays with all accommodation, home nursing care, catering, transportation and follow ups can be seamlessly arranged by your Remedazo team.
EBRT is a painless treatment and recent technology now enables oncologists to be even more precise with dosage and range. Additional options such as three-dimensional conformal radiation therapy or 3D-CRT use computers to map the area that requires treatment and shape the radiation beams to avoid damaging non-cancerous tissues. The even more advanced intensity modulated radiation therapy (IMRT) machine moves around the patient, shapes the beams and adjusts radiation intensities. This may be done with built-in scanners (image guided radiation therapy or IGRT) or using a more rapid but not necessarily more effective technique called volumetric modulated arc therapy or VMAT. You will be able to discuss all of these alternatives with a Remedazo oncology specialist.
The side effects of radiation therapy often depend on its effects upon healthy tissues that are found close to the breast including major blood and lymph vessels, lungs and heart. In addition, radiation treatments can make you feel tired for weeks to months. At Remedazo, all associated information will be given upon or shortly after your consultation; you can then make an informed decision regarding the types of radiotherapy available to you.
Breast cancer chemotherapy
Early stage breast cancer is treated with surgery in combination with radiotherapy. Sometimes the choice is made to undergo a course of chemotherapy after surgery and before radiotherapy in breast cancer types that are expected to recur without this treatment. Chemotherapy may be given to shrink tumours prior to surgery, to treat cancer types with the potential to return, and also to destroy any cancer cells that may have been left behind after surgery. Some women may be able to opt for a lumpectomy instead of a mastectomy if they undergo a course of chemotherapy before surgery. Early stages of cancer can benefit from cytotoxic (cell-toxic) drugs such as epirubicin, methotrexate, carboplatin and capecitabine that are administered over the course of 3 to 6 months. Chemotherapy is given in cycles, giving you time to recover between treatments.
Where surgery is not indicated, chemotherapy is a primary breast cancer treatment usually supported by other non-surgical therapies, most of them listed within this section. Chemotherapy for metastatic breast cancer can include drugs such as ixabepilone, methotrexate, doxorubicin and cisplatin. Multiple cytotoxic (cell-toxic) combinations exist, all of which can be discussed with a Remedazo oncology specialist.
Chemotherapy drugs are administered intravenously via a portacath, PICC line or central venous catheter. Drug cycles usually last for 21 days and, depending on your type of cancer, may be repeated up to 6 times. This can mean up to 6 months of therapy with regular blood tests and follow ups of symptoms and side effects. Ask Remedazo for more information regarding longer-term stays where all of your physical, psychological and emotional needs are catered for during this stressful time. Alternatively, we can arrange similar accommodation and familiar, trusted team members for regular returns to your clinic of choice and cater for your accompanying family members or friends.
Breast cancer hormone (endocrine) therapy
As already discussed, most breast cancers can use oestrogen/or and progesterone to increase in size. Biopsy reports tell the oncologist whether cancer cells contain receptors for certain substances. If they do, stopping these substances from being used by cancer cells can slow or stop cancer growth. Hormonal therapy is not used for triple-negative cancer types.
Hormonal treatment is long-term therapy that needs to be taken for 5 to 10 years. These therapies lower the amount of oestrogen in the body or stop oestrogen from connecting with the cancer cells and encouraging them to grow.
The most well-known anti-oestrogen for breast cancer is tamoxifen. It stops oestrogen from connecting with cancer cells. The reason why tamoxifen is the drug of choice on a global scale is that it is selective and only blocks the action of oestrogen in the breast tissue, not in other organs that use oestrogen such as the bones and the womb.The same can be said for drugs such as onapristone – currently being tested in clinical trials - that prevent PR+ cancer cells from using progesterone. These drugs have a range of uses, from lowering risk, from stopping cancer from recurring, for slowing metastatic cancer and for shrinking tumours. Side effects are similar to those of the menopause. Using these treatments on hormone-responsive cancers should lower your Ki67 results as they stop cancer cells from moving into the multiplication stage.
Drugs that stop oestrogen from being produced in the body are another option. Most oestrogen is made in the ovaries. When the menopause stops oestrogen production in the ovaries, a small amount is still produced in fat tissue. This small amount can cause breast cancer in post-menopausal women. When this production is prevented through drugs such as letrozole or exemestane, breast cancer progression can be halted or slowed within this older age group. Younger women may also take these drugs but in combination with tamoxifen as a combination of drugs works more effectively.
Breast cancer in younger women can also be treated by temporarily stopping oestrogen production in the ovaries. Drugs include goserelin and leuprolide. Sometimes surgery to remove the ovaries is recommended. The woman will then enter the menopause.
