I. Surgical treatment of breast cancer in the elderly
Most elderly breast cancer patients undergo breast-conserving surgery and mastectomy as well as younger patients, and advanced age, by itself, is not a risk factor for surgical treatment. Studies on geriatric anesthetic procedures have shown that the mortality rate of surgery is about 1 to 2 percent. With the development of the discipline of anesthesia, the surgical mortality rate in elderly breast cancer patients is now near zero. The main factor affecting surgical mortality is the concomitant disease rather than age.
Axillary surgery has been historically important for the staging and treatment of breast cancer, but the recent widespread use of anterior lymph node biopsy has challenged whether axillary surgery should continue to be used. Axillary dissection prolongs the duration of surgery and anesthesia and has a higher complication rate than sentinel lymph node biopsy. The importance of axillary lymph node dissection for treatment benefit is still under debate.
II. How to treat male breast cancer
Some male patients with breast lumps or enlarged breasts are ashamed to talk about it and do not go to the hospital; on the other hand, they do not believe that men can also have breast cancer and relax their vigilance, thus missing the early diagnosis and delaying the treatment. As a matter of fact, male breast cancer can also occur, but the incidence is very low. According to statistics, male breast cancer accounts for 1% of all breast cancers and 0.1% of all malignant tumors in men, and its peak incidence age is 50-60 years old.
The cause of male breast cancer is still unclear. The literature reports that factors such as endocrine abnormalities, gynecomastia, radiation injury, local trauma, liver disease and family history may be associated with the development. Breast cancer can occur in patients with prostate hypertrophy or prostate cancer after long-term estrogen application. Patients with liver damage, which reduces the ability to inactivate estrogen and leads to excess estrogen in the body and thus gynecomastia, are also prone to breast cancer. In addition, cryptorchidism, testicular atrophy, and inflammatory diseases are also risk factors for breast cancer. Long-term use of drugs such as isoniazid and fenadine may also cause breast cancer.
The clinical manifestation of male breast cancer is a painless lump under the areola.
Because male breast tissue is not well developed, the ductal area is mainly concentrated in the subareolar or near-areolar area and lacks fatty tissue, the lump is hard and the boundary is unclear. Bloody nipple discharge is often the main manifestation of malignancy. However, male breast enlargement is not always breast cancer. It should be differentiated from gynecomastia. The clinical manifestations of gynecomastia are centripetal and uniform enlargement of breast tissue, soft, sometimes cystic, or subareolar lumps with clear borders, movable, soft, no obvious skin adhesions, and rare nipple discharge.
The male breast is small in size and breast cancer can easily invade into the pectoral muscle. In addition, because of the shorter breast lymphatic ducts in men, it is easy to cause lymph node metastasis. Therefore, clinical suspicion of breast cancer should be treated immediately. The treatment of male breast cancer should be a comprehensive treatment based on surgery. Among the surgical methods, radical and extended radical surgery has better efficacy. If there is metastasis in lymph nodes, radiation therapy and chemotherapy should be performed after surgery. Endocrine therapy is mainly used for advanced or recurrent male breast cancer patients, commonly used methods include bilateral orchiectomy and endocrine drugs such as tamoxifen and aminoglutethimide, which often have better results.
The prognosis of male breast cancer patients is relatively poor, but with early detection, early diagnosis and appropriate treatment, their prognosis can be similar to that of female breast cancer patients.
What are the methods of radiotherapy for breast cancer?
In recent years, with the rise of breast-cancer preserving surgery plus radiation therapy, radiation therapy has become not only an adjuvant or palliative treatment for breast cancer, but also an important part of comprehensive treatment for all stages of breast cancer.
In early stage breast cancer, if breast preservation surgery alone is performed, the local recurrence rate on the affected side is high after surgery, so further treatment of the preserved breast is needed. Irradiation of the whole breast with radical doses of radiation can achieve the same efficacy as radical surgery, and this method is also called minor surgery with major radiotherapy.
