BREAST CANCER

The treatment of a patient with breast cancer rests with diagnosis, multidisciplinary
assessment and a combination of local and systemic therapy. Whether a patient is
diagnosed as a result of symptoms or through screening, the approach is the same.
The assessment of clinical, radiological and pathological findings is required:
• Clinical examination may help distinguish cyst from solid lump.
• Mammography may identify malignant calcification or other features of
concern, or the presence of a cyst. This may be complemented by ultrasound,
and MRI may help if the findings are equivocal.
Cytology from fine needle aspirate (FNA) and/or histopathology from a core biopsy
including measurement of tumour grade, oestrogen receptor status (ER) and in some
cases progesterone receptor (PR) and/or Her-2 status. These can be performed
(probably more accurately) on a definitive resection specimen (wide local excision or
mastectomy).
Once a diagnosis of invasive cancer is made, further staging is performed (Box 11.11,
p. 259).
Local disease
Patients are treated with a combination of radical local therapy and systemic anti-
cancer therapy. If breast conservation is possible and desired by the patient, surgical
excision is performed if it is likely to remove all known disease. In other cases,
particularly when there is extensive pre-invasive cancer, mastectomy may be needed.
If the relative size of a tumour to the breast is too big for breast conservation, an
alternative approach is to give systemic anti-cancer therapy before surgery, which has
been shown to reduce the need for mastectomy with no effect on overall survival.
Successful breast conservation is followed by locoregional radiotherapy, although in
older women with low-risk cancers the added benefit may not outweigh the
disadvantages. All women should be considered for adjuvant systemic therapy, either
hormonal or chemo-therapy or both (Box 11.21). For women with very low-risk
tumours, the benefit of this may be too small to justify it in all cases.
11.21 POST-OPERATIVE THERAPY IN EARLY BREAST
CANCER
'Chemotherapy, ovarian ablation in pre-menopausal women, and tamoxifen in
oestrogen receptor-positive tumours all reduce recurrence and mortality from breast
cancer.'
For further information: http://www.cochrane.org"
target="_blank">www.cochrane.org
http://www.ctsu.ox.ac.uk/projects/ebctcg.shtml"
target="_blank">www.ctsu.ox.ac.uk/projects/ebctcg.shtml

The exact choice of systemic therapy is beyond the scope of this chapter, but where
chemotherapy is indicated it most commonly consists of an anthracycline, either in
combination or in sequence with either an alkylator such as cyclophosphamide or a
taxane. When the likelihood of benefit is small, treatments should not be offered
except as a last resort. Patients with breast cancers that do not express any hormonal
receptors (ER- and PR-negative cancers) should not be offered adjuvant endocrine
therapy such as tamoxifen or an aromatase inhibitor, as it will only increase the risk of
toxicity. Similar predictors of response to chemotherapy are not at present defined,
but may be in the future.
Metastatic disease
The treatment is primarily systemic with chemotherapy and/or hormonal therapy;
there is little role for surgery. Local treatment to an ulcerating primary may be given
(such as radiotherapy or 'toilet' mastectomy), but most will improve with effective
systemic therapy. However, when previous hormonal therapies have failed to work, or
if the patient's disease is rapidly growing and involving vital organs such as liver or
lung, effective control is more likely with chemotherapy.

Cervical cancer

ENDOMETRIAL AND CERVICAL CANCER

For many years, a large part of the workload of radiotherapy departments has been the
treatment of cancer of the cervix and endometrium. These are the sites most
commonly treated with intra-cavitary radioactive isotopes, usually caesium.
Applicators may be inserted into the vagina and/or the uterus under a general
anaesthetic to guide placement and maintain the position of the isotope. For reasons of
radioprotection, an afterloading technique is usually used whereby the radioactive
sources are inserted into the preplaced applicators automatically using a system such
as a Selectron (Fig. 11.11).
CARCINOMA OF THE CERVIX
The most common is squamous cell carcinoma. The disease is usually staged using
the FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) staging system.
Investigations include an examination under anaesthetic and cystoscopy to assess
local extent, as well as staging by intravenous urography (IVU), chest X-ray and
blood tests.

Figure 11.11 Selectron treatment of cervical cancer. An X-ray taken after the
insertion of metal applicators into the vaginal vault and endometrium. Radioactive
sources will be inserted into the applicators remotely (afterloading technique). The
fine lines are in gauze packing, to keep the applicators in place.
Treatment depends on the stage:
• Pre-malignant disease (cervical intra-epithelial neoplasia, CIN): local ablation
with laser therapy or diathermy.
• Microinvasive disease: cone biopsy or a simple hysterectomy in older patients
past child-bearing age will be curative in the majority of cases.
Invasive but localised disease: radical surgery with a Wertheim's hysterectomy or
radical radiotherapy offers potential cure. There are advantages and disadvantages
associated with both of these treatments and patient preference is an important
consideration. Often radiotherapy is offered to older patients and those not fit for
surgery.
In selected cases where there is a high risk of recurrence, there may be a role for post-
operative radiotherapy. Where there is incurable disease, chemotherapy with a
combination such as methotrexate and cisplatin may be beneficial.
CARCINOMA OF THE CORPUS UTERI
The mainstay of treatment is surgery. An examination under anaesthetic and dilatation
and curettage are essential as part of the staging investigations. The FIGO staging
system is used. The extent of surgery will depend on the stage of the disease, but will
include an abdominal hysterectomy and bilateral salphingoophorectomy with a
lymphadenectomy in those at high risk of nodal spread. Post-operative radiotherapy
may be necessary depending on the risk of loco-regional recurrence and may include
intra-cavitary treatment to the vaginal vault as well as external beam treatment to the
pelvis.
For inoperable, recurrent and metastatic disease, medroxyprogesterone produces an
objective response in 30% of cases.