The incidence of breast cancer is increasing day by day. As a result of this reality, the chance of catching breast cancer at an early stage is also increasing with the growing awareness, screening programs, advanced imaging, and biopsy methods. The chance of success is much higher in diseases detected at an early stage. In addition, breast cancer has become a treatable disease as a result of innovations in surgical applications, new-generation chemotherapy and targeted drugs, and developments in radiotherapy. As a result of increasing successes in diagnosis and treatment, breast patients have started to demand treatments with fewer side effects, comfortable, and good cosmetics.
In light of these data, we have been serving in a single center since 2011 with an experienced, knowledgeable team aiming to offer new applications in the world to patients. We provide service with a holistic approach in our center that contains all disciplines related to breast diseases, and we maintain our feature of being the only breast health center in the region with increasing experience day by day.
Our Main Goals:
- To detect breast cancer at an early stage with advanced imaging and biopsy methods such as contrast-enhanced mammography, 3D digital tomosynthesis mammography, ultrasonography - elastography, and magnetic resonance imaging.
- To make an accurate and timely diagnosis in a peaceful environment.
- To organize the surgical and oncological treatment of breast cancer most effectively and to produce simultaneous aesthetic solutions.
In our center, our patients are examined on the same day and evaluated radiologically with mammography and ultrasound located in the same unit, and the necessary advanced diagnostic processes are planned by being evaluated together by the breast surgeon and breast radiologist on the same day. Biopsy procedures are performed on the same day for a significant part of the patients who need a biopsy, accompanied by modern methods.
The biopsy application accompanied by contrast-enhanced mammography, which has become a part of our center's current practice, is performed flawlessly with the help of advanced technological equipment such as 3D laser-guided biopsy. All patients diagnosed in the center are evaluated by specialists in breast surgery, breast radiology, breast oncology, radiation oncology, and breast pathology, and the treatment planning of the patients is made jointly by all relevant departments in the councils held weekly.
Breast Radiology
Radiological methods used in breast imaging have different advantages and disadvantages. The age of each patient applying to our clinic, breast structure, familial and individual risk factors, complaint, and physical examination findings are evaluated together, and the most suitable imaging method or methods are applied.
Methods Used in Breast Imaging
- Ultrasonography
- Elastography
- Breast MRI
- Digital mammography
- Digital mammography with 3D tomosynthesis
- Contrast-enhanced mammography (CESM)
Breast Biopsy Methods
- Breast biopsy with ultrasound guidance
- Breast biopsy with 3D tomosynthesis guidance
- Breast biopsy with contrast-enhanced mammography guidance
Ultrasonography
It is a diagnostic method that shows the internal structure of the breast tissue using sound waves. There is no radiation exposure. It may be more effective in detecting some breast changes that may be difficult to see on mammography. It can be useful in showing the internal structure of breast masses (fluid or solid content). Ultrasound is not usually used as a routine screening test for breast cancer. Especially in women with dense breast tissue that makes it difficult to see abnormal areas on mammography, ultrasound can be very helpful. It can also be used to better examine a suspicious area seen on mammography.
Elastography
It is a test that can be performed as part of an ultrasound examination. It is based on the principle that breast cancers are generally harder than the surrounding breast tissue. This technique can show how hard the suspicious area is on ultrasound. It can be useful in assessing the likelihood of the suspicious area being cancerous or benign (cancer-free).
Breast MRI (Magnetic Resonance Imaging)
It is an imaging method that uses radio waves and strong magnets to create detailed images of the breast. In our center, breast examination is performed with a 3 Tesla MRI device.
There is no radiation exposure. It can be used to evaluate the breast in the presence of symptoms that may indicate breast cancer. If the results of other imaging tests such as mammography and breast ultrasound are not clear, MRI may be requested.
It can be used in breast cancer screening in women at high risk. However, MRI is not recommended as a screening test on its own because it can miss some cancers that mammography can detect. While MRI can find some cancers that are not detected by mammography, it can also lead to unnecessary biopsies. For this reason, MRI is not recommended as a screening test for women at average risk of breast cancer.
If breast cancer is diagnosed, an MRI may sometimes be done to determine the full size and location of the cancer, to see if there are other
tumors in the breast, and to check for tumors in the opposite breast.
It can be used to assess leaks in silicone breast implants.
