Breast Cancer Treatment in Gurgaon India

Breast cancer doctor in gurgaon: The breasts are paired, hemispherical-shaped, glandular organs of variable size on the chest of a woman (between the 2nd and 6th ribs and anterior to pectoral muscles). They are mostly made up of adipose (fatty) tissue and connective (fibrous) tissue that surrounds and support about 12 to 20 lobes. The nipple is surrounded by the dark skin called the areola.

Epithelial breast carcinoma or adenocarcinoma (affecting epithelial cells of the glandular tissue within breast) is the most commonly encountered (more than 95% of all cases) type of breast cancer. Breast adenocarcinoma includes ductal carcinoma in situ, invasive ductal carcinoma, and invasive lobular carcinoma.

Normal breast cells and some breast cancer cells have specialized proteins on/in their surface called hormone receptors. Hormones – estrogen and progesterone can bind to these receptors (estrogen receptor [ER] and progesterone receptor [PR], respectively) and promote the growth of these cells.

Some breast cancer cells have another growth-promoting protein on/in their surface known as the human epidermal growth factor receptor 2 (HER2/neu or HER2). Certain breast cancer cells do not have any of the above receptors, that is, negative for ER, PR, and HER2. These are called triple-negative breast cancer.

How do I know if I am at risk for Breast Cancer? What are the causes of Breast Cancer?

Breast cancer risk factors may be modifiable or non-modifiable. Modifiable risk factors are those that are related to lifestyle factors. Whereas, non-modifiable are ones that are related to genetic factors, age, ethnicity, etc.

Hormonal causes may be included in both. Like early menarche or late menopause comes under non-modifiable, whereas, intake of hormone replacement therapy, late marriage or late childbirth and obesity come under modifiable risk factors.

Below are some common modifiable and non-modifiable risk factors for breast cancer.

Non-Modifiable

• Age
• Genetic factors – mutations in BRCA1 or BRCA2; 50-60% of women inheriting a BRCA1 mutation from either parent will have breast cancer by age 70.
• Family history of breast cancer (not related to BRCA mutations)
• Personal history of hyperplastic breast disease.
• Race: incidence is higher in Caucasian compared with African-American, Hispanic or Asian women.
• Radiation treatment: chest irradiation as a child/young woman can significantly increase risk of developing breast cancer.
• Menstrual history: early menarche (<12 yr) or late menopause (>50yr) has some association with increased risk. Also nulliparous, or first childbirth at >30 yrs.

Modifiable

• Oral contraceptives.
• Hormone replacement therapy – >5 years of therapy with combined estrogen and progesterone may increase risk.
• Not breast feeding.
• Diet and obesity; physical inactivity.
• Smoking.
• Alcohol – 2-5 drinks/day can increase risk x 1.5 over non-drinkers.

What are the Tests or Investigations to be done to confirm the diagnosis of Breast Cancer?

Mammography

It uses low dose X-rays to examine the breasts. In this test, a special machine has used that consist of two plates to compress and flatten the breast to be examined. Thereafter, an X-ray image of the breast is taken. This test can provide information about the cancerous changes within the breast tissue which generally appears as a lump/mass, microcalcifications, or other changes. Any abnormality observed during this test warrants detailed investigations to establish the diagnosis of breast cancer. Mammograms are not very sensitive in case of dense breast tissue. Mammography imaging of the breast is reported as a score called BIRADS score.

• BIRADS 1 means absolutely normal breast, with 0% chances of malignancy.
• BIRADS 2 means the presence of benign findings, with 0% chances of malignancy.
• BIRADS 3 means the presence of findings that are probably benign, with less than 2% chances of malignancy. Needle testing of breast is not required in BIRADS 1, 2 or 3.
• BIRADS 4 means suspicious for malignancy, with 2-95% chances of malignancy. Needle testing should be considered in this.
• BIRADS 5 means highly suggestive of malignancy, with more than 95% chances of malignancy. Needle testing should be done in this.

Needle testing of breast may be done by FNAC or biopsy, but biopsy is preferred as it is more accurate, and provides sufficient tissue for ER, PR and HER-2 testing.

Breast ultrasound

This test can distinguish between fluid-filled cysts (mostly benign) and solid tumor masses. This technique can also be used to guide a needle to collect biopsy samples.

