Breast cancer - symptoms and treatment

This page presents information on the symptoms and treatment of breast cancer including in-situ carcinoma,early breast cancer and advanced breast cancer.

Breast cancer symptoms and treatment

 
 

Breast cancer symptoms

Many breast cancers are detected by mammography before any symptoms are noticed.

Other signs include:

  • breast lumps (although most of these are benign),
  • change in size or shape of the breast,
  • dimpling of breast skin,
  • nipple inversion,
  • change in the nipple,
  • swelling or lump in the armpit
  • and very rarely a blood-stained discharge from the nipple or rash around the nipple.

A recent meta-analysis concluded that breast self examination is not an effective method of reducing breast cancer mortality. 1 The NHS recommends that all women are 'breast aware': know what is normal for them and what signs of disease to look for 2 , and that women aged 50 or over attend for breast screening.

Treatment guidelines have been published to improve and standardise the treatment of breast cancer in the UK. 3-7

Surgery and radiotherapy are used to control local disease, and systemic treatments (chemotherapy and /or hormonal therapy) to combat frank or occult metastatic disease. Systemic treatments may also be administered up front as a primary treatment to reduce the size of the tumour prior to surgery.

Nearly all patients, whatever the stage of their disease, have some form of surgery. Other tests are carried out to assess the extent of the disease. The main stages of invasive breast cancer are shown in Table 6.1.

Table 6.1: The main stages of breast cancer

Download this table (19kb)

A patient's treatment will depend upon a number of factors including the stage and grade of their tumour, hormone receptor (oestrogen and progesterone) status, menopausal status and general health.

Many breast cancer patients are elderly and there is growing concern that they may receive inadequate treatment on the grounds of age alone. The elderly are under-represented in clinical trials making it difficult to determine best practice for the growing numbers of elderly patients. 8-11

Less aggressive treatment may be appropriate for frail, elderly patients but a recent trial reported that older patients receiving tamoxifen alone for early breast cancer has an unacceptably high rate of local recurrence or relapse compared to those treated by surgery (modified radical mastectomy). 12 A parallel trial comparing tumour excision and tamoxifen with modified radical mastectomy showed that good local control could be achieved in selected patients treated with tumourectomy and tamoxifen, avoiding mastectomy and irradiation. 13

Another trial reported that elderly patients are less likely to receive conservative surgery than younger patients, yet their quality of life is better if they do. 14

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Breast cancer treatment - Carcinoma In-Situ

The standard treatment of lobular carcinoma in situ is surveillance, whereas ductal carcinoma in situ (DCIS) is often treated by complete local excision as there is a strong possibility that it will progress to invasive carcinoma. 15

Cancer Research UK has supported two trials of treatment for DCIS: a European study showed the value of radiotherapy and the UK/ANZ DCIS trial reported on the benefit of radiotherapy over tamoxifen for women with completely excised ductal carcinoma in situ. 16-17

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Breast cancer treatment - Early Breast Cancer (Stage I-III)

Early breast cancer is potentially curable. Surgery is carried out to remove the tumour with an increasing trend towards more conservative surgery and reconstruction of the breast.

The timing of surgery may be important: premenopausal women with early breast cancer seem to have a significantly better prognosis if their tumours are excised during the luteal phase I of the menstrual cycle. 18

During surgery, axillary lymph nodes are checked to see whether cancer has spread beyond the breast. New techniques of sampling lymph nodes may help to reduce the significant disability of lymphoedema of the arm.

A short course of radiotherapy is given to patients who have had conservative surgery or are considered at high risk of local recurrence. Around 6% of women treated with breast conserving surgery and radiotherapy have local recurrence, and if this is within the first two years they appear to have a worse prognosis than those with longer disease-free survival.

Some patients, for example young patients with large tumours, may receive chemotherapy before surgery (neo-adjuvant) to shrink the tumour, allowing more conservative surgery.

Women who have oestrogen sensitive (ER positive) tumours 19 receive some form of hormonal therapy to block the cancer-promoting effect of oestrogen. The use of tamoxifen was shown to significantly reduce the risk of recurrence and increase ten year survival in women with ER positive and ER unknown status tumours 20, 21 and its gradual widespread use is one of the main factors associated with the dramatic fall in mortality during the late twentieth century.

Trials are ongoing to establish even more effective drugs and regimens for pre- and postmenopausal patients, taking into account side-effects as well as survival times. The ATAC trial recently reported its early results comparing anastrazole alone, anastrazole plus tamoxifen, and tamoxifen alone for postmenopausal women and has shown the benefits of anastrozole over tamoxifen in disease-free survival in early breast cancer. 22

Most postmenopausal women receive tamoxifen for five years. In pre-menopausal women oestrogen production may be stopped by surgery (removing the ovaries), radiotherapy or drugs that reversibly suppress the ovaries (LHRH analogues) such as Goserelin.