For locally advanced breast cancer, radiation therapy alone or surgery are both very ineffective. It is now recognized that multiple treatment modalities are more effective than a single treatment modality, sometimes using pre-surgical radiation therapy plus radical surgery. Pre-surgical radiation therapy can improve the surgical resection rate, give some inoperable breast cancer patients another chance to have surgery, and inhibit the viability of cancer cells, which can reduce the recurrence rate and metastasis rate after surgery, thus improving the survival rate. Pre-surgical radiotherapy should be applied to patients with large primary foci, or rapid tumor growth, or primary foci with obvious skin edema, or adhesions with pectoral muscles to estimate the difficulty of direct surgery; or those with unsatisfactory tumor regression by applying pre-surgical chemotherapy.
Radiation therapy also has great value in the treatment of recurrent or advanced breast cancer. The treatment of local recurrent lesions can be surgical excision alone, or radiation therapy, or both, while giving drug therapy, and most patients can be controlled. For patients with limited bone metastases, radiation therapy has a good effect on pain relief, and some of them can survive for more than several years. For patients with brain metastases, whole brain irradiation can be performed, which can relieve symptoms, reduce pain and prolong life after treatment.
In conclusion, radiation therapy is one of the important means to treat breast cancer. Regardless of the early or late stage of the disease, it can achieve better local curative effect, but it still needs to cooperate with surgery, chemotherapy and endocrine therapy to obtain better curative effect.
Treatment and prognosis of male breast cancer
At present, surgery is the first treatment for male breast cancer, followed by chemotherapy, radiotherapy and endocrine therapy according to the condition. The standard surgical treatment for localized lesions of male breast cancer in the 20th century was radical mastectomy, but retrospective studies have shown that radical mastectomy has been replaced by modified radical mastectomy or simple mastectomy due to its high invasiveness and failure to clearly improve the overall survival rate, and for those with no metastasis yet For patients with breast cancer that is not metastatic and can still be treated surgically, simple or radical mastectomy is usually performed, and for patients with metastasis, chemotherapy, radiotherapy, and hormone therapy are available.
The prognosis of male breast cancer is generally considered to be worse than that of female breast cancer because of the small size of male breast and its shorter lymphatic vessels, late stage of the disease, and the ease of infiltration and metastasis of the cancer. There are many factors that determine the prognosis of male breast cancer, such as clinical stage, type of pathology and lymph node status, which may have an impact on the prognosis of female breast cancer, may also have an impact on the prognosis of male breast cancer.
Because of the low incidence of male breast cancer, many of the current treatment options are derived from the experience of treating female breast cancer. Endocrine treatment experience regarding male breast cancer is limited, and biomarkers can play a supporting role for clinicians to judge prognosis and guide treatment, but at present, the application of biomarkers is limited to clinical studies, and further exploration is needed to determine whether they can be used in clinical practice.
V. What are the reactions to chemotherapy for breast cancer?
Because of the lack of fundamental metabolic differences between tumor cells and normal cells, all cancer chemotherapy drugs inevitably damage normal tissues. The adverse reactions of anticancer drugs can be divided into two categories: those common to various anticancer drugs and those unique to some anticancer drugs. The former ones appear earlier and mostly occur in tissues that proliferate rapidly, such as bone marrow, gastrointestinal tract, hair follicles, etc. Some anticancer drugs can cause local tissue damage when spilled during intravenous injection. The main adverse effects of chemotherapy for breast cancer are.
1. Breast cancer chemotherapy drugs affect the stomach or vomiting center of the brain and cause nausea and vomiting.
2. Adriamycin drugs can often cause hair loss in breast cancer patients.
Breast cancer chemotherapy can inhibit the bone marrow’s ability to produce red blood cells and cause tissue hypoxia, leading to anemia, which can make patients feel weak, fatigue, dizziness or shortness of breath.
4.Many anti-cancer drugs affect bone marrow hematopoietic function and reduce white blood cells, which can easily lead to infections in various parts of the body, such as the mouth, skin, lungs, urinary tract, intestines and reproductive tract.
5. Since anticancer drugs inhibit bone marrow and cause thrombocytopenia, subcutaneous petechiae, bleeding spots, hematuria and black feces will easily appear.
6.Breast cancer chemotherapy affects intestinal mucosa cells will lead to diarrhea.
7. Chemotherapy may directly cause constipation, or it may be caused by the patient’s reduced activity and unreasonable diet structure after chemotherapy.
