Breast cancer: Treatment and follow-up

Part of our GP resources on tumour types, this focuses on the treatment and follow-up for breast cancer, including treatment pathways, side-effects and recurrence

Treatment

There are five main types of treatment for breast cancer. The patient’s treatment pathway will depend on a broad range of factors including its stage, immunohistochemical profile, and the patient’s general health.

  1. Surgery: the two main types of surgery are lumpectomy and mastectomy. Advances in surgical techniques mean that full mastectomies are less common than twenty years ago. As more and more women survive breast cancer, the importance attached to reconstruction is greater to ensure patients achieve an optimum quality of life.  Reconstruction can be immediate or delayed and use either the patient’s own tissue or implants. The oncoplastic surgeon will discuss the patient’s options with them to ensure they receive the optimum result.
  2. Radiotherapy: radiotherapy treatment is often given post-surgery to destroy any remaining cancer cells. Generally, breast cancer patients tolerate radiotherapy well, with side effects limited to skin reactions, lymphoedema, pain and swelling. These side effects can be mediated with specialist support and are often not long lasting. A long-term risk of radiotherapy that is becoming increasingly apparent is damage to heart tissue, resulting in heart problems for women many years after radiotherapy treatment. New techniques such as breath holding have been developed to minimise damage to the heart.
  3. Chemotherapy: in breast cancer, chemotherapy drugs are often given in combination to some patients. Cancers which are not responsive to hormone treatments are more likely to be treated with chemotherapy.
  4. Targeted therapy: targeted drugs block the growth and spread of cancer by interfering with specific molecules on the cells’ surface. Cancers which test positive for the HER2 receptor can be treated with one of the most well-known targeted therapies, Herceptin. About 15% of all breast cancers are HER2+. Herceptin is given every three months for a year and side effects can include infection, hot flushes, fatigue and diarrhoea. Patients who have heart problems are can have relative contra-indications for Herceptin.
  5. Hormone therapy: hormone treatments either lower the levels of oestrogen or progesterone or block their effects. In order to work, the tumour must be ER+, that is have oestrogen receptors on the surface of the cell. About 70% of breast cancers fall into this category.

The most common hormone treatments are Tamoxifen and Aromatase Inhibitors. They are often taken over extended periods of time (five years or sometimes longer) to both treat the tumour and reduce the risk of recurrence. The side effects mimic that of the menopause and include hot flushes, nausea, mood changes, fatigue and vaginal dryness/discharge.

Follow up

Around two-thirds (65%) of women diagnosed with breast cancer in England and Wales now survive their disease for twenty years or more and so issues of long term follow up in primary and secondary care are becoming increasingly important. In many centres routine appointments are not offered but instead the patient can access the service at any time when they develop any new symptoms or concerns

Women are recommended to have annual mammograms for five years, or until the patient reaches the age at which the National Breast Screening Programme starts.

Patients with hormone sensitive cancers are prescribed antihormone tablets, also known as endocrine therapy. Anti-hormone therapy will include Tamoxifen, Letrozole and other medications such as Anastrozole (arimidex) and Exemestane.. After the first five years The Royal Marsden will write to the patient and their GP and confirm if the prescription should stop, continue or be switched.

Even if patients are having irregular or no periods due to breast cancer treatment, there is still the possibility of pregnancy and effective contraception is important.

There is some evidence to suggest that some drugs such as antidepressants paroxetine (Seroxat®) and fluoxetine (Prozac®) may decrease the efficacy of Tamoxifen, but it is still a cause for debate. Please discuss with the treating clinician before prescribing this SSRIs to patients taking Tamoxifen.

Side effects

Patients should be allocated a key worker or nurse specialist to support them through the side effects of their cancer treatment. However there is also a role for the GP in supporting patients. Common side effects include:

  • Breast discomfort or tenderness: general and low level pain in the breast, chest or shoulder is common and can be treated with standard painkillers. Patients may find that wearing a sports bra, physiotherapy or acupuncture may help relieve symptoms. Nerve pain, characterised by shooting pains, can be a sign of neuropathy. Whilst nerve damage can’t be corrected, some patients find NSAIDS or other pain modifying agents, transcutaneous electrical nerve stimulation (TENS) or acupuncture provide relief. For difficult to treat or persistent cases, patients should be referred to a specialist pain clinic.
  • Menopausal related side effects: generally speaking, breast cancer patients should not be prescribed HRT to manage menopausal symptoms. Some over the counter preparations used to manage menopausal side effects can contain phyto oestrogens.
  • Fatigue: patients can feel more tired than usual for several months after treatments end. This is normal and should resolve in time.
  • Lymphoedema: patients with lymphoedema should seek support from a specialist, who can advise on exercises, massage and skin care to lessen symptoms. To reduce the risk of lymphoedema, patients should protect the skin from sources of damage (sun, burns, cuts etc), keep the skin clean and moisturised, and treat and cover any small grazes quickly to lessen the risk of infection.
  • Depression/anxiety: there is a wide spectrum of emotional response to cancer and some patients can develop anxiety or depression as a result of their cancer treatment or at any point in the pathway. There are a wide range of support services available, see the Macmillan website for more information.

Late effects

  • Osteoporosis: Aromatase inhibitors such as Letrozole, Anastrozole, (arimidex) or Exemestane or an early menopause induced by breast cancer treatment, may accelerate loss of bone density. Patients may need regular bone density scans (DEXA scans) which will be arranged either by the hospital or GP in line with the patient’s treatment plan. Patients should be advised on how to improve their bone health through regular exercise such as walking as well as a diet high in calcium.
  • Heart disease: women who have undergone radiotherapy on the left breast may very occasionally experience heart problems in later life. GPs should be alert to the increased risk and treat or refer cardiovascular issues as early as possible.
  • Breathlessness: radiotherapy can cause short term inflammation of the lungs (radiation pneumonitis) within the first three months of treatment. This presents as breathlessness, chest pain and a dry cough, and is temporary.  Long term, radiotherapy can very rarely cause fibrosis of the lung tissue which can cause breathlessness months or even years after treatment. As radiotherapy techniques have improved this long term effect has become less common. If a patient does present with it, they should be advised on general lung health (giving up smoking, weight loss etc) but can also be prescribed bronchodilators or steroids.

Signs of recurrence

Refer patients if they have had a previous breast cancer and they present with any of the following:

  • a lump or a swelling in the breast, in the skin after a mastectomy, above the collarbone or in the neck area, or under the arm
  • any skin changes including dimpling, puckering, redness or raised spots on the breast or mastectomy scar
  • nipple discharge
  • lateclymphoedema (affected side arm swelling)
  • any new, ongoing pain in any part of the body, especially in the back or hips, that does not improve with pain killers and which is often worse at night
  • pins and needles and/or a loss of sensation or weakness in the arms or legs
  • unexplained weight loss and loss of appetite
  • a constant feeling of nausea
  • discomfort or swelling under the ribs or across the upper abdomen
  • a dry cough or a feeling of breathlessness
  • severe headaches - usually worse in the morning