Digital Mammography
Mammography is a low-dose X-ray used to show changes in breast tissue. Mammography can usually detect breast cancer when it is small and even before a lump is felt. This is likely to make treatment easier.
It can be used for breast cancer screening in women without any symptoms. Diagnostic mammography can also be used in those with suspected cancer. The main breast changes evaluated in mammography are calcifications, masses, asymmetries, and structural distortions. Mammography can usually show abnormal areas in the breast. They cannot definitively say whether an abnormal area is cancerous, but they can help your doctor decide if further tests (such as a breast biopsy) are needed.
3D Tomosynthesis Feature Digital Mammography
Three-dimensional (3D) mammography, also known as breast tomosynthesis or digital breast tomosynthesis (DBT), compresses the breast like in standard two-dimensional (2D) mammography. While the machine moves around the breast in a small arc, it takes many low-dose X-rays. The computer then converts the images into a series of thin sections. This allows doctors to see breast tissues in three dimensions more clearly. It can enable the detection of masses that cannot be seen in standard mammography. It can contribute to the diagnosis of breast cancer in women with dense breast tissue. In our center, we can take 3D mammography with as low doses as standard 2D mammography with our new device.
Contrast-enhanced (CESM) Mammography
Contrast-enhanced mammography is a method in which an iodine-containing contrast dye is injected into a vein a few minutes before mammography. This contrast helps visualize abnormal areas in the breast. It can show suspicious areas better than standard mammography. It can reduce the limitations of screening mammography in women with dense breasts. It can contribute to assessing tumor size, detecting possible additional foci, and evaluating the opposite breast in newly diagnosed breast cancer cases. It is a fast imaging method compared to MRI. It can also be used as an alternative for patients who cannot be applied MRI. In our center, we can take high-quality contrast-enhanced mammography.
Breast Biopsy with Ultrasound Guidance
If breast examination or imaging tests result in a suspicion of breast cancer, your doctor will recommend a breast needle biopsy to make a definitive diagnosis. During this procedure, the suspicious area is visualized on ultrasound and a biopsy is taken. A clip is also placed in the biopsied area.
Breast Biopsy with 3D Tomosynthesis Guidance
Microcalcifications that can be detected on mammography before a mass is felt by hand or structural distortions may be early-stage signs of breast cancer. In this case, if the suspicious areas cannot be detected on ultrasonography, the only option for biopsy used to be surgery. In our center, a biopsy can be performed from suspicious areas without surgery with the 3D tomosynthesis-guided breast biopsy system.
Breast Biopsy with Contrast-enhanced Mammography Guidance
This procedure allows biopsy of suspicious areas that cannot be seen on normal mammography or ultrasound but can be detected on contrast-enhanced mammography. It is faster and more comfortable than breast biopsy with MRI guidance.
Benign Breast Diseases
Breast Cysts
The breast consists of glands that produce milk and ducts that carry the produced milk to the nipple. These glands and ducts are surrounded by fat tissue and connective tissue. Sometimes fluid-filled sacs form in the breast, which are called breast cysts. They are most commonly seen in women over 35 who have not yet reached menopause. If they are located deep in the breast, they can be felt as a hard lump. Some women's cysts can cause discomfort and pain. Even these cysts can grow and become more sensitive and painful before the menstrual period. If a lump is detected in the breast, it is necessary to distinguish it from other lumps. Breast ultrasonography and mammography are the methods used to make this distinction. If the cysts do not shrink over time, even if they grow and cause discomfort, the fluid inside is drawn with a needle. In this way, the pain decreases or even disappears. Rarely, the fluid taken from the inside may need to be sent to the laboratory for examination. If blood is detected, it may indicate breast cancer, but generally, the presence of cysts in the breast does not increase the risk of breast cancer. Therefore, its follow-up and treatment should be done by physicians specialized in this field.
Fibroadenoma of the Breast
Fibroadenomas are rubbery-textured, well-defined, round, or lobulated (nodular structured), benign lumps. They are painless. When examined by hand, they are seen to be movable. They are most commonly seen in young women.
Sometimes there can be more than one. The majority are 1-3 cm in diameter. Sometimes they can reach large sizes in young adulthood. These are called giant or juvenile fibroadenomas.
