Understanding breast cancer management
The majority of patients who come to the breast clinic have a benign diagnosis (non-cancerous) and do not need ongoing care as they have been reassured at the one-stop clinic. However, if a diagnosis of cancer has been made for you or your relative, a number of the following options will be discussed following our multi-disciplinary team meeting.
Breast cancer treatment
Once you have been diagnosed with breast cancer, you will be offered treatment. There are several different ways of treating breast cancer and most people will be offered a combination of treatments. For example, you may be offered surgery only, or surgery followed by radiotherapy and/or chemotherapy. Alternatively, you may be offered chemotherapy before surgery or you may not require any chemotherapy at all. Your treatment plan will depend on a number of different factors including; the features of your cancer (such as size of the cancer, appearances on biopsy, lymph node involvement in the armpit), whether you are fit to undergo a particular treatment and your preferences (such as whether you want to have a mastectomy with breast reconstruction).
In common with most breast cancer units in the UK, any significant treatment recommendations for you will have been discussed in a meeting of the multi-disciplinary team (MDT) which includes different specialist in the treatment of breast cancer. Usually, this team consists of a specialist breast oncologist, surgeon, radiologist and pathologist. In practice, the MDT meeting usually includes several representatives from each discipline, along with a coordinator, unit manager, breast care nurses as well as doctors in training and medical students. In your next clinic appointment after this meeting, your treatment plan or potential options will be discussed with you. Many people find it helpful to bring a friend or family member to these clinic appointments.
As sometimes there is a lot of information to take on board, one of the breast care nurses will usually be present in the consultation to support you and afterwards will make sure you have any written information you need to take away.
Breast cancer surgery
Most people who are diagnosed with breast cancer will be offered surgery as part of their treatment. If you are offered surgery, there are two main considerations: what surgery you wish to undergo to remove the cancer from the breast and what surgery is needed to the lymph nodes in your armpit (the armpit is also called the 'axilla', and hence surgeons talk about 'axillary surgery').
Breast surgery to remove the cancer falls into two main groups: mastectomy which involves removing the whole breast and breast conserving surgery (BCS, wide local excision (WLE), therapeutic mammoplasty, ''lumpectomy') in which the cancer is removed from the breast but the shape of the breast is preserved. If you have a mastectomy, breast reconstruction may be an option for you. Your surgeon and breast care nurse will be able to discuss all your surgical options with you.
For some patients it is necessary to remove all the breast (mastectomy). For these patients, we can offer breast reconstructive surgery. Our surgeons and breast care nurses provide counselling and information on the options available for reconstruction, with the aid of photographs of patients who have had reconstructions at Hillingdon Hospital and the Royal Free Hospital.
We can offer implant-based breast reconstructions and incorporate new techniques to carry these out. This could involve using biological meshes through a pre-pectoral approach (in front of the pectoralis major muscle) which differs from the previous traditional approach of sub-pectoral implant reconstruction (behind the pectoralis major muscle).
Patients can also undergo reconstructions using purely the patient’s own tissue (autologous) such as the DIEP flap. For these we work in conjunction with the plastic surgeons at the Royal Free Hospital. We work closely with our plastic surgeons and there is a weekly clinic with them to facilitate our reconstructive practice. We can offer immediate reconstructions during the same mastectomy operation or as a delayed procedure for patients who have had previous simple mastectomy operations.
We also schedule procedures on the opposite breast, if this becomes necessary to achieve better symmetry. This may involve reducing its size or lifting the breast by tightening the skin, with or without an additional implant.
Axillary surgery has changed in recent years and therefore the procedure and outcomes may be different from how you’ve previously heard it described. The surgery involves removing the lymph nodes into which any tumour may drain. The commonest axillary surgery is sentinel lymph node biopsy (SLNB) in which more than one lymph node is removed from your armpit and sent to the pathologist to look at under the microscope.
By removing the first few lymph nodes adjacent to the cancer a pathologist can look at them under the microscope and find out whether any cells from your breast cancer have spread to the lymph nodes in your armpit. This is important to know as it can affect what treatments you need after your surgery (eg chemotherapy).
If you are found to have significant deposits of breast cancer cells in those nodes, you may be advised to come back for further surgery, which would be axillary node clearance (ANC). If you are already known to have cancer deposits in your armpit before your surgery (through a needle biopsy), you may be advised to have axillary node clearance (rather than sentinel lymph node biopsy) at the same time as your breast surgery.
This is provided by our team of medical and clinical oncologists with the support of our breast care nursing team and acute oncology nurse specialist. Oncology treatment is usually offered after surgery however occasionally chemotherapy is given at the beginning of treatment depending on the tumour biology.
We participate in research as well as national trials, and occasionally patients are asked to participate in these trials if eligible. Opting out of such trials does not impact on your breast cancer management