Breast Biopsy

Biopsy sample is generally collected from the suspected areas observed during the mammography or the breast ultrasound. Depending on the size and location of the suspicious area, a fine needle biopsy, a core needle biopsy, or a surgical biopsy technique is utilized. Sometimes, a biopsy sample from lymph nodes under the arms may also be collected.

The collected biopsy samples are examined in a laboratory and can provide information about the type of cancer, grade of cancer, and the presence of specific defective genes or proteins in the cancer cells. Breast cancer is classified into hormone receptor positive, Her-2 Neu positive or triple negative disease based on biopsy testing and it is very important as it determines the further treatment of the disease.

Systemic Imaging

So first we did a local imaging, when we had a suspicious mass in breast. Then we did a needle testing to confirm that it is cancer. Once the diagnosis of breast cancer is confirmed, we have to do the systemic imaging depending upon clinical presentation, to stage the disease, whether it is localised, locally advanced or metastatic. Any one or more of the following investigations may be required for staging work-up of the tumor-

• Whole Body PET CT Scan
• CT Scan
• Bone Scan
• X Ray Chest
• USG Abdomen

How do I know my Stage of Breast Cancer?

Clinical Staging

Clinical TNM Staging for breast cancer is done by physical examination of the patient and laboratory and radiology investigations (discussed below).

T Staging

• T1 when the tumor size is less than or equal to 2 cm.
• T2 when the tumor is 2 cm to 5 cm.
• T3 when the tumor is more than 5 cm.
• T4 disease, first we have to know the structures. Deep to the breast there is pectoralls fascia and pectoralls major muscle.

And when the breast cancer progresses very rapidly to cause diffuse erythema and edema of skin breast, involving more than one-third of the skin, then it is called as inflammatory breast cancer.

N Staging

Now, we move on to the N-staging. To understand the N staging, first you have to know the local structures in that area.

•  If they are not palpable, it is NO.
• If palpable, and freely mobile, it is N1.
• If level 1 or level 2 lymph nodes are palpable, but they are fixed or matted, it is called as N2a.
• If only internal mammary lymph nodes are seen in CT scan without any level 1 or level 2 nodes, the it is called as N2b.
• If infraclavicular lymph nodes are involved, it is called as N3a.
• If internal mammary and axillary lymph nodes both are involved that is N2a and N2b, then it is N3b.
• Involvement of both internal mammary and axillary lymph nodes Involvement of supraclavicular lymph nodes are called as N3c

M Staging

Now, let’s move ahead. Next comes the M-staging If the disease has spread to the distance organ it is called as M1 otherwise it is M0. This figure shows spread to both lungs in the form or multiple metastatic nodules.

Similarly, the spread may occur to brain, bones or other part of the body.

Pathological Staging

T Staging

• Tis – Pre-cancerous changes or carcinoma in situ (CIS). No spread to nearby lymph nodes or distant body parts.
• T1 – Tumor size is 2 cm or less. No spread to nearby lymph nodes or distant body parts.
• T2 – Tumor size >2 cm, but
• T3 – Tumor size >5 cm. No spread to nearby lymph nodes or distant body parts.
• T4 – Tumor of any size with direct extension to the chest wall or skin or inflammatory breast cancer.

N Staging

• N1 – Cancer spread to 1-3 axillary lymph nodes or tiny cancer deposits in internal mammary lymph node(s) on sentinel lymph node biopsy.
• N2 – Cancer spread to 4-9 axillary lymph nodes or enlargement of internal mammary lymph node(s).
• N3 – >/=10 axillary lymph nodes (>/=1 area >2 mm)
  • Cancer spread to the infraclavicular (those under the collarbone) lymph nodes (>/=1 area >2 mm) [N3a]
  • Cancer spread to >/=1 axillary lymph nodes (>/=1 area >2 mm) with internal mammary lymph node(s) enlargement, or cancer spread to >/=4 axillary lymph nodes (>/=1 area >2 mm) with micrometastasis in internal mammary lymph node(s)[N3b]
  • Cancer spread to >/=1 axillary lymph nodes (>/=1 area >2 mm) with internal mammary lymph node(s) enlargement, or cancer spread to >/=4 axillary lymph nodes (>/=1 area >2 mm) with micrometastasis in internal mammary lymph node(s)[N3b]
  • Cancer spread to the supraclavicular (those above the collarbone) lymph nodes (>/=1 area >2 mm)[N3c].