Fibroadenomas are benign lumps that develop mainly from the supporting connective tissue of the breast. The presence of a fibroadenoma in the breast does not increase the risk of developing breast cancer in the future. Ultrasonography is the most commonly used method for diagnosis. If necessary, needle biopsies can be used. Small fibroadenomas that do not leave any doubt in the diagnosis can be followed up. If the patient is young and the fibroadenoma is large, it is preferred to be removed instead of follow-up. If recurrence occurs, the possibility of a phyllodes tumor, which closely resembles fibroadenomas, should be considered.
Granulomatous Mastitis
Granulomatous mastitis is one of the rare inflammatory diseases whose cause has not been well elucidated. Granulomatous mastitis is divided into two as granulomatous mastitis with a known cause and idiopathic (unknown cause).
Granulomatous mastitis with a known cause can develop after tuberculosis, sarcoidosis, Wegener's granulomatosis, foreign body, and fungal and parasitic infections. In addition, it can be seen in women who smoke, use birth control pills, and have recently given birth.
The diagnosis of idiopathic granulomatous mastitis is made by excluding other factors and detecting chronic lobulitis along with granulomatous inflammation in the biopsy.
Although it is a benign condition, it can have comfort and hygiene-disrupting effects such as abscess formation, sinus formation, and cellulitis development in the breast due to its ability to mimic breast cancers. Since it can mimic breast cancer, repeated biopsies may be required to rule out this diagnosis. Although the appropriate treatment method for idiopathic granulomatous mastitis is not clear, observation of the diseased area alone, regional injection treatments in patients with increasing findings, and steroid cream or steroid tablet use or limited removal of the diseased tissue by surgery in case of limited disease are other treatment approaches currently applied. Due to the nature of the disease, its tendency to limit itself is kept in mind, and the treatment decision and timing are made in this direction.
Phyllodes Tumor
Phyllodes tumors are rare fibroepithelial tumors of the breast. They constitute 0.3-1% of all breast tumors. Their clinical behavior varies. They can behave benignly similar to fibroadenomas, but they can also tend to metastasize. They are classified as benign (benign), borderline malignant (malignant), and malignant based on their histological features. No morphological and radiological finding is completely reliable in predicting the biological behavior of phyllodes tumors.
Core needle biopsy is helpful in diagnosis in the hands of experienced pathologists, although it has a margin of error. Especially in recent times, the sensitivity of magnetic resonance imaging (MRI) in the diagnosis of malignant phyllodes tumors has been increasing.
They are mostly seen in women aged 35-55. The treatment of phyllodes tumors is surgical. If the diagnosis is made correctly before surgery, wide excision of the mass is generally the preferred surgical method.
Breast Nipple Dermatoses
Nipple dermatoses are quite rare and their macroscopic appearance is similar to each other, so differential diagnoses are very important. Lesions are generally scaly and red in the early stages and can be confused with inflammatory skin lesions or nipple eczemas.
Malignant ones are called Paget's diseases. Benign ones include nipple adenomas, molluscum contagiosum, fibroma, epidermal cyst, and cellular blue nevi. Their treatments are in the form of regional treatments.
Breast Pain
Many women experience breast tenderness or breast pain. These pains can be periodic pains that recur according to the menstrual period, or they can be independent of the menstrual period.
The periodic pain is often seen in young women and is usually felt as tension and tenderness in both breasts at the same time. Pain usually spreads to the arm and armpit. The main reason for this type of pain is the cystic structure of the breast. This completely benign condition ends with menopause.
The non-periodic pain is common in women aged 30-50. Most of the time, it occurs in only one breast. It is often felt as a sharp and stabbing pain in a specific area of the breast. The most common causes are fibroadenomas and simple cysts. Both are benign conditions.
All types of breast pain are more common before menopause. The hormonal drugs used or the woman's hormone levels may increase according to use. All kinds of physical and mental stress can increase breast pain.
Is there a relationship between pain and cancer?
Contrary to popular belief in society, it is not correct to associate pain with cancer. Every kind of good or bad formation in the breast can be painful or painless.
What can we do to reduce benign breast pain?
After being evaluated by a breast disease specialist, in addition to the hormone or hormone suppression drugs that are deemed appropriate, reducing coffee consumption, reducing the fat ratio in nutrition, and doing regular exercise have been shown to have positive effects on breast pain.
