How do doctors make treatment decisions?

If you have been given a breast cancer diagnosis, your doctor will need to understand certain factors about your cancer including the stage and subtype of your tumour. This will help to determine which treatment may be most beneficial.

What are the first things your doctor needs to know?

There are several medical factors your doctor will consider before deciding which treatment options would be suitable for you. Some of the key information they need to know can be found by answering the questions below.

Sub-Types

Hormones are chemical messengers that are produced by cells in one part of the body to help regulate cells in other parts of the body. Once they are made, hormones are carried to their destinations via the bloodstream and bind to specific proteins, called receptors, on the surface of the target cells. The hormones oestrogen and progesterone are produced naturally in the body. Normal breast cells and some breast cancer cells have receptors that attach to oestrogen and progesterone and rely on these hormones to grow. If your type of breast cancer is stimulated by one or both of these hormones, it is hormone-receptor positive cancer. Therefore, it is important to know the hormone-receptor status of your breast cancer (also referred to as the tumour biology). If your breast cancer is hormone-receptor positive, specific treatments can help to reduce the supply of oestrogen to the tumour or block its effects.Click here to learn more about treatments for hormone-receptor positive breast cancer
Human epidermal growth factor receptor 2 (HER2) proteins are found on the surface of breast cells and are involved in normal cell growth. Some breast cancer cells “overexpress” HER2 proteins, which means that the levels of the protein are higher than normal. If this is the case, your breast cancer is HER2-positive (HER2+). Specific treatments are able to target the HER2 proteins and act against cancer growth. Learn more about treatments for HER2+ breast cancer
This kind of breast cancer tests negative for oestrogen receptors, progesterone receptors, and excess HER2 protein. Triple-negative breast cancer therefore does not respond to hormonal therapy or medicines that target HER2 protein receptors but can be managed using other treatments such as chemotherapy or targeted therapy.
Click here to find out more information on subtypes of breast cancer

Size and location

A primary tumour is a tumour growing at the original site before progression started. It is important to assess the primary tumour size as the size of the tumour can affect the possible treatment outcomes.
Tumour location within the breast can vary with the most common being towards the nearest shoulder.

Progression

Locally advanced breast cancer are tumours of any size that have progressed beyond the breast into the chest wall but have not yet spread beyond the lymph nodes in that area. In other words, it has grown but not metastasised.
  • a. Has the cancer spread to the lymph nodes?
  • b. Has the cancer spread to the bones?
  • c. Has the cancer spread to visceral organs, such as the lungs or the liver?
If the cancer spreads to other parts of the body it is said to have 'advanced' or metastasised. This may only occur months or years after early breast cancer, and not all breast cancers will spread and become metastatic at all.
Whilst secondary breast cancer cannot yet be cured, it can be treated and people can go on to live for many years beyond their diagnosis. Management is aimed at maintaining quality and length of life.
Treatment depends on hormone and HER2 status of the cancer and previous treatments will also be taken into account. Treatment for this stage of breast cancer can include hormone therapy, chemotherapy, targeted therapy and/or radiotherapy.
Growth rates vary between individual tumours and size is part of the assessment for the stage of cancer’s development. Cancer stage is an important consideration for its management and its speed of growth can be related to the appearance of the cancerous cells.

History

It is important that doctors know if someone has had breast cancer before because this is likely to affect the way the cancer is managed. Medical teams will need to establish a full history and ascertain how long you have been free from disease as this may affect the choice of treatments.
  • a. When were you diagnosed?
  • b. What subtype were you diagnosed with?
  • c. What treatment did you receive for primary breast cancer?
  • d. Are you still receiving treatment? If not, how long has it been since your treatment ended?
Sometimes, people with breast cancer are not identified until their cancer has progressed to a more advanced stage – but most primary breast cancers are identified and treated before they progress. If advanced cancer is suspected, it is important that a full medical history is taken because subsequent management may be affected by the primary tumour’s subtype and previous treatment. It is also important to establish if a cancer has progressed whist taking a specific treatment because that may indicate that the cancer is no longer sensitive to it.

General

There may be some general symptoms such as tiredness or loss of appetite – but it’s important to establish more specific signs and symptoms because they may give clues about the site of spread and appropriate treatment. For example, swelling in the armpit may suggest the cancer has spread to the lymph nodes; bone pain may indicate bone metastasis; jaundice and a swollen abdomen may suggest spread to the liver. Symptom duration and previous investigation will help to determine diagnosis, rate of progression and future management. It is important to remember that the symptoms you may experience may not be caused by secondary breast cancer. If you experience any symptoms, speak to your doctor.
A comorbidity is an additional illness that is present at the same time as the primary condition. For example, diabetes may be present in addition to breast cancer. It’s important to identify comorbidities because they may affect outcomes, alter treatment and complicate management.
Recommended treatment can vary according to age. Age can also influence where the cancer is likely to spread to.
The menopause does not in itself increase the risk of breast cancer, but cancer rates generally increase with advancing age. The reason why doctors need to know about menopausal status is that treatment may be different for postmenopausal women compared with those who have yet to go through the menopause. This is particularly the case for women with hormone-receptor positive cancer because levels of oestrogen and progesterone naturally change at the menopause.
Not only does physical exercise improve quality of life for women with breast cancer, but it may influence doctors’ overall approach to treatment.

Questions about subtype are particularly important. Your doctor needs to determine the subtype of breast cancer by confirming two key factors: 

  • the hormone-receptor status
  • the HER2 status

Once your doctor knows the subtype and has all the information set out above, the treatment options suitable for you can be discussed.