Introduction
Breast cancer is a cancerous disease caused when breast ductal and lobular epithelial cells, due to a variety of carcinogenic factors, lose their normal characteristics and lead to dysplasia, thus exceeding the limits of self-healing. It has the highest incidence among female cancers with complex pathological types. Because it is a systemic disease, patients with low degrees of cell differentiation can have systemic metastasis at an early stage.
Breast mass is the most common manifestation of breast cancer. The symptom of nipple discharge mostly means benign change. But patients more than 50 years old with unilateral nipple discharge should be alerted to the possibility of breast cancer. Nipple retraction, nipple itching, scaling, erosion, ulceration, scab, and eczema-like changes are often clinical manifestations of mammary Paget’s disease. Some patients present breast skin and contour changes. For example, when the cancer invades the Cooper ligament of the skin a “dimple syndrome” can be formed, cancer cells blocking subcutaneous lymphatic capillaries can result in skin edema, and depressions at the hair follicles can form the “orange peel” syndrome. When the skin is widely invaded, many hard nodules or small cords are formed in the epidermis or even integrated into pieces. If lesions extend to the back and to contralateral chest wall, breathing can be restricted and corset cancer can be formed. Inflammatory breast cancer can present significantly enlarged breasts with skin congestion, redness, and swelling and with increased local skin temperature. In addition, advanced breast cancer can present skin ulceration and form cancerous ulcers. Some patients present with lymph nodes: the ipsilateral axillary lymph nodes can undergo swelling. Advanced breast cancer can transfer to contralateral axillary lymph node metastasis and cause swelling; moreover, the ipsilateral and contralateral supraclavicular lymph nodes are palpable in some cases.
Common pathological types are noninvasive cancer (including ductal carcinoma in situ and lobular carcinoma in situ) and invasive cancer (including invasive ductal carcinoma, invasive lobular carcinoma, carcinoma simplex, medullary carcinoma, hard carcinoma, mucinous adenocarcinoma, and papillary carcinoma). The overall development of breast cancer is slow, and after active treatment most patients have shown better long-term efficacy. Prognostic factors are mainly primary cancer size and local infiltration; lymph node metastasis; pathological type of cancer and degree of differentiation; intratumoral microvessel density; vascular, lymphatic cancer thrombus; patient’s immune function; tumor molecular biological morphology and expression; and so on. Detection of hormone receptors by immunohistochemistry is also a reference index for prognosis. If ER and PR are positive, prognosis is relatively good. If ER and PR are negative, prognosis is relative poor. DNA aneuploidy or increased cell ratios at S-phase or positive CEA prompt poor prognosis.
Treatments
1. Surgery
Surgical resection has been the main treatment of breast cancer. The current surgical approach is developed toward the narrower resection, including breast-conserving surgery and sentinel lymph node biopsy. Patients of stages I and II should be applied with modified radical mastectomy; patients of stage III can do preoperative chemotherapy first and then modified radical mastectomy. Part of the patients of stage I can receive breast-conserving surgery and postoperative radical radiotherapy.
2.Radiotherapy
Radiotherapy is the main component of breast cancer treatment and is one of the means for local treatment. Patients with cancer combined with lymph node metastasis, patients with positive surgical margin, and patients with breast-conserving surgery are required to do radiotherapy. At present, most experts do not advocate radiotherapy alone for curing breast cancer. Radiotherapy is mostly used in integrative treatments, including adjuvant therapy before or after radical surgery, and palliative treatment of advanced breast cancer. In the past 10 years, local excision in parallel with integrative treatments has been mainly carried out for early-stage breast cancers. Radiotherapy plays an important role in narrowing the scope of surgery.
3.Chemotherapy
A primary cancer with diameter greater than 1 cm is required to carry out adjuvant chemotherapy. Preoperative chemotherapy can promote retreat of local breast cancer and metastases, expand surgical indications, and narrow the scope of surgery. It can also reduce the activity of cancer cells, prevent the spread of cancer cells during surgery, control micrometastases undetectable clinically, reduce breast cancer metastasis, and augment cancer sensitivity to chemotherapy regimens used. The efficacy of adjuvant chemotherapy in combination with routine chemotherapy is better than that of single-agent chemotherapy, and early postoperative application is preferable. Because the side effects of chemotherapy used in breast cancers are significant, the treatment period should not extend too long. Postmenopausal patients with positive lymph node metastasis generally do not have to use adjuvant chemotherapy except when there are high-risk factors for recurrence. If there are high-risk factors for recurrence, adjuvant combination chemotherapy should be applied. For patients who are node positive and hormone receptor positive, adjuvant combination chemotherapy should be used.