M Staging

• M0 – No spread of the disease to distant body parts.
• M1 – Cancer spread to distant organs like bones, lungs, liver, brain, etc.

In addition to staging, estrogen receptor (ER), progesterone receptor (PR), HER2/neu (HER2) status, and grade of the cancer is evaluated on the surgical specimen to assess the prognosis of the disease, and planning the treatment.

To make things easier, we stage the breast cancer into stage groups. It can broadly be divided into localized, locally advanced or metastatic disease.

Localised disease includes cases up to T2 N1 M0 and T3 N0 M0. Starting from T3 N1 M0 and onwards all N2 and N3 and T4 cases are included under locally advanced disease. Metastasis to other sites, as we have discussed previously is called M1 disease.

What is the Treatment for Breast Cancer? Where can I get the best treatment for Breast Cancer in Gurgaon?

Oncoexperts is a cancer clinic in Gurgaon for treatment for breast cancer from our team of cancer experts that include surgical oncologists, breast oncosurgeon, medical oncologists, and radiation oncologists who are experts in treating all types of breast cancer.

Treatment of breast cancer depends on the stage of disease (as discussed above). Other factors that determine the treatment are type and grade to tumor, hormone receptor status, Her 2 neu status, menopausal status, performanace status of patient, etc. But the final treatment decision is taken by the oncologist after clinical evaluation of the patient.

Localised Breast Cancer

Breast Cancer surgeon in Gurgaon: If we see the localised disease in detail, it includes cases till T3, that is tumor more than 5 cm but not infiltrating the skin or chest wall, or N1, that is presence of mobile axillary lymph nodes.

So, the treatment for Localised Breast Cancer may be summarized as follows:-

Localised disease includes cases upto T2N1M0 and T3N0M0. It may be treated with Breast Conservation Surgery (BCS) or Modified Radical Mastectomy (MRM).

For early stage disease and small tumor size, if the patient fulfills the criterion and is willing for the same, BCS is a suitable option. In case of large tumors, when BCS is not possible upfront, neoadjuvant chemotherapy may be given and then tried for BCS.

If the tumor size is large, or the patient doesn’t fulfill the criterion for BCS, or is unwilling for the same, then the suitable option is MRM. In this technique whole breast tissue and draining lymph nodes are removed.

Decision to add chemotherapy in the neoadjuvant or adjuvant setting is taken on the basis of size of tumor, involvement of axillary lymph nodes, type of surgery (BCS or MRM), performance status, etc. Adjuvant radiation is required in all patients after BCS, but only in selected cases after MRM.

Locally Advanced Breast Cancer

Locally advanced breast cancer includes cases with a T4 disease, that is infiltration of the chest wall or skin or N2 or N3 disease, that is, fixed or matted axillary lymph nodes. This figure shows T4 disease, with infiltration into the chest wall or skin, and N2 or N3 disease, with a presence of matted or fixed axillary lymph nodes.

So, the treatment for Locally Advanced Breast Cancer may be summarized as follows-

It is treated as localised breast cancer (as discussed above), with addition of radiation therapy in all cases.

These cases are upfront unresectable, so neoadjuvant therapy is required in all the cases. Thereafter, decision for BCS and MRM is taken depending on response to neoadjuvant treatment, patient’s preference and other factors. Then, adjuvant radiation is required for all patients. Decision to add adjuvant chemotherapy, targeted therapy and/or hormonal therapy is taken by the oncologist on individual patient basis.

Metastatic Breast Cancer

Metastatic disease constitutes for 5-10% of the cases of breast cancer. The treatment options for metastatic breast cancer are chemotherapy, hormonal therapy for ER PR positive disease, and anti Her-2 therapy for Her-2 positive disease. Radiotherapy or surgery may be added for palliation, i.e., reduction of symptoms, and bone redirected therapy may be given in presence of bone metastasis.

Remember cure is not the intent for giving treatment in metastatic disease. It is mainly given to prolong the life, reduction of symptoms, and improvement of quality of life. Treatment for metastatic disease is decided based on the site of metastasis, previous treatments taken, ER, PR, HER-2 status, performance status of the patient and the comorbidities in the patient.

