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BREAST CANCER TREATMENTS With the help of modern technology and better understanding of breast cancer, there are many ways to treat breast cancer. Types of therapy can be divided into four main categories:

__Local Therapy__ Local Therapy is intended to treat a tumor without affecting the rest of the body. Ex. Surgery, radiation therapy

__ Systemic Therapy __ Systemic Therapy refers to drugs which can be eaten or injected directly into the bloodstream to reach cancer cells anywhere in the body. Ex. Chemotherapy, hormone therapy, targeted therapy

__Adjuvant Therapy__ Adjuvant therapy is given to patients who have no detectable cancer after surgery. Doctors believe cancer cells may break away from the primary breast tumor and spread through the body through the blood stream, even in early stages. Cells can’t be detected on physical exam or x-rays and they cause no symptoms. However, they can be harmful by being able to establish new tumors in other organs/bones. The goal of adjuvant therapy is to kill these hidden cells.

__ Neoadjuvant Therapy __ Neoadjuvant therapy is a type of systemic surgery used on some patients before surgery to shrink a tumor in hope a less extensive operation to be done. Neoadjuvant therapy is usually chemotherapy.

Most breast cancer patients will choose to use one of the following four treatments:
 * Surgery
 * Radiotherapy
 * Hormone Therapy
 * Chemotherapy

SURGERY There are four different types of surgery that a patient of breast cancer may choose from:

// 1. Mastectomy // []

Mastecomy removes the whole, infected breast. There are three different types of mastectomy. A simple mastectomy removes only the breast tissue. Although this type of surgery is given rarely, a radical mastectomy removesthe breast tissue and muscles on the chest wall. Finally, a modified radical mastectomy removes the breast and lymph nodes, but leaves the major chest wall muscles intact. Mastectomy is suitable if the patient has a large lump, particularly in a small breast; a lump in the middle of the breast; more than one area of cancer in a breast; or areas of DCIS in the rest of the breast.

// 2. Lumpectomy // []

During a lumpectomy (also called a Wide Local Excision), only the infected lump is removed. A lumpectomy takes away just the cancer, and leaves behind as much healthy tissue as possible. The surgeon will removed the cancer along with a border of healthy tissue around it. The removed, healthy tissue goes to the pathologist who examines the borderline for any cancer cells. If the border is clear of cancer cells, the patient can be sure that all cancer cells have been taken away.

// 3. Segementectomy // In a segmentectomy, only part of the breast is removed. This surgery is not given often. It is like lumpectomy, but more breast tissue is taken away. Quadrantectomy removes about a quarter of the breast tissue, and the result is more noticeable than a lumpectomy. After this surgery, breast reconstruction is possible. // 4. Axillary clearance //

[] An axillary clearance removes all the lymph nodes under the arm. If breast cancer spreads from the primary breast tumor into other parts of the body, it will most likely have spread into nearby lymph nodes. Once cancer has spread into this place, it is extremely difficult for the patient to move his/her arm in large motions. To check if the lymph glands look normal, patients can use a special underarm ultrasound scan.

RADIOTHERAPY Radiotherapy cures breast cancer using high-energy rays or particles that destroy cancer cells. This method may be used to kill any cancer cells that remain in the breast, chest wall, or underarm area after breast-conserving surgery. Radiotherapy may also be needed after mastectomy if the cancer is larger than five centimeters or is found in the lymph nodes. There are two types of radiotherapy:

// 1. External beam radiation // External beam radiation is radiation that is focused from a machine outside the body on the area affected by cancer. The extend of the radiation depends on whether a lumpectomy or masctectomy was done and whether lymph nodes were involved. It also depends on the size and extend of the cancer. If the cancer has grown enormously in both facotrs, radiation may also be focused on the chest wall and underarm area. To have external beam radiation is like having an x-ray - it is painless, doesn't last more than a few minutes, but the radiation is more intense.

// 2. Brachytherapy // Brachytherapy is internal radiation. Internal radiation can be given in many ways, but there are two that are used the most often: In intracavitary brachytherapy, a deflated balloon is attached to a thin tube, which is inserted into the space left by the lumpectomy. It isfilled with a salt water solution, and is left in place throughout treatment. Twice a day, a source of radioactivity is placed into the middle of the balloon through the tube and then removed. This process is repeated over and over again for five days. In interstitial brachytherapy, small hollow tubes called catheters are inserted into the breast around the area of the lumpectomy and are left in place for a few days. Radioactive pellets ar inserted into the tubes for short periods of time each day and then removed.
 * Intracavitary brachytherapy:
 * Interstitial brachytherapy:

HORMONE THERAPY Before understanding how hormone therapy works, we need to understand what hormones are and how they are linked to breast cancer.

Hormones are substances that occur naturally in the body where they control the growth and activity of normal cells. Two types of hormones that exist mainly in females, estrogen and progestrone, are naturally produced by ovaries before menopause. After menopause, estrogen is created in much smaller amounts by small glands above the kidneys, called adrenal glands.

Estrogen and progesterone affect the growth of breast cancer cells. Estrogen promotes the growth of two out of three breast cancers. In order to know if hormone therapy is suitable for them, patients need to go through tests to see whether his/her cancer cells have estrogen or progesterone receptors. These receptors allow the hormone (estrogen or progestrone) to lock onto the cancer cell, which stimulates it to grow. Patients who have estrogen receptors on their cancer cells are referred to as "ER positive", and those with progestrone receptors are called "PR positive".

Hormone therapy is only used on patients who are ER positive or PR positive. It is systemic therapy used as an adjuvant therapy to help reduce risk of cancer recurrence after surgery.

Types of hormone drugs include:
 * Aromatase inhibitors (it blocks estrogen from being made in women who are past menopause)
 * Tamoxifen
 * Pituitary downregulators (blocks a hormone in the brain that stimulates ovaries to make and release estrogen)

CHEMOTHERAPY Chemotherapy is treatment using cancer-killing drugs that may be given intravenously (injected into a vein) or by mouth. Drugs travel through bloodstream to reach the area of cancer. Chemotherapy is recommended in the following situations: Adjuvant chemotherapy is given to patients after surgery who have no evidence of the cancer spreading. It reduces the risk of breast cancer coming back. The goal of adjuvant chemotherapy is to kill any hidden cancer cells that have traveled from the breast. Cancer cells that break away from the primary breast tumor do not show up on imaging tests or physical exams. They may create new tumors in other places of the body if they are allowed to continue growing. Neoadjuvant chemotherapy is given to patients before surgery. It can shrink large cancers so that they are small enough to be removed by a lumpectomy, instead of a mastectomy. Chemotherapy can be used as the main treatment for women whose cancer has already spread outside the breast and underarm area at the time it is diagnosed.
 * // Adjuvant //
 * // Neoadjuvant //
 * //For advanced breast cancer//

Chemotherapy is a treatment used by many patients of breast cancer. However, it causes patients to experience side effects, such as:
 * hair loss
 * mouth sores
 * loss of appetite
 * nausea and vomiting
 * increased chance of infections (due to low white blood cell level)
 * easy bruising or bleeding (due to low blood platelet level)
 * fatigue (due to low red blood cell level)

QUIZ QUESTION: What are the four main treatments used for breast cancer?