• OPD Consultations and Breast Cancer Screening
• Mammography, Ultrasonography and MRI for Breast Cancer
• Routine and Image guided FNAC and breast biopsies
• Surgical Biopsies (Excisional Biopsy, Incisional Biopsy)
• X-Ray Chest, CT, Bone Scans, PET CT for Staging work up
• Receptor Tests
• Estrogen and Progesterone receptor
• Human epidermal growth factor type 2 receptor (HER2/neu)

Tumour Board Evaluation

Each and every breast cancer patient is evaluated by a special team of surgical oncologists, medical oncologists, Radiation Oncologists, Onco-pathologists and Imaging Specialists. Depending on the age, general condition, type of pathology and stage of the disease, a custom made treatment plan is charted out for each and every patient as per International Treatment Guidelines.

Modalities of Treatment Available for Breast Cancer

• Surgery
• Radiation
• Chemotherapy

Treatment Team

• Surgical Oncologist (Breast Unit)
• Plastic and Reconstructive Surgeons
• Radiation Oncologists
• Medical Oncologists
• Nurses
• Physiotherapist
• Psychotherapist
• Psychologist

Breast Cancer Surgery

DHRC offers full range of the latest surgical techniques and procedures to treat patients with breast cancer. Surgeons provide individualized information and work with patients to help determine the appropriate treatment and provide timely surgical care. Surgical options for breast cancer treatment include:

Breast Conservative Surgery (BCS)

BCS is offered to patients to remove the cancer but not the breast. The following procedures are being done at Dharamshila Hospital And Research Centre.

Lumpectomy - Removal of the lump along with the margins of the surrounding normal breast tissue.

Partial Mastectomy - A segment of the breast which has cancer along with surrounding normal breast tissue is removed.

Other Types of Breast Surgeries

Mastectomy- is the surgical removal of a breast. Breast reconstruction is possible in many patients after the mastectomy.

Simple or total mastectomy- removal of the breast, with its skin and nipple, but no lymph nodes. In some cases, a separate sentinel node biopsy is performed to remove only the first level one to three axillary (armpit) lymph nodes.

Modified Radical mastectomy - removal of the complete affected breast with nipple/areolar region and lymph nodes. Breast reconstruction

Breast reconstruction after cancer surgery is an option for most women undergoing mastectomy. Surgical options offered at DHRC include reconstruction with implants and autologous flap reconstruction (using the patient's own tissue), including:

• TRAM surgery
• DIEP surgery
• SIEA surgery
• Reconstruction of the nipple and areola

Axillary Node Dissection

Axillary node dissection, the surgical removal of the axillary (armpit) lymph nodes, is usually performed on patients with invasive cancers. A radical mastectomy, modified radical mastectomy, or lumpectomy operation often includes removal of axiliary lymph nodes.

Localization

Localization may be used to pinpoint the location of a breast tumor that appears on a mammogram but cannot be felt. In localization, a radiologist uses either mammography or ultrasound to insert a fine wire into the tumor site. The surgeon then follows the wire to locate and remove the targeted area.

As an alternative, a radioactive seed (a metal capsule that contains a small amount of radioactive material) the size of a grain of rice may be placed at the tumor site. The seed may be placed a day or more before the operation. The surgeon locates the seed with a handheld Geiger counter and removes the targeted area.

Frozen section analysis

Breast Cancer Specialists may use frozen section evaluation and intra-operative pathology consultations during breast cancer surgery to determine whether all of the cancer has been removed. Frozen sections ensure adequate clear margins during tumour resections. Frozen section also provide an intra-operative histological diagnosis where pre-operative evaluation may not have been done. Thus second surgeries with the attendant risks of anaesthesia are totally avoided and we are able to provide our patients with the best Surgical Oncology Services.

Evaluation of lymph nodes

If breast cancer is invasive (spreading into surrounding healthy tissue), it usually spreads first to the axillary lymph nodes in the axilla (armpit). When an invasive cancer is found in the breast, the surgeons remove axillary lymph nodes to confirm whether the cancer has spread.

Surgeons at DHRC use several procedures to evaluate lymph nodes:

• Fine-needle aspiration (removal of body tissue through a thin, hollow needle), which may be performed before surgery if lymph nodes appear abnormal on ultrasound
• Sentinel lymph node biopsy is done for the majority of our patients with breast cancer, who are unlikely to have cancer in the lymph nodes
• Dissection (surgical removal) of the axillary lymph nodes is performed when the cancer is known to have spread to the lymph nodes

Ductal Carcinoma In Situ (DCIS)

Treatment of ductal carcinoma in situ (DCIS) may include the following:

• Breast-conserving surgery and radiation therapy with or without tamoxifen.
• Total mastectomy with or without tamoxifen.
• Breast-conserving surgery without radiation therapy.