Breast cancer immunotherapy
Checkpoint inhibitors allow your immune system to respond to the presence of specific cancer cells and attack them. This response is often absent during tumour growth. It has been shown that some advanced breast cancers respond well to immunotherapy treatment but this certainly does not apply to all. Ask about immunotherapy options during your free Second Opinion.
Drugs such as atezolizumab block the activity of a protein that prevents your immune cells from recognizing and attacking inflamed tissues and cancer cells. Atezolizumab in combination with chemotherapy has recently been approved for the treatment of triple-negative metastatic breast cancer. Oncologists partnered with Remedazo are renowned for their knowledge of the most recent clinical studies and research pertaining to effective and new cancer-fighting drugs.
Each intravenous immunotherapy treatment requires at least a 2 hour stay in a clinical setting and should be repeated every 2 to 3 weeks. Immunotherapy has been shown to increase survival times in metastasised cancer; however, it is rarely offered before other types of therapy have been tried. This may change as research continues.
The side effects of immunotherapy are many and can be serious. Those offered this type of treatment are given in-depth information regarding side effects and the detection of their early signs. Remedazo can put you in touch with one of our specialist oncologists to discuss your eligibility for immunotherapy based upon your personal medical history.
Breast cancer HER2 targeted therapy
Human epidermal growth factor receptor 2 (HER2) acts as a tyrosine kinase. Tyrosine kinase proteins encourage cancer cell growth. In breast cancer, HER2 proteins bind to part of the cancer cell membrane and make them more likely to multiply. A drug called trastuzumab inhibits this connection. Trastuzumab in combination with checkpoint inhibitors (immunotherapy) has been proven to be effective in the treatment of non-invasive and metastatic breast cancer; however, not every type of breast cancer responds in the same way to either inhibitory drugs or immunotherapy. Only about 15% of breast cancers will respond to HER2 inhibitors.
Tyrosine kinase inhibitors are drugs that prevent the growth of a tumour’s own blood supply network and are sometimes combined with early treatment modalities such as lumpectomy. These drugs either alone or in combination with other treatments have achieved breakthrough advances in the management of a number of hard-to-treat malignancies, including advanced cases of breast cancer.
Benefits of breast cancer treatment
Breast cancer surgeries aim to remove cancer in its entirety and so have the potential to be curative procedures. Surgery is always recommended in cases of non-metastatic cancers; however, most treatment pathways integrate multiple therapies. In the case of breast cancer, these are most commonly chemotherapy and radiotherapy. Prophylactic mastectomy can increase peace of mind in those who have a family history of breast cancer or the BRCA gene. Breast cancer has benefitted from extensive research and even invasive cancers can be successfully treated.
Breast cancer surgery is not linked to high levels of pain and recovery times and hospital stays are short. Advances in surgical techniques mean that larger amounts of breast tissue can be left intact and preserve the shape of the breast. Biopsies can be removed for immediate testing without the need of multiple surgeries. For mastectomy that does not require postoperative courses of radiotherapy, simultaneous reconstructive breast surgery is an option.
Disadvantages of breast cancer treatment
Postoperative infection is a slight risk with this type of surgery and patients are sometimes administered antibiotics as a preventive measure before surgery commences. Other short-term risks include bleeding, adverse reactions to the anaesthesia, blood clots and breathing problems.
Long-term complications of breast cancer surgery are few. Where larger numbers of lymph nodes are removed, lymphedema may cause swelling of the arm on the operated side.
Lumpectomy procedures usually require further radiotherapy treatment that can last for approximately 6 weeks, bringing with it a number of unpleasant side effects. Postoperative radiation therapy also applies to some mastectomy operations. Unpleasant and serious side effects are also linked to adjunct non-surgical cancer treatments such as chemotherapy and immunotherapy, and in a lesser degree, targeted therapy. Breast cancer treatment is obligatory if you wish to slow or stop its progression; unfortunately, the majority of current treatments bring with them unpleasant and often serious side effects.
Breast cancer treatment alternatives
It is possible that you have been given a choice of one or more alternative treatments or have not yet made an appointment for your free e-consult and are simply browsing the possibilities.
The accepted and current breast cancer treatment alternatives have been described in detail above. Recent advances mean that some stage IV breast cancers can go into complete remission for well over 5 years. Complementary breast cancer remedies are unproven and should not take the place of accepted treatment courses. Cancer stem cell therapies for breast cancer are, as yet, insufficiently developed to be used as first-line treatment.
Of course, there is no alternative for professional medical advice. Please call us to arrange your free e-consult and the opportunity to speak personally with specialist surgical oncologists and radiologists to determine the best treatment type for you. You can discuss all breast cancer treatment alternatives with them, ask for second or third opinions, and take the first step towards your personalised Remedazo holistic care package.
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