Nipple Discharge
It is the condition of various types of fluid coming from the nipple outside of normal situations such as breastfeeding and pregnancy. Although this situation often causes anxiety in women, it usually originates from harmless causes. The most common non-hormonal cause of nipple discharge is breast duct dilatation (ductal ectasia) and intraductal papillomas, which are often unilateral.
The discharge can be transparent, yellow, green, or white. The color of the discharge does not indicate whether the underlying condition is good or bad. Bloody nipple discharge is never considered normal.
The main causes of nipple discharge are
- Fibrocystic changes in the breast: It is the situation where the outer part of the glands that produce milk in the breast tissue hardens and tiny fluid-filled sacs form between them. Fluid accumulation in the milk ducts leading to the nipple and leakage from the nipple can occur.
- Galactorrhea: It is the situation where the breast produces milk outside of pregnancy and breastfeeding. This situation can occur in the presence of tumors that cause overactivity of a gland in the brain (pituitary gland) (pituitary adenoma), some drug use, and substance addictions (such as marijuana), anise and fennel use, and cases where the thyroid gland is underactive.
- Inflammatory conditions of the breast (breast abscesses): Although it is mostly seen during breastfeeding, it can also be seen in other periods.
- Ductal ectasia: It is a condition that is typically seen in women approaching menopause (around 40-50 years old) and occurs over the years as the milk ducts under the nipple gradually dilate.
Although the cause of non-hormonal nipple discharge is mostly benign changes, breast cancer can also be seen in breast cancer diseases originating from the milk duct or nipple. Nipple discharge is mostly due to benign changes, but it can also be a harbinger of breast cancer.
Lactation
Towards the end of pregnancy, the breasts become ready for breastfeeding and become tense under the influence of hormonal changes during this period, and some problems may arise with the start of birth and breastfeeding. These are cracks that occur in the nipple, abscesses formed by the progression of microbes through the breast ducts, and sometimes milk fever (milk abscess) caused by the inability to empty the breasts sufficiently.
To avoid this situation, nipple hygiene should be done after breastfeeding, care should be taken for small cracks that occur, and thus breast abscess formation should be prevented. Preventing the accumulation of milk by milking the breasts that do not empty will be the most effective way to prevent breast abscess formation.
Gynecomastia (Male Breast Enlargement)
Gynecomastia is the development of breast tissue and the acquisition of a similar appearance to the female breast in men. It can occur in one or both breasts. Physiological gynecomastia is most common in the neonatal period, puberty, and old age. The main reason is the increased estrogen hormone stimulation. There is usually some sensitivity in the growing breast. Gynecomastia does not predispose men to breast cancer, but the risk of breast cancer increases in some genetic diseases (Klinefelter syndrome, Reifenstein syndrome).
Pathological gynecomastia can develop in cases of excess estrogen-producing tumors (testicular, adrenal gland, liver tumor), situations where androgen (male hormone) deficiency (testicular non-function, congenital genetic diseases such as Klinefelter syndrome), and some drug side effects. In the treatment, the breast tissue is removed by entering around the nipple. In large gynecomastias, breast tissue and breast skin are removed together, preserving the nipple.
Breast Cancer
Risk Factors for Breast Cancer
1) Having a first-degree relative such as a mother and sister who has had breast cancer: It is stated that having someone in the family who has had breast cancer increases the likelihood of women getting breast cancer. Especially if a woman's sister or mother has had breast cancer, her risk of getting breast cancer is 2 to 5 times higher than other women.
2) Those who had their first childbirth after the age of 30: The age at which women give birth to their first child is important in terms of the risk of breast cancer. The rate of breast cancer in women who have their first child after the age of 30 is twice that of those who give birth before the age of
20. The risk is even higher in women who have never given birth.
3) Those over the age of 50: Being older is an important risk factor. 70% of women with breast cancer are over 50 years old. The risk of breast cancer in women over the age of 50 is 4 times higher than in women under 50.
4) Early first menstruation (before the age of 12), late menopause (over the age of 50): Early onset of menstruation and late onset of menopause prolong the fertility period. During this time, the woman remains under the influence of the estrogen hormone for a longer period, which increases the risk of breast cancer.
5) The presence of cancer in one breast increases the risk of it occurring in the other breast: Women who have had and treated breast cancer have a 3-4 times higher risk of cancer developing in their other breast than women who have not had breast cancer.