8.Vincristine chemotherapy drugs such as Novocain can often cause peripheral neuropathy, which can lead to itching, numbness, weakness, burning sensation in hands and feet, or unstable walking, difficulty in holding objects, loss of hearing, etc.
9.Some anticancer drugs such as cyclophosphamide can stimulate the bladder or cause temporary or permanent damage to the kidney, which may manifest as painful urination, urgent urination, frequent urination, hematuria, fever and chills.
For women, anti-cancer drugs can damage ovaries and affect their hormone production, resulting in menstrual disorders, amenorrhea, accompanied by menopausal syndrome, which can also lead to sterility.
Timing of chemotherapy for advanced breast cancer
The decision to apply cytotoxic drugs to treat advanced breast cancer must be carefully considered. Because hormonal therapy can provide effective relatively non-toxic and long-lasting lesion control. Therefore, whenever a new therapeutic measure is needed, the pros and cons of applying hormonal therapy or chemotherapy must be weighed.
VII. Treatment of elderly breast cancer
The treatment of elderly breast cancer is generally not different from the treatment of young and middle-aged breast cancer. In the past, too much consideration has been given to the age of elderly women and their co-morbidities, as well as their declining cardiopulmonary function. As a result, elderly breast cancer patients are not adequately treated. The choice of treatment for elderly breast cancer is based on the clinical stage and the appropriate treatment plan. In general, when the lesion is still limited to local or regional lymph nodes, such as clinical stage I or II and some stage III cases, local treatment such as surgery or radiotherapy should be the main treatment, while local treatment is only used as a complementary one.
The current treatment methods for breast cancer include surgery, chemotherapy, radiation therapy, endocrine hormone therapy, etc., and if necessary, 2-3 methods are combined.
(I) Surgery.
Surgery is still the main treatment for breast cancer. There is no unified opinion on the choice of surgical style; the general principle is to minimize surgical damage without affecting the complete resection, and if technical conditions allow, breast preservation should be strived for early stage breast cancer. Regardless of the choice of procedure, the basic principles of radical treatment and preservation of function and appearance must be strictly followed.
1.Traditional radical surgery: Since its introduction in 1894, it has been commonly used as a conventional procedure for the treatment of breast cancer at home and abroad for a century. However, since the 1980s, the trend of using this procedure has gradually decreased, mainly because this procedure is more destructive and causes postoperative functional and cosmetic damage, and secondly, it has been proved that the efficacy of modified radical surgery with preservation of pectoral muscle is not inferior to that of traditional radical surgery. The scope of conventional radical surgery includes the removal of all breast tissue on the affected side, the surface skin covering the tumor, the pectoralis major and minor muscles, the fat and lymphatic tissue in the axilla and subclavian area. Radical surgery is mainly suitable for patients with invasive cancer and clinical stage III. In China, the 10-year survival rate after this operation is 74.0%, 50.6% and 25.3% in stage I, II and II respectively.
The simultaneous removal of internal breast lymph nodes on top of radical surgery is called extended radical surgery, which requires the removal of the 2nd, 3rd and 4th ribs cartilage. It has been reported that the long-term outcome of this procedure is better than that of traditional radical surgery for stage II and III cases.
2.Modified radical surgery: also known as mock radical surgery. The difference with traditional radical surgery is that the pectoralis major muscle is preserved in this procedure, and whether the pectoralis minor muscle is preserved depends on the disease. Since this procedure is relatively less destructive and less effective than traditional radical surgery, it has gradually become the most common procedure for breast cancer surgery. Modified radical surgery is mainly suitable for non-invasive cancer and stage I and II invasive cancer.
3.Total mastectomy: The operation covers the whole breast. This procedure is mainly applicable to non-invasive cancer, or invasive cancer that is old and frail, or has important organ dysfunction and cannot tolerate radical surgery, or localized tumor foci that are advanced, so that this surgery is part of the comprehensive treatment, and is supplemented with radiotherapy or chemotherapy after surgery.
