INFORMATION ON DIAGNOSIS AND TREATMENT

Breast cancer is the most common female cancer in the United States. Every year, approximately 205,000 American women are diagnosed with it and more than 40,000 die from the disease. The number of new cases of breast cancer continues to rise although the death rate from breast cancer has declined about 20 percent over the past decade. This is due in part to increased screening which usually catches the disease at an earlier stage when the chances of successful recovery are higher.

Adjuvant systemic therapy is anti-cancer treatment that is given after surgery. It may include hormone therapy, chemotherapy and antibody therapy. The goal of this therapy is to eliminate any tumor cells that remain in the body after surgery. It significantly decreases the chance that a cancer will return and improves the chance of surviving breast cancer.

Diagnosing breast cancer

Some women’s breast cancer is discovered when a lump or change in the breast is found by the woman herself of the clinician. To evaluate the breast, a mammogram or breast ultrasound is usually recommended first. A suspicious lump should never be ignored as 20 percent of new breast cancers are not visible on mammogram. Breast MRI may be recommended to aid in the diagnosis of breast cancer in selected situations. If breast cancer is suspected, the next step is to remove a small piece of the abnormal area (called a biopsy) to confirm the diagnosis. If the abnormality is only found on mammogram and the breast feels normal, then the biopsy will need to be done using a test to guide where to perform the biopsy.

Types of breast cancer

Is situ – the earliest breast cancers, arise and are limited to the ducts of the breast (ductal carcinoma in situ or DCIS) or in the lobules of the breast (lobular carcinoma in situ or LCIS). These cancers seldom spread beyond the breast tissue and are cured with surgery sometimes followed by radiation.

Invasive – the majority of breast cancers have invaded beyond the ducts or lobules of the breast. Several varieties of invasive breast cancers are identified (eg, ductal, lobular, medullary, tubular, metaplastic). In general they are treated similarly.

Hormone receptors – about 50 to 70 percent of breast cancers require the female hormone estrogen to grow, while other breast cancers are able to grow without the estrogen. Estrogen dependant breast cancer cells produce estrogen receptors (ER), progesterone receptors (PR) or both. They are called hormone responsive and might benefit from treatments that block the hormone receptors or lower the levels of estrogen.

Her2 – is a protein that is present in about one third of breast cancers. The level of the Her2 can be determined by the pathologist. Trastuzumab (Herceptin) is an antibody treatment that can benefit women whose breast cancer is Her2 positive.

Has the breast cancer spread?

Breast cancer can take three routs of spread: local migration in the breast tissue surrounding the original tumor (this is why radiation therapy to the remaining breast is offered after breast preservation surgery or lumpectomy), via lymphatic system into the lymph nodes of the armpit called the axilla (this is why sampling of the axillary lymph nodes at the time of the breast surgery is important) and via the blood vessels (this can happen even if the lymph nodes are clean).

Staging work-up – For all cancers, treatment and prognosis depend on the stage of the cancer (how far it has spread). This is based on the size of the tumor, involvement of the axillary lymph nodes and whether the cancer has spread to other organs like bones, lungs, liver or brain (metastasis). Stages go from I to IV (earliest stage to most advanced). Staging studies may include a complete physical examination, including a neurologic exam, to evaluate for signs of distant metastatic disease, blood tests, including a complete blood count and liver function tests, bone scan, chest X-ray or CT scan, CT scan of the abdomen and pelvis, CT scan or MRI of the brain, a PET scan. The scans are usually reserved for patients with larger tumors, positive lymph nodes, physical exam findings worrisome for cancer spread or abnormal blood tests.

Stages I and IIbreast cancers are referred to early stage. Stage I breast cancer means that the tumor is no larger than 2 cm and the lymph nodes are negative. Stage II breast cancer means that the tumor is between 2 to 5 cm with either positive or negative axillary lymph nodes. A tumor that is larger than 5 cm must be node negative to be considered early stage.

Stage III breast cancers are referred to as locally advanced. They are usually larger than 5 cm, extend to underlying muscles of the chest wall or the overlying skin, and/or have extensive axillary nodal involvement, or nodal involvement of the soft tissues above or below the collarbone (termed the infraclavicular and supraclavicular nodes).

Stage IV breast cancer – includes tumors that have metastasized to organs outside the breast.

Overview of treatment

The treatment of breast cancer must be individualized and requires collaboration between surgeons (breast surgeon and plastic surgeon), radiation oncologists and medical oncologists. The medical oncologist is the specialist who guides the steps and types of treatments.

Women with early stage breast cancer have two surgical options: mastectomy (removal of the breast) and breast conservation surgery (lumpectomy, wide excision, quadrantectomy, or partial mastectomy). The later procedure needs to be followed by radiation therapy to the remaining breast. Rarely, radiation therapy to the chest wall is offered after a mastectomy if the surgical margin was positive, the tumor involved the chest wall or the skin, or it spread to many local lymph nodes. Breast reconstruction is an important option for women who undergo mastectomy, and may be considered at the time of the mastectomy or at a later date.

Adjuvant therapy – refers to anti-cancer therapy that is given to patients with stage I, II, and III breast cancer after surgery. The goal of adjuvant therapy is to eradicate micrometastatic cells that might have escaped from the tumor in the breast before diagnosis and surgical treatment. The goal of this therapy is to improve the odds for a cure. Adjuvant hormonal therapy is recommended for majority of women with hormone receptor positive breast cancer. It does not benefit women with hormone receptor negative disease. Adjuvant chemotherapy is generally recommended for women with hormone receptor negative disease and high risk women with hormone receptor positive breast cancer. Adjuvant therapy with Trastuzumab is reserved for women with Her2 positive breast cancer rregardless of hormone receptor status.

Inflammatory breast cancer is a rare type of more aggressive breast cancer that makes the breast apear red and swollen. Although the likelihood of curing inflammatory breast cancer is lower than earlier stage disease, cure is possible with aggressive treatment using a combination of chemotherapy, radiation therapy and surgery. IN most cases, chemotherapy is given before surgery.

Metastatic breast cancer is rarely curable. The goal of treatment is prolongation of life and maintenance of quality of life by relieving cancer related symptoms. The choice of treatment for metastatic breast cancer depends upon many individual factors, including features of the woman’s breast cancer, the extent and location of metastases, the expected response of the cancer to various therapies, treatment related side effects, and a woman’s personal preferences.

Where to get more information – Your health care provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation. A number of web sites have information about medical problems and treatments, although the frequency with which they are updated is variable.

www.nci.nih.gov
www.cancer.net/portal/site/patient
www.nccn.org/patients/patient_gls.asp
www.cancer.org
www.komen.org