6) Those who have never breastfed
7) Those carrying genetic mutations associated with breast cancer
8) Use of birth control pills: There are conflicting interpretations of the effect of birth control pills on the risk of breast cancer. It is stated that long-term use (>10 years) slightly increases the risk, but in women who have stopped using birth control pills for 10 years, this risk completely disappears.
9) Those who have never given birth
10) Taking estrogen and using birth control pills: Women who have received estrogen therapy for a long time (more than 10 years) due to menopause are at increased risk of breast cancer.
11) Obesity and fatty nutrition: Obesity increases the risk of breast cancer, especially in women over the age of 50.
12) High socio-economic level: Women who are wealthy and have a high socio-economic level have a higher frequency of breast cancer.
13) Use of alcohol: Although there is no clear interpretation, the risk of breast cancer is higher in women who use alcohol.
14) Smoking: Although a definite relationship between smoking and breast cancer has not been fully established, some studies have found that cigarettes have an effect on the development of breast cancer.
Is it possible to prevent breast cancer?
- Consumption of fresh fruits and vegetables rich in vitamins A and C,
- Breastfeeding,
- Giving birth under the age of thirty,
- Sports and exercise,
- Avoiding obesity,
- Nutrition with more fibrous foods by staying away from animal fats,
- Not consuming smoked, salty, and canned foods,
- Staying away from cigarettes,
- Not using alcoholic beverages,
- Removal of both breasts as a protective measure in patients with a high risk of cancer can reduce the risk of breast cancer.
Symptoms of Breast Cancer
The symptoms of breast cancer vary depending on the degree of spread of the disease in the body and the individual. Although most women with breast cancer do not have pain in the initial period, it should be known that the symptoms listed below can be seen in many patients who do not have cancer. Although the vast majority of these changes are harmless, they can also be the first signs of breast cancer in a small probability. For this reason, we recommend women know what is normal for them, examine their breasts, detect what changes are, and report them without delay. In addition, even if there is no change, we expect them to participate in breast screening programs compatible with their age.,
Symptoms of breast cancer
- The presence of a mass in the breast,
- The breast taking on an orange peel-like appearance,
- The nipple being pulled inward for reasons other than congenital,
- Bloody or non-bloody discharge from the nipple,
- The formation of retraction, ulcer (wound), redness, and edema (swelling) on the breast skin,
- Swelling in the lymph nodes around the breast,
What should be done for early diagnosis of breast cancer?
The methods used to make an early diagnosis of possible breast cancer in women who do not have any complaints or lumps in their breasts are called "Screening Methods". This should generally start after the age of 40. However, it would be appropriate for women to become aware of and check their breasts with a monthly self-examination starting from the age of 30. Screening methods are done in 3 ways.
1. Annual Mammography
2. Monthly self-examination
Women should regularly examine themselves every month. This control should generally be done 4-5 days after the end of the menstrual period. Women who have entered menopause, or have had uterine or ovarian surgery, should have a breast examination by a doctor once a year on the same days of the month. In self-examination of the breast, breasts are checked by removing the clothes above the waist in front of the mirror, during the shower, and lying on the back. Women who examine their breasts every month in this way can recognize the tissues inside their breasts and detect abnormalities that occur outside of them early.
3. Annual clinical
Examination
It is recommended that women with familial breast cancer risk factors start at the age of 35, or 10 years before the age at which the first cancer was detected in their family members, and women without any complaints should also have a doctor's examination once a year after the age of 40.
Types of Breast Cancer
Breast cancers are divided into two groups as sporadic (non-hereditary) or hereditary breast cancer. Hereditary breast cancers constitute approximately 10-15% of all breast cancers.
If the cancer develops from the milk duct (ductus) of the breast, it is called ductal carcinoma,if it develops from the breast lobule (milk gland), it is called lobular carcinoma.
If the cancer has not passed the inner lining (first layer of cells) of the breast duct, it is called ductal carcinoma in situ (DCIS). This stage is considered the very early stage of cancer and is the group in which we are most successful in treatment. The rate of diseases detected at this stage is increasing day by day with the increasing awareness in society and the application of advanced diagnostic methods.