4.Endocrine Therapy
Endocrine therapy is one of the means for breast cancer systemic therapy. Endocrine therapy plays a very important role for hormone-dependent recurrent and metastatic breast cancer, and adjuvant treatment of early breast cancer. It can even be used for high-risk healthy women to prevent breast cancer, which depends on whether patients have entered menopause or not, as well as the condition of ER and PR receptors.
5.Hyperthermia
Hyperthermia in combination with chemotherapy and radiotherapy can enhance the sensitivity of therapy, improve cancer control rates, and enhance the chemoradiotherapy-sensitizing effect for recurrence of breast cancer. For breast cancer patients at stage I who do not need postoperative chemotherapy, it can be added in the whole-body medium-low temperature mode to improve immunity and reduce the risk of postoperative recurrence. The application of whole-body hyperthermia and local hyperthermia combined with chemotherapy and radiotherapy for patients at stage II or above can improve the cancer control rate and can enhance the chemoradiotherapy-sensitizing effect for recurrence of breast cancer. When breast cancer patients present skin damage, such as orange peel–like appearance or ulceration or upper extremity lymphedema, hyperthermia combined with radiotherapy can significantly improve the control rate. When advanced patients present widespread metastasis at lung, liver, bone, and so on, as well as emergence of pain, whole-body hyperthermia can significantly improve symptoms, reduce pain, and improve the patients’ quality of life. Microwave hyperthermia, RF local hyperthermia, regional hyperthermia, and whole-body hyperthermia can be applied.
6.Chelation Detoxification Therapy
Chelation detoxification therapy is one of the main treatments for patients with advanced breast cancer. The application of appropriate doses alternating with chemotherapy can have great benefits for the survival of patients and their quality of life. Chelation detoxification therapy can not only effectively remove toxins from the body, and improve immune function, but also reduce the side effects of chemotherapy and enhance sensitivity to chemotherapy.
7.Medical Ozone Therapy
Medical ozone therapy may increase oxygen content of cancer lesions. It not only can directly kill cancer cells, unspecifically increase immune system function, and promote the release of TNF but also has significant radio- sensitizing effect and can improve the sensitivity of cancer cells to chemotherapy.
8.Traditional Chinese Medicine
For the syndrome of stagnation of qi due to depression of the liver, modified Xiaoyao Powder is given. For the syndrome of disharmony of Chong and Conception Channels, modified Zhibai Dihuang Pill is given. For the syndrome of stagnation of heat and toxin, modified Wuwei Xiaodu Decoction is given. For the syndrome of deficiency of both blood and qi, modified Ginseng Tonic Decoction is given. Chinese formulated products commonly used are Xiaojin Dan, Xihuang Pill, Xiaoxing Pill, Pingxiao Capsule, and so on.
9.Acupuncture
The syndrome of stagnation of qi due to depression of the liver appears mostly at the early stage. The therapeutic principle should focus on soothing the liver and regulating the circulation of qi, as well as removing phlegm and resolving mass.
The type of accumulated heat toxicity or deficiency of both qi and blood is mainly for the medium- advanced stage. The therapeutic principle should focus on clearing away heat and toxic substances, removing blood stasis and relieving pain, replenishing qi and blood, and strengthening healthy qi to eliminate pathogens.
10.Medicated Diet, Nutrition, and so on
Medicated diet is mainly for the early stage. Total parenteral nutrition is given 1 day before thermochemotherapy. Pay attention to rational nutrition collocation. Patients at medium-advanced stage who still can eat are given medicated conditioning. Appropriately apply megestrol acetate and multienzyme tablets for oral administration to improve appetite, supplemented with amino acids, and so on. If patients have difficulty in feeding, total parenteral nutrition is given, and at the same time complications are treated.
11.Others
Qigong, tai chi, music, and mental therapy of TCM support the patient’s mental health and increase confidence in the treatment.