Chemotherapy is usually given to women who have ER negative tumours although it may also be useful for some premenopausal ER positive patients. Standard treatment is usually with a combination of drugs and there is increasing evidence to suggest that one of these should be an anthracycline. 23 Clinical trials are ongoing to establish the best chemotherapy regimens.

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Advanced breast cancer treatment

Most patients do not present with advanced breast cancer. For those that do, some form of systemic treatment will be considered to control the cancer and improve quality of life.

Hormonal therapies include tamoxifen, progestogens and aromatase inhibitors whereas chemotherapy is usually a combination of drugs including an anthracycline.

A monoclonal antibody treatment (Herceptin) has been shown to provide clinical benefit to patients with high levels of HER2 receptor although the accurate determination of HER2 status is still under discussion. 24 High levels of HER2 are associated with ER and PR negativity and poorer prognosis. When Herceptin is combined with chemotherapy survival is significantly improved. 25 Surgery and radiotherapy may also be useful in controlling local disease.

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References for breast cancer symptoms and treatment

  1.  Hackshaw, A.K. and Paul, E.A., Breast self-examination and death from breast cancer: a meta-analysis. Br J Cancer, 2003. 88(7): p. 1047-53
  2.  The NHS Cancer Screening Programme NHS Cancer Screening Website
  3.  NHS Executive: Improving Outcomes in Breast Cancer: Guidance for Purchasers. 1996.
  4.  National Institute for Clinical Excellence, Improving Outcomes in Breast Cancer: Update. 2002
  5.  British Association of Surgical Oncology: Breast Specialty Group, Guidelines for Surgeons in the Management of Symptomatic Breast Disease in the United Kingdom. 1998.
  6.  Scottish Intercollegiate Guidelines Network, Breast Cancer in Women: A National Clinical Guideline. 1998.
  7.  Royal College of Radiologists' Clinical Oncology Information Network Guidelines on the Non-Surgical Management of Breast Cancer. 1999.
  8.  Turner, N.J., et al., Cancer in old age--is it inadequately investigated and treated? BMJ, 1999. 319(7205): p. 309-12.
  9.  Mandelblatt, J.S. et al., Patterns of breast carcinoma treatment in older women: patient preference and clinical and physical influences. Cancer, 2000. 89(3): p. 561-73.
  10.  Wyld, L. and Reed, M.W. The need for targeted research into breast cancer in the elderly. Br J Surg, 2003. 90(4): p. 388-99.
  11.  Bultitude, M.F. and Fentiman, I.S. Breast cancer in older women. Int J Clin Pract, 2002. 56(8): p. 588-90.
  12.  Fentiman, I.S., et al., Treatment of operable breast cancer in the elderly: a randomised clinical trial EORTC 10851 comparing tamoxifen alone with modified radical mastectomy. Eur J Cancer, 2003. 39(3): p. 309-16.
  13.  Fentiman, I.S., et al., Treatment of operable breast cancer in the elderly: a randomised clinical trial EORTC 10850 comparing modified radical mastectomy with tumorectomy plus tamoxifen. Eur J Cancer, 2003. 39(3): p. 300-8.
  14.  de Haes, J.C., et al., Quality of life in breast cancer patients aged over 70 years, participating in the EORTC 10850 randomised clinical trial. Eur J Cancer, 2003. 39(7): p. 945-51.
  15.  Fentiman, I.S., The dilemma of in situ carcinoma of the breast. Int J Clin Pract, 2001. 55(10): p. 680-3.
  16.  Julien, J.P. et al., Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet, 2000. 355(9203): p. 528-33.
  17.  Houghton, J., et al., Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet, 2003. 362(9378): p. 95-102
  18.  Fentiman, I.S., 12. Timing of surgery for breast cancer. Int J Clin Pract, 2002. 56(3): p. 188-90.
  19.  Wishart, G.C., et al., Hormone receptor status in primary breast cancer--time for a consensus? Eur J Cancer, 2002. 38(9): p. 1201-3.
  20.  Early Breast Cancer Trialists' Collaborative Group, Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. 133 randomised trials involving 31,000 recurrences and 24,000 deaths among 75,000 women. Lancet, 1992. 339(8784): p. 1-15.
  21.  Early Breast Cancer Trialists' Collaborative Group, Tamoxifen for early breast cancer: an overview of the randomised trials. The Lancet, 1998. 351(9114): p. 1451-1467
  22.  Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trial. The Lancet, 2002. 359(9324): p. 2131-2139
  23.  Poole CJ, Dunn JA et al. NEAT(National Epirubicin Adjuvant Trial) and SCTBG BR601 (Scottish Cancer Trials Breast Group) phase III adjuvant breast trials show a significant relapse-free and overall survival advantage for sequential ECMF. ASCO. 2003.
  24.  Bartlett, J., Mallon, E., and Cooke, T., The clinical evaluation of HER-2 status: which test to use? J Pathol, 2003. 199(4): p. 411-7.
  25.  Eisenhauer, E.A., From the molecule to the clinic--inhibiting HER2 to treat breast cancer. N Engl J Med, 2001. 344(11): p. 841-2.