Breast Cancer and Genetics
About 10-15% of breast cancers are associated with genetic changes. The majority of hereditary breast cancers are associated with mutations in genes known as BRCA-1 and BRCA-2. In recent years, it has been thought that BRCA-1 and BRCA-2 gene mutations may also play a role in non-familial, sporadic breast cancer cases. BRCA gene changes have been observed in triple-negative breast cancers, which are negative for estrogen, progesterone, and HER2 receptors. Women who carry BRCA-1 or BRCA-2 gene mutations have a lifetime risk of developing breast cancer of 80-90%, and a risk of developing ovarian cancer of 30-40%. This poses a very high risk. For this reason, it is recommended that women with BRCA-1 and BRCA-2 gene mutations have both breasts removed (mastectomy) to protect themselves from breast cancer. In addition to BRCA, genetic changes in breast cancer susceptibility have been increasingly identified in recent years. Among the most known ones are TP53, PTEN, STK11, CDH1, APC, MLH1, MSH6, MUTHY, ATM, ATR, and CHEK2 genes.
In light of all this information;
• Having a personal or familial history of ovarian cancer
• Having a first-degree relative diagnosed with breast cancer before the age of 50 or having more than two first-degree relatives diagnosed with breast cancer
• Having more than three second-degree relatives diagnosed with breast cancer
• Having both breast and ovarian cancer in first or second-degree relatives
• Having a history of breast cancer in male relatives requires genetic counseling poses breast cancer risk
Pregnancy and Breastfeeding Period Breast Cancer
Breast cancer occurs in one out of every 3000 pregnancies. It is the most common cancer during pregnancy and the postpartum period. Sensitivity and growth occur in the breasts during pregnancy and the postpartum period, which are prepared for breastfeeding under the influence of hormonal changes during this period, and some problems may arise with the start of birth and breastfeeding. These are cracks that occur in the nipple, abscesses formed by the progression of microbes through the breast ducts, and sometimes milk fever (milk abscess) caused by the inability to empty the breasts sufficiently.
To avoid this situation, nipple hygiene should be done after breastfeeding, care should be taken for small cracks that occur, and thus breast abscess formation should be prevented. Preventing the accumulation of milk by milking the breasts that do not empty will be the most effective way to prevent breast abscess formation.
Male Breast Cancer
One percent of all breast cancers occur in men. Although men have a small amount of breast tissue under their nipples, cancer can develop in this area. Breast cancer in men is most commonly diagnosed in men over the age of 60. Since breast cancer is considered a disease specific to women, men become aware of this situation late. For this reason, the disease is advanced when the cancer is diagnosed.
The most common symptom in men with breast cancer is a mass in the breast tissue. Breast pain is rarely seen in breast cancer. Enlargement or pain in the breast area is often due to gynecomastia (an increase in breast tissue in men). Breast changes should be examined by a doctor when noticed.
The presence of breast cancer in a close relative, the presence of breast cancer in more than one relative, especially under the age of 40, increases the risk of breast cancer. When a mass and other symptoms are observed, it is important to be examined by a doctor as soon as possible for early detection of the disease.
Paget's Disease of the Nipple
The distortion of the structure of the nipple, the formation of hard irregular retraction and indentations, and the "orange peel" appearance are often observed, which may indicate
the malignant transformation of the nipple. It can accompany cancer originating from the breast duct or breast tissue.
It can develop as a secondary change in the nipple due to a cancer that has developed in the breast or as a cancer disease of the nipple itself. It should not be confused with benign dermatological diseases of the nipple (such as eczema, which is an itchy disease). Any minor change that occurs in the nipple and tip should be evaluated by a breast specialist.
Biopsy is required for diagnosis, and if Paget's disease is diagnosed, treatment requires the complete removal of the breast.
Breast Cancer Staging What is it? How is it done?
The stage is an indicator of how advanced a tumor is.
The stage is closely related to the size of the tumor, the spread to lymph nodes, and the spread to distant organs (metastasis).
The larger the tumor and/or the more it has spread to the armpit, the more advanced the stage. It is considered the most advanced stage if it has metastasized to distant organs such as the liver, lung, bone, or brain.
