Breast Cancer Treatment Services

Radiation Therapy

Radiotherapy has withstood the test of time and has become an indispensable

That radiotherapy adds onto the benefit both in terms of progression free survival and overall survival is a well-established fact amongst scientific community on the backdrop of numerous well conducted research work spanning over decades.

Since the inception of radiotherapy in the cancer management in general, there has been a constant cynicism with regard to the use of ionizing radiation and the side effects associated with the treatment done using them. Radiation oncology has been in a constant melee to fend off the stigma attached to the use of ionizing radiation in oncology clinics. Riding on the astounding technological progress made in the way radiation treatment is being planned and delivered, radiation community has been able to mitigate most of the doubts with regard to the safety of radiotherapy. Radiation treatment nowadays is meticulously planned on planning CT scans and delivered with daily imaging confirmations of the planned areas to be treated leaving very little chances for toxicities. Techniques like DIBH (deep inspiratory breath hold) have only cemented the safety profile of the breast radiotherapy further by minimizing the dose to the heart. With the addition of protons and other heavy particles to the ever-evolving armamentarium of radiation oncologists the delivery of radiation has only become safer in breast cancer patients with several trials being underway to substantiate these early results.

Radiation oncologists have been able to take note of the unique radiobiological properties of breast tissue and utilize that to squeeze the treatment to 3 weeks rather than the conventional 5 weeks with equivalent results both in terms of tumour control as well as from toxicity point of view. Newer trials have taken a major leap in shortening of the overall treatment time to only a week with sustained benefit and acceptable long-term sequelae.

With the technology involved in the radiation treatment making enormous strides stepping into the future, the effectivity and safety involved in the radiation treatment of breast cancer is only going to get better than ever and it will continue to be an inseparable part of the management of this malignancy whose incidence is on the rise.

Chemotherapy/ Hormonal therapy/ Targeted Therapy

Breast cancer is not one disease but it includes variety of histopathological malignancies that requires different approaches to treatment. The mainstays of breast cancer treatment are surgery, radiation, chemotherapy, hormonal therapy and targeted therapies but the research is continuously ongoing in this field with newer agents being added to the treatment armamentarium every year increasing the chances of survival and responses. New additions in targeted therapies included not only novel oral therapies like Cyclin dependent kinase (CDK) inhibitors, PIK3CA inhibitors and small molecule tyrosine kinase inhibitors but also various parenteral molecules in form of monoclonal antibodies and antibody drug conjugates.

The predominant three types of breast cancer are hormone receptor positive, Her2 positive and triple negative (TNBC) sub types. Treatment vary as per stage and type of cancer detected on Immunohistochemistry.

Early stage breast cancer is first subjected to loco-regional treatment in form of surgery and radiation while chemotherapy is contemplated to control micro metastatic disease and prevent recurrences. However, all early breast cancers may not require chemotherapy and hormone receptor positive and Her₂Neu negative breast cancer may even not require any chemotherapy in early stage. With the advent of tests that can determine the types of genes that cancer express allowed us to tailor therapy as per need of patient and more specifically help to determine which patients are more likely to benefit from treatment with chemotherapy in addition to hormonal therapy. The progress is also ongoing in other subtypes of breast cancer, including triple negative breast cancer where survival benefit has been seen with dose dense regimens which has now became standard of care and in Her2 Positive breast cancer where dual Her2 blockade strategy has resulted in significant reduction in chances of pathological complete responses and further reduced chances of recurrences.

The way metastatic breast cancer patient performed in the last decade has also changed with addition of lot of newer agents to the treatment paradigm across all the subtypes. With the addition of CDK inhibitors the progression free survival of hormone receptor positive breast has doubled and this has resulted in overall survival benefit too. Lot of further research is ongoing in understanding the resistance mechanism to these drugs and targeting those resistance mechanisms to improve patient outcome. Similarly the strategy of frontline dual Her2 blockade for Her2 positive metastatic breast cancer has resulted in significant survival advantage in this subset of patient. Even on progression on dual blockade, with availability of antibody drug conjugate like Kadcyla has resulted in further improvement in survival. Newer oral tyrosine kinase inhibitors like Tucatinib has not only increased survival but also intracranial responses in patients with brain metastasis providing new hopes in treatment of this grave condition. Triple negative breast cancer is also not one disease and genomic signatures tests has sub-classified into several subtypes (basal like 1, basal like 2, Luminal androgen receptor, mesenchymal, mesenchymal stem-like and immunomodulatory) all of which fall under the umbrella of TNBC and differ in prognosis.

In this most aggressive triple negative subset of breast cancer addition of immunotherapy (Atezolizumab/Pembrolizumab) has changed entirely the way in which patients were previously counseled for outcome and now the survival of this dismal subset has also improved even in metastatic stage. Prognostication of this subset on the basis of their programmed death ligand 1 (PDL1) expression and tumour mutation burden (TMB) has provided further insights into the disease biology and scope of further drug development.

To summarize, last decade has given has lot of newer agents in the treatment of breast cancer and the vision to improve outcome. For years, people have associated the word ‘cancer’ with being an expensive disease. No discussion is complete without considering cost of treatment and the sad side of story is the cost of these newer molecules which is mostly unaffordable for majority of the general population. Even though characterized as ‘low-cost’ by global standards, it still remains unaffordable for the majority of the population.

With new, advanced, improved, and innovative breast cancer treatments, the problem is being tackled by several cancer treatment institutes and startups. With continued research and development, startups are striving to make the tests even cheaper and affordable for a large segment of the population.

The need for the hour is to spread awareness about these options among patients and their loved ones.

The outcomes in Breast Cancer

The outcome or prognosis in breast cancer depends on –

• Stage of cancer
• Hormone receptor status and Her 2 neu status
• Comorbidities
• Biological behaviour of the tumour

The outcome is individualized, no two cancer behave similar so the treatment and outcome is customized for each and every patient.

Breast Cancer Treatment facilities at RGCIRC

At RGCIRC we see around 1800 breast cancer patients every year. The facilities include-

• Screening of Breast cancer
• Imaging- Digital, mammography , Tomosynthesis, MRI , CT scan
• Nuclear Medicine- PET CT Scan, Bone scan, Sentinel node mapping, Scintimammography
• Image guided biopsies – USG guides, Stereotactic biopsy, MR guided, PET guided or Vacuum assisted breast biopsy ( VABB)
  Histopathology including immunohistochemistry and Fish testing
• Molecular Testing- BRCA testing and other genetic mutation testing and counselling
• Surgery, Radiation and Medical Oncology
• Rehabilitation by Physiotherapy
• Survivorship Program- Maitri and The Pink Clinic

Research Project : Breast Cancer in Young Women – Global Consortium (GCBCYW)

Globally Breast Cancer in young women is the biggest challenge. Rajiv Gandhi Cancer Institute & Research Centre in collaboration with  Lisbon Academic Medical Center, Portugal; Kyoto University, Japan; Young Survival Collation, New York USA; Team Shan, Canada; Tata Memorial, India; Himalayan Institute of Medical Sciences, India join hands in the fight against breast cancer in young women.

All the patients are seen by dedicated Breast cancer management team which includes Surgical , Medical and Radiation oncologist along with Radiologist, Pathologist and Nuclear medicine specialist. The cases are discussed in tumor board to decide the best treatment protocol for them and then they are explained the treatment plan.