Role of Targeted Therapy

Examples of targeted drugs for breast cancer include

• Anti Her2 therapy (eg, trastuzumab, pertuzumab, etc) for Her2/Neu receptor-positive disease,
• CDK4/6 inhibitors (e.g. Palbociclib, ribociclib, abemaciclib, etc) that target cyclin-dependent kinases (CDKs, particularly CDK4 and CDK6),
• mTOR Inhibitors like everolimus
• PARP Inhibitors like Olaparib in BRCA positive breast cancers

Role of Chemotherapy

Breast Cancer treament in gurgaon As discussed above, chemotherapy for breast cancer may be given as neoadjuvant (before surgery), adjuvant (after surgery) and palliative (for metastatic disease). The chemotherapy regimens are different in these settings. 

Some of the chemotherapy agents that have a role in breast cancer treatment are-

• Adriamycin/Doxorubicin, Liposomal Doxorubicin
• Cyclophosphamide
• Paclitaxel, Docetaxel
• 5 Fluorouracil
• Epirubicin
• Gemcitabine
• Capecitabine
• Cisplatin, Carboplatin
• Eribulin
• Ixabepilone

Even cytotoxic chemotherapy may play a role in ovarian suppression. Current regimens cause ovarian dysfunction (premature menopause) in a relative minority of premenopausal women. Although it causes amenorrhea (stoppage of menstrual cycles) in many patients, but that doesn’t ovarian suppression. The hormonal secretion from ovaries may still be there, even during amenorrhea.

Moreover, chemotherapy is not given in all the patients with breast cancer and is not a guaranteed mechanism of suppressing ovaries. There are no mature randomized phase III trials comparing ovarian suppression (OS) via chemotherapy with other methods.

Should I undergo Breast Conservation Surgery or Modified Radical Mastectomy? Where can I undergo Breast Cancer Surgery in Gurgaon?

In early stage disease, the decision to move ahead with BCS depends on patient as well as oncologist. The patient has to be willing for it and give consent for the same, and oncologist has to look for any contraindications for the procedure. If everything is in favor, and the tumor size is small, breast conservation surgery maybe done directly.

Whereas if the tumor is large, we first have to give neo-adjuvant chemotherapy to shrink the tumor, and then reassess for breast conservation surgery, depending upon the response to chemotherapy.

So, the decision to add chemotherapy in the neoadjuvant or adjuvant setting is taken on an individual patient basis, after discuss in a tumor board. Also the decision to add hormonal therapy and targeted therapy is taken depending upon the ER, PR and her-2 receptor status and along with other factors.

After Breast Conservation Surgery, radiation therapy is given in all the cases. Where as after modified radical mastectomy, the decision to add radiation therapy is taken by the radio oncologist depending upon the T-status, N-status, margins of resection along with other factors.

Locally Advanced breast cancer cases are not upfront resectable. That is why, neoadjuvant chemotherapy, that is, chemotherapy before surgery, is required in almost all the cases of locally advanced breast cancer. The neoadjuvant chemotherapy will be different for triple negative, Her-2 neu positive and hormone receptor positive disease.

One exception is T3N1 disease, that may be upfront resectable, but neo adjuvant chemotherapy may be required in these cases if planning for breast conservation surgery, in these cases.

In locally advanced disease also, the decision to do BCS or MRM is taken after neoadjuvant chemotherapy, depending upon the response to chemotherapy, as we have discussed previously for localized disease.

So the decision to add neoadjuvant or adjuvant che In locally advanced disease also, the decision to do BCS or MRM is taken after neoadjuvant chemotherapy, depending upon the response to chemotherapy, as we have discussed previously for localized disease.motherapy is taken in an individual basis, after discussion in the tumor board. The decision to add hormonal therapy or targeted therapy depends upon the ER, PR and HER-2 status, as we discussed previously for localized disease.

Radiation therapy is required in almost all cases of locally advanced disease but the final decision is taken by the radiation oncologist by completely assessing the patient.

Surgery for breast cancer depends on the stage of disease and performance status of patient, choice of the patient along with other factors. But the final treatment decision is taken by the oncologist after clinical evaluation of the patient.