4.Local excision: In principle, all primary cancer foci should be excised, and there are two main excision methods, i.e. local excision and extensive local excision, the latter including at least 2cm of breast tissue around the lesion. Axillary lymph node excision is generally advocated to remove the whole axillary lymph nodes as far as possible, and postoperative radiotherapy to the axilla can no longer be performed. Local excision is generally indicated for patients with primary cancer, clinical stage I or II, with a single smaller lesion, or a lesion located in the periphery of the breast. Postoperative radiotherapy is usually conventional, supplemented by chemotherapy or endocrine therapy. Care should be taken to avoid local recurrence after local excision surgery. The local recurrence rate of those with extensive local excision + radiotherapy is 25% and 48% in stage I and II, respectively, while the local recurrence rate of stage I and II cases after radical surgery is 11% and 21%, respectively, which is only 1/2 of that of local excision.
(B) Radiotherapy.
Radiotherapy as a local treatment for breast cancer is generally considered to have positive efficacy. Radiotherapy for breast cancer can be divided into preoperative radiotherapy and postoperative radiotherapy.
1.Pre-operative radiotherapy: The purpose of pre-operative radiotherapy is to reduce the size of the tumor, increase the rate of surgical resection, and give some inoperable patients another chance to have surgery; reduce the rate of recurrence and metastasis after surgery, and improve the survival rate. However, preoperative radiotherapy may increase the complications of surgery, affect the correct postoperative staging and hormone receptor determination, and cannot solve the subclinical metastases that may exist before treatment, so it has been replaced by preoperative chemotherapy in recent years. Preoperative radiotherapy is mainly suitable for those who have large primary foci and have difficulty in direct surgical resection, those who have rapid tumor growth within a short period of time, those who have adhesions between primary foci or axillary lymph nodes and the surrounding area, or those whose tumor regression is not obvious with preoperative chemotherapy. Preoperative radiotherapy often adopts three-field irradiation, i.e. the second tangential field and the axillary field of the clavicle. The irradiation dose is 40-50Gy/4-5 weeks for the primary foci and 50Gy/5 weeks for the clavicular region. Surgery is ideal 4-6 weeks after the end of radiotherapy.
2.Postoperative radiotherapy: It is generally believed that radiotherapy after radical surgery is not beneficial for stage I cases, and may reduce the local recurrence rate for patients after stage II. At present, radiotherapy is routinely applied after radical surgery, but only for cases with the possibility of recurrence, radiotherapy is selectively applied to reduce the recurrence rate and improve the quality of survival. According to the postoperative irradiation tightly selected clavicular area and inner breast area. The chest wall was irradiated after mastectomy alone, including the whole anterior chest wall up to the lower end of the scar. The subject of postoperative irradiation is 50Gy/5 weeks.
III. Chemotherapy.
Comprehensive treatment of tumors is one of the effective measures to improve the cure rate, and adjuvant chemotherapy for breast cancer is more certain. As the long-term follow-up after post-operative treatment and radiotherapy of breast cancer found that where there is metastasis in axillary lymph nodes, 2/3 of patients will have recurrence within 5 years, which suggests that most patients actually have more bloodstream dissemination when they receive surgery or radiotherapy. It is estimated that by the time breast cancer is clinically diagnosed, about 50%-60% of patients have already developed hematogenous metastasis, therefore, breast cancer should be considered as a systemic disease to enhance systemic treatment. Chemotherapy is mainly applied to patients with axillary lymph node metastasis, and is generally not recommended for patients with negative axillary lymph nodes, but should be used for those with high-risk recurrence factors. The purpose of chemotherapy is to eliminate some subclinical metastatic lesions in order to improve the survival rate. According to statistics, chemotherapy can generally reduce the postoperative recurrence rate by 40%.
IV. Hormone therapy.
The mechanism of hormone therapy is to change the endocrine microenvironment required for hormone-dependent tumor growth, so that tumor cell proliferation stops in G0/G1 phase, thus achieving clinical remission. Already, as described in the etiology, the presence of ER can be detected in about half of breast cancer patients. The site of estrogen production in the organism is related to the menopausal status. In premenopausal women, estrogen is mainly produced by the ovaries, and after menopause, the ovaries atrophy and estrogen is mainly transformed in the peripheral tissues by androgen precursors secreted by the adrenal glands and regulated by the hypothalamic-pituitary-adrenal axis. E2 is the most biologically active of the estrogens, followed by estrone, and the ratio of their biological activity is 10:1. It has been shown that breast cancer has the enzyme system necessary to convert androgen precursors and E1 into E2 intracellularly, resulting in higher levels of E1 and E2 in cancer cells than in serum.
