Management Plan

Management Plan

After examination, investigation and biopsy results, almost full diagnosis should
have been made. The Surgeon, in conjunction with the Medical Oncologist,
should have a management plan for every individual patient.
1. Local control: management of the Breast.
2. Regional control: management of the Axilla.
3. Systemic control: management of the whole body – protection.

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.o Surgery
.o Chemotherapy
.o (Herceptin) Monoclonal antibodies
.o Hormone therapy
.o Radiotherapy
Management plan will depend on many factors and will be planned between the Patient, the Surgeon and the Medical Oncologist
.It could include some, all or some of the above mentioned modalities
.The plan could be Surgery first or Chemotherapy first

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 If the size of the Tumor, relative to the size of the Breast, is big and the
Patient wishes to preserve her Breast.
 Locally advanced – inoperable tumor-, to make Surgery feasible (To make
inoperable, operable)
 Inflammatory Breast Cancer.
 It has been proven that in many cases, upfront Therapy reduces
recurrences more than otherwise, for instances Triple Negative disease
and Her2 Positive cases.

Could be either Chemotherapy for, 4, 6 or 8 Cycles – 3 weeks apart- =12-
18 0r 18 weeks or Hormone therapy for 4-6 months

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• • Surgical Management::

  The usual is to try Breast Preservation.
  Excision of the Lump + Radiotherapy = Mastectomy

   Lumpectomy (WLE), Breast Conservation whenever the tumour is
  relatively small and the Breast could be preserved without deformity
  and respecting the Patient`s wish.
  Contraindicated if INFLAMMATORY Breast cancer.

   Mastectomy: It also depends on the size of the Tumor relative to
  the size of the Breast and definitely indicated if:
  – Inflammatory Breast Cancer.
  – Locally advanced Breast Cancer.
  – Multi-centric Tumors (unless experienced surgeon).
  – Recurrent Tumors.
  – In the very young may be advisable (e.g, under 30 years).
  – Patients wish

   Mastectomy and Immediate Reconstruction: Every patient should
  be offered Reconstruction, regardless of age, culture or race.
  The exceptions are:
  – Inflammatory Cancer.
  – Heart or Lung severe restrictions.
  – Insulin dependent diabetics are to be avoided.
  – Chronic Kidney conditions.
  – Auto-immune diseases, for example SLE, Rheumatoid….
  – Smokers are to be discouraged.

   Dealing with the Lymph Glands: Removal of some or all of the
  axillary Lymph Nodes is part of the local control as well as informing
  the treating team about the behavior of the Tumor, allowing optimal
  complementary treatment. It is as follows:
  – No Excision: If Non-Invasive Tumor.
  – Sentinel Node Biopsy, Is the gold standard. This is studying the
  first Lymph Node Tumor cells would reach if tried to move.
  – Axillary Clearance, total removal, if the nodes prove to be
  involved.

• 2.Adjuvant Chemotherapy: Complementry therapy after surgery.
  The Medical Oncologist together with the Surgeon decides after
  surgery the need for Chemotherapy. They take into consideration:
  Age – Grade – Size – Hormone Receptors – Her2 Receptors – Lymph
  Node status and General condition of the patient.
  Could be – None – 4 – 6 – 8 cycles with 3 weeks in between.
  Could last up to 24 weeks.
  The benefits and needs will be discussed with the Medical Oncologist.
  4.  3. Radiotherapy after surgery:Many factors are considered before
     Radiotherapy is planned.
     If both Chemotherapy and Radiotherapy are indicated, the priority is always
     Chemotherapy followed by Radiotherapy.
     Could take up to 3- 5 weeks = 15- 31 sessions..

  4. Hormone Therapy:

  70% of Tumors are Hormone sensitive (The tumor cells
  use the patient`s own hormones to grow). Manipulating or Blocking
  Hormone production in these cases is beneficial in depriving any remaining
  cancer cell (if any) from its feeds.

  – Tamoxifen: is used at any age. 20 mg/day 5-10 years
  – A I : Femara , Arimidex, Aroumasine are used ONLY in post-
  menopausal patients.
  – LHRH Agonists: Zoladex injections for example are used to
  render a young lady postmenopausal, (Chemical Ovariectomy)
  – Ovarian ablation: By Surgical removal or Radiation destruction of
  the Ovaries to induce menopause.

• 5. Targeted Therapy –Monoclonal Antibodies, HERCEPTINE:

around 20% of tumors are Her2 Positive, carrying this protein on their surface. The drug HERCEPTINE targets these cells only and hopefully destroys or disables them. Shame for its COST.
Only used if the patient needs chemotherapy
Usually for a year around 17 sessions, 3 weekly

• 6. ZOMETA – PROlEA – X-GEVA:

are used (when needed) either monthly if there is spread to bones or 6 or 12 monthly to treat or protect from osteoporosis.
Have to be taken with plenty of calcium and vitamin D
Have to have the Kidney function regularly checked