Breast Conservation Surgery (BCS)

In this surgical procedure, only a part of the affected breast is removed, along with the axillary lymph nodes. This surgery is sometimes referred to as lumpectomy, quadrantectomy, partial mastectomy, or segmental mastectomy. The advantage of this technique is that the patient can retain most of her breast. In most of the cases, breast-conversion surgery is followed by radiation therapy to prevent disease recurrence.

• If the patient is willing for BCS, it may be done upfront in the early stage disease.
• Or after neoadjuvant chemotherapy in the advanced stage if the patient is the suitable candidate for the same as assessed by the oncologist.

Modified Radical Mastectomy (MRM)

Modified radical mastectomy In this surgical procedure, the entire breast containing the tumor is removed, along with axillary lymph nodes. modified radical mastectomy for breast cancer Radiation therapy is not required in all the cases after mastectomy, hence the procedure can be employed in patients who are not good candidates for the same (e.g., pregnant women, prior radiation to the chest wall). Also, it may be preferred in patients with certain genetic mutations (eg, BRCA) when there are high chances of tumor recurrence. Some patients may wish to restore their breast’s appearance after deformation of breasts due to breast cancer surgery. This can be achieved by a breast reconstruction surgery that can be performed at the same time as breast cancer surgery or at a later time as a separate procedure. Artificial graft or patient’s own tissue may be used for breast reconstruction.

Sentinal Lymph Node Biopsy (SLNB)

In this surgical procedure, sentinel lymph node (the first lymph node affected by cancer) along with some nearby lymph nodes are removed and checked for the presence of cancer cells. An absence of cancer in the sentinel lymph node indicates cancer has not spread to other lymph nodes. To find sentinel lymph node, a surgeon first injects a radioactive substance and/or a dye into the cancer tissue. The sentinel lymph node is then determined as the first node detected to have radioactivity and/or the dye color. The advantage of SLNB is that it allows removal of relatively less number of lymph node when lymph node involvement is suspected. The chances of locoregional complications like arm swelling (lymphedema), sensory changes, etc are relatively lesser with this procedure as compared to axillary lymph node dissection.

Axillary Lymph Node Dissection (ALND)

In this surgical procedure, axillary lymph nodes are removed and checked for the presence of cancer cells. ALND can be performed along with mastectomy or breast-conservation surgery or as a separate procedure. Side effects of ALND may include pain, swelling, bleeding, blood clots, infections, difficulty in arm movement, and lymphedema. The chances of side effects is relatively higher compared to BCS.

Breast Reconstruction Surgery

Some patients may wish to restore their breast’s appearance after deformation of breasts due to mastectomy. This can be achieved by a breast reconstruction surgery that can be performed at the same time of breast cancer surgery or at a later time as a separate procedure. In some cases, especially when a patient requires radiation therapy after surgery, it is good to wait for some time before this procedure is performed. Some artificial grafts or patient’s own tissue may be used for breast reconstruction.

What is the Hormone Therapy for Breast Cancer?

In patients with hormone positive breast cancer, hormonal therapy should be considered in breast cancer patients before surgery (neoadjuvant), after surgery (adjuvant) or as palliative therapy in metastatic breast cancer patients.

Adjuvant Endocrine Therapy

Addition of hormone therapy should be considered after surgery in patients with hormone receptor positive breast cancer. Tamoxifen remains tndocrine he standard of care in all premenopausal women with ER+ve disease irrespective of PR-ve and HER-2 Positive disease. Ovarian ablation and LHRH analogue are not superior to tamoxifen.

In adjuvant setting, aromatase inhibitors are more effective than tamoxifen in reducing the risk of recurrence, distant recurrence and contralateral breast cancer. Absolute difference between AIs and tamoxifen continues to increase over time, and extends beyond completion of treatment.

Neoadjuvant Endocrine Therapy

Neoadjuvant endocrine therapy is the one given before surgery in patients with locoregionally advanced breast cancer who are not upfront resectable.

Tamoxifen is an effective option as primary neoadjuvant therapy for elderly women (age 70 years or more) with locoregional breast cancer Response rates of 49% to 68% and stable disease (SD) rates of 22% to 30% were observed in various studies. The concern with neoadjuvant endocrine therapy is low response rates observed in various studies. But response rates with neoadjuvant chemotherapy are also low in hormone positive tumors. So, hormone therapy is an effective option for neoadjuvant treatment in hormone-positive breast cancer, especially in elderly women, or patients with poor performance status and/or significant comorbidities.