The effectiveness of hormone therapy is related to the age of the patient and the effectiveness of hormone therapy is related to the age of the patient, especially to menopause or not. Five years of amenorrhea is used as a marker of menopause. Older breast cancer patients are essentially amenorrheic. The main hormonal treatment modalities are competitive therapy, also known as anti-hormonal therapy, and the main drug is triamcinolone acetonide, which is the first line of hormonal therapy and is most widely used. Estrogen receptor measurement is done at the time of surgical excision of breast cancer to guide the subsequent endocrine therapy. Most believe that the effect of TAM is the result of blocking E2 and ER by competing with E2 to bind ER. The common dose is 10mg 2 times/day. Less toxicity is the advantage of TAM, followed by additive therapy, including estrogen, progesterone, and androgens, etc. At present, the progesterone class of megestrol and megestrol is the most widely used as the second-line drugs, and its effect is lower than the first-line drugs. The commonly used dose is 500-1000mg/day for megestrol and 160-200mg/day for megestrol. Other hormone suppression therapy is also available, mainly to suppress the secretion of estrogen, and the commonly used drugs include aminogestrel, with a common dose of 1g/day, which can be started from 0.25.2 times/day and increased to 0.25.3 times/day after 2 weeks, and then to 0.25.4 times/day after 2 weeks.
It has been observed that the factors expected to achieve better efficacy with hormone therapy are ER positive, PgR positive, soft tissue or bone metastases, 1-2 metastases, postmenopausal patients, age >50 years, and for those with effective previous hormone therapy, the combination of two drugs has no significant advantage and anti-increases toxic side effects.
VIII. Measures to reduce recurrence and metastasis after breast cancer surgery
Breast cancer is one of the most common malignant tumors in women, accounting for 7%-10% of all kinds of malignant tumors in China, and the trend is increasing year by year, and the age of onset is also advanced. The treatment of breast cancer is generally based on surgery, supplemented by comprehensive treatment. However, due to various reasons, breast cancer often leads to recurrence and metastasis after surgery.
9. Measures to reduce recurrence and metastasis after breast cancer surgery include
1.Strengthen the propaganda of prevention knowledge, carry out regular screening of breast diseases, and enable adult women to master the methods of self-examination, so that once breast lumps or nipple overflow are found, they can seek medical consultation in time to improve the early diagnosis rate of breast cancer and enable timely treatment.
2. Pay attention to surgical operation, emphasize the concept of tumor-free, and reduce medical dissemination; properly protect the operation field from tumor tissue contamination during surgery, and do not excessively pull or squeeze the lump to avoid accelerating the hematogenous dissemination of tumor. The experiment of Wu Yunfei et al. shows that when the tumor is >2cm, the metastasis of axillary lymph nodes has a great possibility. Therefore, the whole breast and its related tissues should be excised as much as possible during surgery, hands and instruments should not touch the tumor as much as possible, and the surgical field should be flushed with 5-fluorouracil and a large amount of distilled water after surgery to reduce the chance of tumor implantation.
3. Standardized postoperative comprehensive treatment for breast cancer: breast cancer is a systemic disease, and postoperative adjuvant chemotherapy is an indispensable component, which is a treatment measure taken to eliminate occult metastases throughout the body. It is generally advocated to start at 2 weeks, because at this time the tumor load in human body is reduced, the tumor cell multiplication time is shortened, the proliferation ratio is large, and the drug sensitivity is high. Radiotherapy is also an important means to reduce the recurrence of breast cancer after surgery. For those with indications for radiotherapy, the best timing of radiotherapy should be mastered in order to achieve good results. Meanwhile, endocrine therapy for those with ER(+) and PR(+) for not less than 3 years can also achieve satisfactory results.
Breast cancer is a systemic disease and one of the common malignant tumors in women, which needs to be treated with comprehensive treatment mainly by surgery. If early detection, early treatment, strict mastery of the concept of tumor-free during surgery and standardized adjuvant therapy after surgery can be achieved, the tumor-free survival of patients can definitely be greatly improved.