Before breast cancer surgery, the disease is evaluated for spread (metastasis). If breast cancer has spread to anywhere other than the armpit lymph nodes (liver, lung, bone, etc.), limited surgeries are usually performed in most cases. After surgery, patients are evaluated for preventive treatments. Breast cancer is considered a systemic disease even in the early stages. Even in very early-stage diseases, cancer cells are present in the blood. Cancer can recur even 10-20 years after surgery. For this reason, patients are given adjuvant treatments called adjuvant therapy after surgery to reduce the risk of spread. These treatments are chemotherapy, hormonal treatments, and biological agents. Which of these treatment options the patient will use or which ones are evaluated separately for each patient after surgery? There is no standard single treatment given to every patient. These treatments are selected according to the stage of the disease and the characteristics of the tumor in breast cancer patients. The most guiding factors in the selection of treatment are:
- The diameter of the tumor,
- Whether there is metastasis to the armpit lymph nodes,
- The patient's menopausal status,
- The results of special stains made by the pathology department (estrogen receptor, HER-2), histological grade (the degree of richness of the tumor with atypical cells).
- In addition, genetic tests such as Oncotype dx and mammaprint, which have been performed on breast cancer tissue in recent years and are specific to the individual, also show whether the patient will benefit more from chemotherapy or hormonal therapy. The use of these tests in suitable patients can prevent unnecessary chemotherapy use.
Chemotherapy can sometimes be given before surgery. This application is called neoadjuvant therapy. In cases where the tumor size is large but the patient wants breast-conserving surgery and it is not possible due to the size of the tumor, chemotherapy can be given before surgery. Surgery is performed after 4 or 8 cycles of chemotherapy. One of the advantages of neoadjuvant chemotherapy is the ability to monitor the effectiveness of chemotherapy on the tumor.
Chemotherapy
It is usually the treatment option that patients with breast cancer are most afraid of receiving treatment. The risk of death or very serious side effects due to chemotherapy is very rare with current chemotherapy drugs. It is recommended for most patients after surgery in recent years. Chemotherapy usually starts within a month after surgery. The patient and their relatives need to receive good training about side effects before treatment. The patient should be informed about what possible side effects may occur and know when to go to the polyclinic or emergency room if necessary. In addition to the information given by the oncologist, training should be received from the oncology nurse, and the chemotherapy handbook prepared should be carefully examined. With the anti-nausea drugs that have come into use in recent years, nausea and vomiting are no longer a feared side effect of chemotherapy. Chemotherapy is usually applied once every 21 days. It is given 4-8 times depending on the condition of the disease. This corresponds to a total chemotherapy duration of 3-5 months.
Hormone Therapy
Some breast cancer cells may be sensitive to the female hormone estrogen through the hormone receptors they contain. That is, the estrogen hormone can cause these cancer cells to grow and multiply. Hormone therapy aims to prevent the growth of cancer by eliminating the effect of estrogen in cancer types that contain estrogen receptors and are sensitive to this hormone. In premenopausal patients, tamoxifen therapy is usually given for 5 years. Patients taking tamoxifen should be followed by the obstetrics and gynecology department for the risk of uterine cancer. In addition, in premenopausal patients with estrogen-sensitive breast cancer, injection treatments that suppress menstruation are used for 2-3 years after chemotherapy, once or every three months. In postmenopausal patients, let
rozole and anastrozole tablets are used. Hormonal therapy is not performed in patients with negative receptors.
Biological Therapy
The human epidermal growth factor receptor-2 (HER-2) is found in approximately 20% of breast cancer patients. Patients with HER-2 positive have an increased risk of recurrence compared to other patients. Trastuzumab, a drug that was first used in metastatic disease in the 2000s and has started to be used in early-stage breast cancer in recent years, has significantly reduced the risk of recurrence. This drug, known as a smart drug among the public, does not have side effects such as hair loss and nausea and vomiting caused by classical chemotherapies. It rarely causes heart failure and patients are followed by cardiology every three months in this regard. In recent years, a new drug called pertuzumab has also taken its place in the treatment as a complement to the same purpose.
In addition to all these drug treatments, new-generation targeted biological drugs and immunotherapy drugs are used as second-line drugs, especially in patients who have not fully achieved results in the first stage. These drugs are included in the treatment range as part of many ongoing cancer research studies in the international scientific field, which is a feature that distinguishes our center in the region and the country and brings it to international standards.
Radiotherapy in Breast Cancer
Breast cancer treatment is done with surgery, chemotherapy, and radiotherapy. Therefore, when planning the treatment of patients diagnosed with breast cancer, the opinions of all departments are taken.