Adequate time to know the response is 6 to 8 weeks. There is no benefit with combination of hormone therapy and with combination of hormone therapy with chemotherapy. Response rate or survival benefit with different endocrine therapies is similar. So, the decision for the type of hormonal therapy is taken based on toxicity.

Breast cancer cells have specialized proteins on/in their surface, called receptors. Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) are most common receptors detected on breast cancer cells, which can promote the growth of these cells.

This treatment approach is based on the fact that ER or PR positive breast cancer cells grow under the influence of estrogen and progesterone, respectively. Estrogen is predominately produced by the ovaries and a small amount is also produced by the fat tissue in the females.

Selective Estrogen Receptor Modulator, SERM (Tamoxifen)

Tamoxifen, a triphenylethylene that was first synthesized in the 1960s, binds with high affinity to cytoplasmic endoplasmic reticulum and was the first oral agent demonstrated to be an effective therapy for the treatment of advanced breast cancer.

Tamoxifen competes with estradiol for binding to estrogen receptors and arrests cell in Go G1 phase. Cells which are dependent on estrogen for survival become refractory to estrogenic stimulation and die. It is not a pure estrogen antagonist. It has partial agonistic activity at extramammary sites and estrogen agonistic activity in bone, endometrium, and against lipids. Because of its dual effect, tamoxifen and subsequent agents in its class are termed SERMs.

This agonist effect also results in toxicities, including a small increase in the risk for endometrial cancer, cataracts, thromboembolic disease, ovarian cysts (in premenopausal women), and endometrial polyps,along with short-term side effects, such as hot flashes.

Selective Estrogen Receptor Downregulator, SERD (Fulvestrant)

Fulvestrant is an ER antagonist that has no known agonist activity and results in ER downregulation. Like tamoxifen, fulvestrant competitively binds to the ER but with a much stronger affinity, approximately 100 times greater than that of tamoxifen. Fulvestrant selectively and permanently blocks and degrades the estrogen receptors in breast cancer cells.

Fulvestrant has been approved in the United States for the treatment of postmenopausal women with hormone receptor–positive metastatic breast cancer after progression on antiestrogen therapy. It is generally used for the treatment of ER and/or PR positive metastatic breast cancer. It is administered as once a month IM injection (250 mg).

Common side effects of fulvestrant include hot flushes, headache, nausea, bone pain, etc.

Aromatase Inhibitors (AIs)

Aromatase inhibitors are established as first-line and second-line treatments in postmenopausal women with hormone sensitive advanced breast cancer.

Aromatase is an enzyme that helps in the production of estrogen from fatty tissue. In post-menopausal women, fatty tissue is the main source of estrogen. AIs cause selective and potent inhibition of aromatase in fatty tissue. Thus, AIs (e.g. letrozole, anastrozole, and exemestane) help in lowering estrogen level in post-menopausal women and used for the treatment of breast cancer in these patients.

AIs can also be used in pre-menopausal women in combination with surgical or medical oophorectomy (with GnRH/LHRH analogs). Side-effects of AIs include hot flushes, muscle pain, joint stiffness, arthralgia, osteoporosis, etc. But unlike tamoxifen, they do not cause increase in endometrial cancer and increase in thromboembolism.

Oophorectomy

Since the ovaries are the chief source of estrogen before menopause, their surgical removal reduces the blood estrogen level significantly, which leads to shrinkage of ER-positive breast cancers. It may be used in premenopausal women, or in combination with AIs in postmenopausal women.

It causes immediate, permanent reduction in ovarian steroid production, thereby reducing the chances of hormone-dependent breast cancer. Also, it may reduce the risk of ovarian cancer in women with BRCA1 or BRCA2 syndrome.

Where can I find the best specialists for Breast Cancer treatment in Gurgaon?

Dr Sunny Garg is a renowned Medical Oncologist in Gurgaon with an experience of more than 10 years of treating breast cancer patients. He has treated breast cancer patients with chemotherapy, targeted therapy, hormonal therapy and personalized cancer treatment. He is currently practicing at Sanar International Hospitals, Golf Course Road, Gurgaon.

Call or watsapp +91 9686813020 for appointment