Typical Case
59 years old female patient from the US was admitted to Clifford Hospital for “four years with right breast invasive ductal carcinoma, which has progressively increased, 3 months of weight loss, one week of skin redness and swelling”. In October 2003, patient discovered a hardened mass the size of a peanut in the right breast. No pain was felt. Prior to this, patient had been taking estrogen for more than 3 years. The patient was diagnosed with breast invasive ductal carcinoma by local tissue biopsy with PR (+), ER (+), and CerbB2 (+ + +) in a local hospital. Patient refused to accept invasive treatment, including surgery and chemoradiotherapy. Instead, she received natural therapies such as vitamin C, medical ozone, massage, hydriatrics, and others. The disease remained relatively stable. The mass gradually increased in size 3 months before admission, and the entire right breast was hard with skin redness and swelling. Patient was obviously fatigued, with shortness of breath and palpitations after mild exertion. The patient had recurrent paroxysmal coughs. She had lost 10 kg of weight during the 3 months before admission. Subsequently, patient was finally admitted to Clifford Hospital for further treatment.
Physical examination: Patient was gaunt and depressed, weighing only 51 kg. There was bilateral breast surface swelling, local spot ulceration covered with pus, bilateral nipple retraction and particle surface similar to strawberry. Several lymph nodes were palpable at bilateral axillary and left supraclavicular fossa, and the largest approximately 2 cm×2 cm×1.5cm, was hard with poor mobility, and presented clear boundary with the surrounding tissue. Heart rate was at 112 beats /min with regular rhythm and no noise was heard. Dullness was heard by percussion at the gap between the double inferior lung and the fifth intercostal space, and breathing sounds were significantly reduced. Patient could not sleep in the right lateral position. There were pitting swellings at the right upper forearm and the upper arm, and mild swelling at the lower limbs. Her KPS was 60.
Diagnosis: invasive ductal carcinoma of the right breast, stage IV (left internal mammary, lung, liver, chest, and skin metastases).
Integrative treatment prescription: Patient presented liver, lungs, chest, skin, and lymph node and other multiple metastases when admitted. Moderate malnutrition, breast surface ulceration infection, and bilateral pleural effusion was evident. Edema of the right arm caused by chest wall lymphatic flow obstruction was considered. Bilateral lower extremity edemas were caused by hypoalbuminemia. Patient was given debridement and medical ozone cupping treatment on bilateral breast after admission. The surface of the ulcer healed after three days. Swelling eased significantly. After giving pleural drainage of pleural effusion, injected cisplatin 30mg + IL-2 4, 000,000 U, once every week. Bilateral chest local hyperthermia was applied after injection. Close attention was paid to nutritional support when the patient was admitted to the hospital. At the same time, EBOO was applied once every other day, alternating with chelation and detoxification therapy. At the same time, letrozole 2.5mg a time was given, once per day for oral administration. Bilateral pleural effusions basically disappeared after 2 weeks. Then whole body medium-high hyperthermia was conducted once every 10 days and in conjunction with chelation detoxification therapy, once every other day. Local hyperthermia was given in the interim periods of whole body hyperthermia. TCM and acupuncture treatment were given throughout the treatment. Patient received herbal diet, practiced medical Qigong after admission, and received psychological counseling. She was mentally positive and cooperated well with the treatment program.
Treatment outcome: After more than 60 days of integrative treatment, the patient’s ulcers and swelling on the breast disappeared. The huge mass in the right breast was softened and reduced significantly (
Fig.4, Fig.5). Limb edemas disappeared, and fatigue was improved significantly. There was no palpitation when she went up and down the stairs. Her heart rate was 80-90 beats/min. Lymph nodes at bilateral axillary and left supraclavicular fossa were significantly reduced, and the largest was about 1cm×1.5cm×1.5cm, and softened. She had better appetite, and her weight increased to 62 kg. She could lie in the supine position, and activities were normal. Multiple metastases in the bilateral lungs and liver were reduced compared with the previous ones through a review of chest and abdomen CT and there were no new lesions. The left pleural cavity lesion was 3.5cm×4.2cm×3.4 cm. The KPS was 90. Patient continued to take TCM formulas of Shenling Baizhu Decoction and Zuogui Pill, and letrozole 2.5mg each time, once per day,and her condition remained relatively stable.
Fig. 4 Before Treatments
Fig. 5 After Treatments
