Under the Knife with Prof Carol-Ann Benn

The Umbrella of care.

I am often asked, “If I have a bilateral mastectomy (both breasts) or just remove one, will I avoid chemotherapy?” or “If I need radiation, do I not need chemotherapy?” Unfortunately, one treatment does not replace another. Here is my umbrella analogy that hopefully will help clarify this fallacy.

The role of the umbrella is to protect you from the weather – rain or sunshine. I use this analogy when explaining the difference between surgery, radiation, and chemotherapy (we should actually say oncological therapy).

I have written on the personality of the cancer being more important than the size; but I still think a simple explanation, on who gets what and why, is needed.

Picture a large umbrella with many panels; underneath would be the stick and handle. The umbrella represents oncology; it protects one from the acid rain of cancer cells. It is very unusual (almost never) to get no oncology treatment if you’re diagnosed with an invasive breast cancer.

The panels of the umbrella represent various types of oncology treatment. You can be given more than one type of oncology treatment or only one, and you can get some types of oncology treatment before surgery; others before and after surgery; and certain types only after.

What are the panels? One is endocrine therapy; these are medicines, usually tablets – but may on occasion be a drip, that are given to any cancer that is sensitive to the progesterone or oestrogen receptor (ER/PR positive tumours). These drugs are not all hormone blockers.

Endocrine therapies are the marathon runs of the oncology drug system; they work slowly but surely, so if used as an initial treatment, they may take a while to melt cancers away. They also work better as an initial treatment for lazy cancers (low Ki-67 proliferation index scores), the ones strutting in high heels and not sprinting in takkies.

Irrespective of other treatments given, cancers that are ER and PR positive will always get endocrine therapy, and can be taken for as many as 10 years.

Another panel is target therapies; certain cancers have targets for very clever drugs that attach directly to cancer cells at certain cell sites to blow them up – a bit more PAC-MAN-like and less Asteroids-like. If the cancer has this personality (HER2 positive), then these clever drugs are needed. Herceptin (trastuzumab) is a well-known example. More of these drugs are becoming available as more target areas are found on cancer cells.

Another panel today, albeit small for breast cancer, is immunotherapy. These are drugs that manipulate the immune system so as to kill the cancer. This therapy has revolutionised melanoma survival.

Smaller panels, that are interspersed with larger ones, are equally important but often forgotten. They are drugs for bone care and bone strength, as well as medicines for supportive care during treatment and pain control.

The next few panels are chemotherapy, and represent a variety of combinations of chemotherapies that are given (think antibiotics) – different combinations of drugs, mostly given as a drip, but sometimes as tablets. Certain combinations are given for certain types of cancers, and certain combinations are chosen depending on the medical background of the patient. Some chemotherapies are given before surgery, and others afterwards.

So who gets chemotherapy? 

The question everyone asks. Well, any cancers that are not oestrogen or progesterone sensitive (triple-negative); any cancer that is HER2 positive; most cancers that have spread to the lymph nodes; and most cancers that have a high Ki-67 score. How high is high? A Ki-67 score over 15% is considered a luminal B breast cancer, and encourages a discussion in the multi-disciplinary meeting (MDM) about chemotherapy.

Why do some patients start with chemoTHERAPY then only have surgery? 

If the cancer is big and in the glands, most units would suggest starting with chemotherapy. If the cancer is a triple-negative with a high Ki-67 score or a HER2 positive cancer, a discussion in the MDM will likely be suggesting to kill the cancer first.

Remember, there is always fine print in any contract or fine-tuning of any recipe. With very small cancers under 5mm, it’s debatable whether there is need for certain treatments. Please insist that your cancer treatment is discussed in a MDM, and that you’re given feedback on the opinions offered.

The small spokes under the umbrella represent genetic profiling. By profiling certain tumours, you can fine-tune or change what panels may or may not be needed. Genetic profiling is a topic I will discuss

in detail at some brave stage! The simplest comparison is looking at the engine inside the car – what drives the motor and what keeps the motor running.

The stick of the umbrella represents the biology of the tumour – the pathology obtained by a core needle biopsy. Not a surgical biopsy (starting to sound like a nag)!

The mechanism that opens the umbrella is the radiological assessment of the size of tumour, and, most importantly, the lymph node assessment – involved or not; a sentinel lymph node biopsy may be needed.

The handle is surgery and radiation. A single handle means surgery only (no need for radiation). This is a small subset of women choosing mastectomies, who don’t have affected lymph nodes.

A double handle is the addition of radiation. More secure, and given to anyone with affected lymph nodes or anyone having a breast-saving operation. The handles are held together by good reconstructive (oncoplastic) techniques.

So, you can see under the umbrella is the local treatment, which is independent of the umbrella. The umbrella protects you from the acid rain of cancer cells that may fall and not be seen.

Thinking of the scene in Singing in The Rain with Gene Kelly: it’s happy yet bizarre; maybe the joy invoked from the song is in the not getting wet?

So the next time a friend or patient asks “Can I avoid chemotherapy?”, remember the answer is “No”.

One can choose local treatment up to a point but oncology treatments are independent of surgery; and safety should always be the best goal.

MEET OUR EXPERT - Prof Carol-Ann Benn

Prof Carol-Ann Benn heads up breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

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