The treatment of breast cancer requires a multidisciplinary approach. Read on to find out the roles of the various medical specialists working together as a team to battle breast cancer.
Breast cancer is the top cancer affecting women worldwide. In Singapore, it is estimated that 1 in 14 women will develop breast cancer before the age of 75 and its incidence continues to rise.1 The treatment of breast cancer requires a multidisciplinary approach but it was only after 1970s when the first multidisciplinary breast centre was established in the United States.2 Since then, it became evident that better patients’ outcomes were achieved when various medical specialists worked as a team.3
In a local setting, a woman who presents with a clinical symptom such as breast pain, lump or nipple discharge, will usually be referred to the breast surgeon. After a clinical assessment, the patient may undergo breast imaging evaluation such as mammogram, ultrasound and magnetic resonance imaging (MRI). These specialized imaging studies are interpreted by a radiologist.
In most of the symptomatic cases, mammogram and ultrasound are the mainstays of imaging. However, in women less than 40 years of age, ultrasound is the preferred modality for investigation and mammogram is performed only when deemed necessary.
In cases with likely benign findings, close follow-up is generally recommended. In some selected cases where the imaging findings suggest indeterminate features, further evaluation is performed with advanced modalities, like MRI. A breast biopsy is sometimes recommended based on imaging and clinical findings and the biopsy result will be interpreted by a pathologist. The surgeon, radiologist and pathologist will come together in a multidisciplinary meeting to determine concordance between the imaging and pathology findings. This triple assessment process involving clinical, radiological and pathological evaluations, ensures that the correct diagnosis is made, and breast cancer is not missed, so that appropriate management can be advised to the patient.4
Treatment of breast cancer
The treatment may involve various modalities, including surgery, chemotherapy, radiotherapy, immunotherapy, hormonal therapy etc. Surgery is required in nearly all treatable cases of breast cancer and can be divided into breast conservation with radiotherapy or mastectomy with or without reconstruction. Radiotherapy may also be administered in certain cases after mastectomy, especially if the primary tumour is advanced.
However, there are now greater options to conserve the breast with the emerging field of oncoplastic breast conserving surgery (OBCS) which allows patients with large tumours to undergo breast conservation with good cosmetic outcomes instead of a mastectomy.
After resection of the breast cancer, the specimen will be analysed by the pathologist to determine the cancer histology, tumour and nodal stage, and receptor status. With the information from the pathological assessment, the case will be discussed at another multidisciplinary meeting involving the various breast care medical specialists to determine the most suited individualised treatment for the patient.
Treatment recommendations for breast cancer vary according to the extent of disease and the subtype of the tumour (hormone receptor-positive, HER2-positive, triple-negative). Even after surgery, cancer can recur because of the presence of micrometastatic disease. Hence, systemic treatment is given after surgery to reduce the risk of recurrence and improve the overall survival. This treatment is in the form of chemotherapy with or without anti-HER2 agents (for HER2-positive disease), and anti-hormonal therapy (endocrine therapy) if the tumour is hormone receptor-positive. The choice of each of these therapies will be decided upon by the medical oncologist, taking into account, tumour and patient characteristics.
In advanced (stage IV) breast cancer when the cancer has spread to distant sites, there is a variety of treatment options such as chemotherapy, endocrine therapy (eg tamoxifen, aromatase inhibitors, fulvestrant) if hormone receptor-positive, and targeted therapy (trastuzumab, pertuzumab, lapatinib) if HER2-positive. There have been exciting new developments in this area with the oral targeted drugs CDK4/6 inhibitors (palbociclib, ribociclib, abemaciclib) that have been recently approved for use in combination with endocrine therapy. In addition, just this year, a drug was indicated specifically for BRCA-mutated breast cancers. The PARP inhibitor olaparib was approved for use in those with germline BRCA-positive, HER2-negative metastatic breast cancers who had previously received other treatments such as chemotherapy and anti-hormonal therapy.
Immunotherapy has not shown the same level of success in breast cancer as in other cancer types, but has shown promising activity especially in the triple-negative subtype. It is currently being evaluated in various clinical trials including those in the advanced and neoadjuvant settings, and in combination with chemotherapy and other therapeutic targets.
While multidisciplinary team-based approach is adopted in Singapore for breast cancer care, this ideal approach is not widely adopted in other Asia-Pacific countries.5 This may be because a multidisciplinary team approach can be resource-intensive.6 As such, it may not be possible to implement if there is a shortage of accredited trained specialists. There is also limitation to the distance that medical specialists have to travel to attend multidisciplinary meetings which are often held at weekly or fortnightly intervals. These problems can potentially be resolved with better training opportunities and the use of teleconferencing to conduct the meetings online.7
In conclusion, the management of breast cancer involves a multidisciplinary team of breast care specialists working together towards a common goal of improving breast cancer survival. This gives the breast cancer patient the best possible care and benefit.
- Source: National Registry of Diseases Office, Singapore.
- Winchester DP. The United States' national accreditation program for breast centers: a model for excellence in breast disease evaluation and management. Chin Clin Oncol. 2016; 5:31.
- Bensenhaver J, Winchester DP. Surgical leadership and standardization of multidisciplinary breast cancer care: the evolution of the National Accreditation Program for Breast Centers. Surg Oncol Clin N Am. 2014; 23:609-16.
- Kaufman Z, Shpitz B, Shapiro M, et al. Triple approach in the diagnosis of dominant breast masses: combined physical examination, mammography, and fine-needle aspiration. J Surg Oncol. 1994;56: 254-7.
- Saini KS, Taylor C, Ramirez AJ et al. Role of the multidisciplinary team in breast cancer management: results from a large international survey involving 39 countries. Ann Oncol. 2012; 23:853-9.
- Taylor C, Shewbridge A, Harris J et al. Benefits of multidisciplinary teamwork in the management of breast cancer. Breast Cancer (Dove Med Press). 2013; 5:79-85.
- Murad MF, Ali Q, Nawaz T et al. Teleoncology: improving patient outcome through coordinated care. Telemed J E Health. 2014; 20:381-4.