Professor Arlene Chan is one of Australia’s most respected Breast Cancer Oncologist’s, from Hollywood Private Hospital in WA. She spoke with the Pink Hope team to share some health literacy information associated with breast cancer diagnosis and treatment, to help debunk some of the terms we hear in the cancer community which can often be very hard to understand.
Can you explain the different stages of breast cancer?
Breast cancer can be diagnosed in stages 1, 2, 3, or 4. Stages 1-3 are referred to as an early diagnosis, whereas stage 4 represents cancer that is metastatic, advanced or secondary. In more general, terms, stage 4 means the cancer has already spread to other parts of the body, beyond the breast area.
Each of these stages, regardless of whether the cancer is diagnosed at an early or advanced stage, are categorised based on the volume of cancer at the time of diagnosis.
In determining the stages of breast cancer and reaching a diagnosis, oncologists often refer to an internationally accepted classification, referred to as the TNM, which stands for Tumour Nodal Metastasis. This classification firstly looks to see whether the cancer has spread (metastatic disease), and if there is no evidence of this, a patient will be diagnosed as stage 1, 2, or 3.
The specific stage is determined based on a combination of the size of the tumour and whether this has spread to the lymph nodes. For example, stage 1 cancer has not travelled to the lymph nodes and the tumour size less is than or equal to 20mm.
Stage 3 on the other hand, even though it is still classified as early, has a tumour larger than 5cm or more, plus or minus a number of lymph glands under the armpit where the cancer has travelled.
Determining the specific stage of cancer at diagnosis is very important because it is very closely related to the prognosis (likely course of the disease).
How do you determine the right care plan for your breast cancer patients?
It is important to note that every cancer condition is assessed on an individual basis, to assist with identifying the most suitable treatment path.
As with diagnosis, care and treatment plans are based on a person’s individual condition and other contributing factors, such as their age and general wellbeing before cancer.
For example, if you are younger and generally fit and healthy, treatment may be approached differently, compared to someone diagnosed later in life with other existing conditions.
We also spend time discussing treatment options with patients and determining what they want from treatment and what they are willing to endure, providing guidance at every step of the decision-making process.
The one consistency throughout all treatment, is that medical oncologists will draw on published, scientific evidence in creating a treatment plan that is appropriate for each patient.
When it comes to genetic testing, there are a number of factors that can prompt testing. These include multiple family members being diagnosed with breast or ovarian cancer, as well as those who are diagnosed at a younger age.
When it comes to pre-emptive surgery, this is generally limited to women who are known BRCA gene carriers. As such, it can be considered by women who have never been diagnosed with breast cancer but are positive for the gene.
There is data to suggest that women who carry the gene and remove both breasts will reduce their likelihood of developing breast cancer by the age of 70 by approximately 90%.
What is an active treatment?
Active treatment refers to any type of treatment that is directed towards ‘curing’ the breast cancer. This can include surgery, which looks to remove the cancer, radiation therapy, which looks to shrink or sterilise the rest of the tissue of cancer and chemotherapy, which looks to kill the cancer cells.
Beyond these core treatment options, there are other drug therapies, such as anti-hormone, targeted and immunotherapies, which can be used in the active treatment of a woman with breast cancer.
Oral therapy can be divided into oral chemotherapy and endocrine treatment, both of which are only used in the metastatic setting.
Targeted therapies, also known as biological drugs, refer to a number of agents that have been developed over the last 20 years. These agents are based on the scientific evaluation of what drives different types of breast cancer. They can come in intravenous, oral and subcutaneous (injected under the skin) forms.
Targeted therapies differ from endocrine and chemotherapy treatments as they target proteins in the cancer cell that are particularly elevated in a woman’s cancer, with a view that the agent may be able to suppress that protein and in turn suppress the cancer itself.
Immunotherapies are fairly new in breast cancer and are not used as a standard of treatment. Via different methods, they help your own body’s immune system recognize and fight off the cancer. Some breast cancers also have the ability to stimulate the body's immune cells to help the cancer grow – and these therapies target against that.
New research is also taking place with vaccines to try and help the body respond to cancer, similar to how vaccines can be used to fight infections.
This approach looks at each individual person with breast cancer and their needs, both from a treatment perspective, but also in broader life. As we know, many patients with cancer are partners, parents and workers, and cancer impact all facets of their lives.
A comprehensive approach to care helps us to identify not only the best treatment plan for their disease, but also their life.
First and foremost, we do all that we need to assess the kind of cancer that has been diagnosed, the risk of relapse, and if it is advanced, the likelihood that he or she will pass from this cancer.
Then we look at all the additional components that are important to the individual, such as interest in reconstructive surgery, concern about genetic factors, and psychological issues speaking to family about the condition.
Approaching treatment in this manner ensures every healthcare professional involved in each patient’s care is on the same page. Members of the team can include surgeons, radiation oncologists, breast care nurses, clinical psychologists and reconstructive surgeons.
Again, depending on the patient, allied health is also important, with the introduction of physiotherapy to help people recover from surgery, or assist their recovery when another underlying condition or mobility issue is also present.
Oncologists and haematologists know that a patient’s immunity levels can change during the course of treatment for breast cancer and lower immune function. As such, it is important to be mindful of managing the risks associated with catching other infections like influenza, or in these current times, COVID-19.
In all situations, common sense should prevail. I advise my patients to make it known to others they are being treated and their susceptibility to increased infection is higher. Social distancing measures that are currently being practiced are a good way to combat the potential threat of unwanted infection as well.