Lobular Carcinoma In Situ (LCIS)

Treatment of lobular carcinoma in situ (LCIS) may include the following:

• Biopsy to diagnose the LCIS followed by regular examinations and regular mammograms to find any changes as early as possible. This is called observation.
• Tamoxifen to reduce the risk of developing breast cancer.
• Bilateral prophylactic mastectomy. This treatment choice is sometimes used in women who have a high risk of getting breast cancer. We believe that this is a more aggressive treatment than is needed.

Stage I, Stage II, Stage IIIA, and Operable Stage IIIC Breast Cancer

Treatment of stage I, stage II, stage IIIA, and operable stage IIIC breast cancer may include the following:

• Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.
• Modified radical mastectomy with or without breast reconstruction surgery.
• Sentinel lymph node biopsy followed by surgery.

Adjuvant therapy (treatment given after surgery to increase the chances of a cure) may include the following:

• Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.
• Systemic chemotherapy with or without hormone therapy.
• Hormone therapy.
• A clinical trial of trastuzumab (Herceptin) combined with systemic chemotherapy.
• A clinical trial of bisphosphonates combined with chemotherapy and/or hormone therapy.

Stage IIIB and inoperable stage IIIC breast cancer

Treatment of stage IIIB and inoperable stage IIIC breast cancer may include the following:

• Systemic chemotherapy.
• Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.
• Clinical trials testing new anticancer drugs, new drug combinations, and new ways of giving treatment.

Stage IV and metastatic breast cancer

Treatment of stage IV or metastatic breast cancer may include the following:

• Hormone therapy and/or systemic chemotherapy with or without trastuzumab (Herceptin).
• Tyrosine kinase inhibitor therapy with lapatinib combined with capecitabine.
• Radiation therapy and/or surgery for relief of pain and other symptoms.
• Bisphosphonate drugs to reduce bone disease and pain when cancer has spread to the bone.
• Clinical trials testing new systemic chemotherapy and/or hormone therapy.
• Clinical trials of new combinations of trastuzumab (Herceptin) with anticancer drugs.
• Clinical trials of new combinations of lapatinib with anticancer drugs.
• Clinical trials testing other approaches, including high-dose chemotherapy with stem cell transplant.

CHEMOTHERAPY

Medical Oncologists may recommend chemotherapy (treatment using drugs) following surgery to kill cancer cells that may have spread outside the breast. The drugs are usually administered intravenously (into a vein).

Chemotherapy may be recommended before surgery if the breast tumor is large, the lymph nodes are involved or the tumor is attached to the chest wall muscles or skin.

Chemotherapy may also be recommended in cases of inflammatory breast cancer.

Most patients receive chemotherapy after they have healed from the operation and before they receive radiation. We choose the chemotherapy drugs and sequence of treatment based on the details of each patient's tumor characteristics.

RADIATION THERAPY

Radiation therapy involves the use of high-energy beams to kill cancer cells and shrink tumors. Patients who undergo radiation therapy consult with a radiation oncologist before treatment begins. Radiation may be recommended if:

• Breast cancer treatment includes a Breast Conserving Surgery.
• The invasive tumor is more than 5 centimeters in size at the time of the mastectomy
• Many lymph nodes contain cancer cells

HORMONE THERAPY

The term hormone therapy refers to the use of drugs that either block estrogen from reaching cancer breast cells or reduce the amount of estrogen produced by the body to reduce the risk of cancer recurrence.

• Drugs such as tamoxifen or fulvestrant block estrogen from reaching breast cancer cells
• Aromatase inhibitors reduce the amount of estrogen produced by the body.

Hormone therapy is most effective for patients whose tumor cells express (produce) the estrogen receptor. Hormone therapy is not recommended for patients who have tumors that are estrogen negative.

For premenopausal patients with tumors that are estrogen receptor or progesterone receptor positive (sensitive to hormones), medications or removal of the ovaries may also be recommended to prevent cancer recurrence.

BIOLOGICAL AND OTHER THERAPIES

Dharamshila Hospital offers many targeted therapies, including lapatinib and trastuzumab or Herceptin therapy, which is often used to treat breast cancers that produce an abnormal amount of human epidermal growth factor receptor 2 (HER2neu). Targeted therapies offer the benefit of killing the specific target cells and hence, give better outcomes.