As a result of developments in radiotherapy in breast cancer, there have been significant changes in other treatments. The most important of these are changes in surgical practices. After mastectomy (removal of the entire breast tissue) and removal of armpit lymph nodes, radiotherapy is generally applied to patients with a high risk of recurrence in the same place and spreading elsewhere. When making a radiotherapy decision, risk factors related to the patient and the disease are taken into account. Generally, the irradiated areas are the chest wall and/or armpit areas. This treatment lasts approximately 5 weeks and usually starts after chemotherapy. The most common side effect is skin burns, which heal with appropriate treatments.
After breast-conserving surgery: In localized disease, radiation therapy is applied to the breast and tumor area to reduce the risk of recurrence. In patients who have undergone breast-conserving surgery, radiotherapy is usually started approximately 2 weeks later and the treatment duration is approximately 30-33 days. The most common side effect of this treatment is also skin burns, and breast pain is also frequently seen.
Radiotherapy options in breast cancer
- Post-mastectomy: Radiotherapy is usually applied to patients with a high risk of recurrence and spreading after mastectomy and removal of armpit lymph nodes. When making a radiotherapy decision, risk factors related to the patient and the disease are taken into account. Generally, the irradiated areas are the chest wall and/or armpit areas. This treatment lasts approximately 5 weeks and usually starts after chemotherapy. The most common side effect is skin burns, which heal with appropriate treatments.
- After breast-conserving surgery: In localized disease, radiation therapy is applied to the breast and tumor area to reduce the risk of recurrence. In patients who have undergone breast-conserving surgery, radiotherapy is usually started approximately 2 weeks later and the treatment duration is approximately 30-33 days. The most common side effect of this treatment is also skin burns, and breast pain is also frequently seen.
Breast cancer radiotherapy techniques
- 3D conformal radiotherapy: This treatment option is performed using a computerized planning system. The areas to be irradiated (breast and/or lymphatics) and the areas not to be irradiated (lung and heart) are determined by the patient's pre-treatment computed tomography, and radiotherapy is applied according to the appropriate dose distribution.
- Intensity-modulated (IMRT)/image-guided radiotherapy (IGRT): Again, a computerized planning system is used. It is a more complex application. In IMRT, the treatment planning process is longer than conformal planning. In IMRT, areas other than the target area are less damaged, but it should be done with experienced teams and equipment.
- Brachytherapy: It is the process of giving high-dose radiation in a short time (approximately 5 – 7 days) to the tumor or tumor bed by placing suitable catheters or balloons (Mammosite®) in the risky areas. The radioactive source is kept in the placed catheter for the determined time, allowing sufficient radiation to be given to the risky areas. Brachytherapy requires an adequate team (radiation oncology specialist, general surgeon, radiology specialist, physics engineer) and equipment (brachytherapy device and planning system).
Side effects of radiotherapy
- Skin reactions: Skin reactions are the most common side effect seen during radiotherapy. Skin reactions
vary from patient to patient. In tumors close to the skin or in patients with a high risk of recurrence in the chest wall, the skin dose needs to be high. In these patients, common skin reactions are redness of the skin, and dry and wet skin peeling. These skin reactions heal with appropriate treatments and do not cause permanent damage. In patients who have undergone breast-conserving surgery, the area where skin reactions are most commonly seen is the fold area of the breast, and keeping this area ventilated and dry during treatment reduces the occurrence of skin reactions. An important factor that increases skin reactions is the chemotherapy drugs given before radiotherapy and hormone treatments. The most important factor is personal sensitivity. Skin reactions vary depending on the patient's sensitivity to radiotherapy.
- Fatigue, tiredness: During radiotherapy, fatigue, and tiredness may occur due to the effect of chemotherapy drugs given before and possible fluid loss. This effect is not permanent and disappears completely after the end of treatment.
- Edema and pain in the breast: It is frequently seen in patients who have undergone breast-conserving surgery and have undergone breast irradiation. It is especially seen in patients with large breasts and/or receiving hormone therapy. Breast edema is seen during treatment and heals within weeks after treatment.
- Effects on the heart and lungs: With the new treatment planning systems, serious side effects are not expected as the heart and lung doses are significantly reduced. Especially in patients receiving maintenance treatment (trastuzumab) and undergoing left breast irradiation, special attention is paid to heart doses.
In the Radiation Oncology department of Başkent University, the following breast treatments are performed
- 3D conformal radiotherapy
- Intensity-modulated (IMRT) and image-guided radiotherapy (IGRT)
- Brachytherapy (Mammosite brachytherapy will start soon)