Locally Advanced Breast Cancer

LABC, or mostly known as Locally Advanced Breast Cancer, is the medical term used to describe a breast cancer that has progressed locally but had not yet spread outside the breast and local lymph nodes.

What does Locally Advanced Breast Cancer include?

Many of the signs that LABC shows are:

  • Large breast tumors, more than 5 centimeters in diameter.
  • Cancers that involve the skin of the breast or the underlying muscles of the chest.
  • Cancer that involve multiple local lymph nodes, those located in the arm pit or the soft tissues above and below the collarbone.
  • Inflammatory Breast Cancer, IBC, a specific type of LABC, is a rapidly growing type of cancer that makes the breast appear red and swollen.

Although the likelihood of curing LABC is lower than it would be if the cancer were small and confined to the breast, cure is possible with aggressive treatment. In most cases, this requires a combination of chemotherapy, radiation therapy, and surgery.

Signs and symptoms

LABC can be felt by both, the woman and her doctor, and the cancer may also be visible.

Inflammatory Breast Cancer has unique symptoms. This type of Locally Advanced Breast Cancer does not produce a lump that can be felt within the breast. Instead, it causes thickening and swelling of the skin of the breast, which may be reddened and warm to the touch, or may be resemble the texture of an orange peel. The breast is often painful and enlarged and appears inflamed.

Diagnosis and staging

Once the diagnosis of a breast cancer is suspected, several tests will be done to confirm the diagnosis. Most women with locally advanced breast cancer have lymph nodes or glands that can be felt in their arm pit. Testing can be done to confirm this finding and to show what other areas are affected by the cancer.

Mammogram

A mammogram of both breasts is needed to see how large the cancer is and to determine if the opposite breast is affected. A breast is affected magnetic resonance imaging or ultrasound may be also recommended.

Biopsy of the tumor

In order to confirm the diagnosis and type of the breast cancer, a biopsy is required. The biopsy technique depends upon whether a lump is present in the breast. If the physician feels a lump, the biopsy can often be performed in the office. In inflammatory breast cancer, a skin biopsy could be performed.

If a patient shows signs of inflammatory breast cancer, she should be referred immediately for a biopsy to a breast center or a surgeon. Delays in establishing the diagnosis of IBC can have detrimental consequences for the patient.

If the abnormality is only seen on the mammogram and the breast feels normal, then a test is needed to guide where to perform the biopsy. A mammogram is often used for this purpose. The radiologist finds the abnormality on the mammogram and marks its location, often with a thing wire that is inserted into the abnormal areal. A surgeon then uses the wire to know which area to biopsy. This procedure is called a needle localization biopsy.

A doctor will examine the biopsy tissue with a microscope to see if there are signs of cancer. He or she will also perform other tests to see if the tumor is making hormone receptors and a protein called HER2. These two factors are important in selecting the best treatment.

Hormone receptors

About 50 to 70 percent of breast cancers require the female estrogen (estradiol) to grow; other breast cancers are able to grow without estrogen. Estrogen-dependent breast cancer cells produce molecules called hormone receptors, which are essential for the cell to use estrogen for growth. These hormone receptors can be estrogen receptors, progesterone receptors, or both.

  • If a breast cancer contains hormone receptors, the woman is significantly more likely to benefit from treatments that lower estrogen levels or block the actions of estrogen. These treatments are referred to as endocrine or hormone therapy, and such tumors are referred to as hormone-responsive.
  • Women whose tumors do not contain any hormone receptors are not given endocrine therapy.

HER2 expression

HER2 is a protein that is present on about one-third of breast tumors. Having HER2 determines if the cancer will respond to a medicine called trastuzumab.

Treatment for Locally Advanced Breast Cancer

LABC is often treated with a combination of chemotherapy, surgery, and radiation therapy.

Chemotherapy 

Chemotherapy refers to medicines used to stop or slow the growth of cancer cells anywhere in the body. In most cases, chemotherapy includes a combination of two or more drugs, most often given intravenously (IV). These combinations are referred to as regimens.

Chemotherapy is not given every day but instead is given in cycles. A cycle of chemotherapy refers to the time it takes to give the chemotherapy and then allow the body to recover. A cycle of chemotherapy typically ranges from two to four weeks.

Preoperative chemotherapy 

For most women with LABC, chemotherapy is recommended before surgery. Preoperative (also called neoadjuvant) chemotherapy can successfully shrink the breast tumor. In about 30 percent of cases, chemotherapy removes all traces of the cancer from the breast and lymph nodes. This is termed a complete clinical response.

Shrinking a large breast tumor with chemotherapy might allow you to have less aggressive surgery. As an example, it might be possible to remove only the tumor (lumpectomy) rather than the entire breast (mastectomy).

Endocrine therapy

Breast cancers that produce hormone receptors are responsive to endocrine therapy. In some cases, endocrine therapy is given instead of chemotherapy as the first treatment for locally advanced breast cancer.

  • Taking endocrine therapy before surgery can successfully shrink breast cancers that are hormone-responsive. Endocrine therapy has fewer side effects than chemotherapy. This, it might be recommended as a first-line treatment, instead of chemotherapy, for women who are older or who are not healthy enough to tolerate chemotherapy.
  • For most women with hormone-responsive LABC, endocrine therapy is recommended after surgery for five or more years. When endocrine therapy is given after surgery, it is referred to as adjuvant therapy. The purpose of this treatment is to get rid of any tumor cells that remain in the body after surgery.

Adjuvant endocrine therapy is usually started after the entire course of chemotherapy is completed.

Trastuzumab (Herceptin) 

Trastuzumab is a unique drug that works differently than chemotherapy. It targets a protein called HER2, which is found on the cells of some breast cancers. About 20 percent of breast cancers express very high levels of HER2, and trastuzumab appears to work only in this group of women.

Surgery and radiation therapy

Following chemotherapy, tests are performed to see how the tumor responded to treatment. You will have an exam and imaging studies (using mammography, breast ultrasound, or MRI) to see how much of the cancer remains. If there are still signs of cancer, surgery may be recommended.

  • A surgery to remove part of the breast is an option for many women with LABC, as long as there are no signs of Inflammatory Breast Cancer.
  • Mastectomy is necessary if skin involvement was present or if the tumor is still fixed to the underlying chest wall.

After surgery, radiation therapy is recommended to women who had breast conserving surgery. This can significantly lower the chance that the tumor will come back in the remaining breast tissue.

Women who have had a mastectomy will likely receive radiation therapy to the chest wall and likely to the lymph nodes as well. This is especially true if there were involved lymph nodes or inflammatory breast cancer. Having a combination of surgery and radiation therapy decreases the chance that the breast cancer will return in the breast or the chest wall. Radiation therapy is given every day (five days a week) for a period of six to seven weeks.