Breast Cancer

Breast cancer facts

• Breast cancer is the most common cancer among American women.
• One in every eight women in the United States develops breast cancer.
• There are many types of breast cancer that differ in their capability of spreading (metastasize) to other body tissues.
• The causes of breast cancer are not yet fully known although a number of risk factors have been identified.
• There are many different types of breast cancer.
• Breast cancer is diagnosed with physician and self-examination of the breasts, mammography, ultrasound testing, and biopsy.
• Treatment of breast cancer depends on the type of cancer and its stage (the extent of spread in the body).

According to the American Cancer society:

• Over 200,000 new cases of invasive breast cancer are diagnosed each year.
• Nearly 40,000 women will die of breast cancer in 2011.
• There are over 2.5 million breast cancer survivors in the United States.
• A woman should have a baseline mammogram between the 35 and 40 years of age. Between 40 and 50 years of age, mammograms are recommended every other year. After 50 years of age, yearly mammograms are recommended.

What is breast cancer?

Breast cancer is a malignant tumor (a collection of cancer cells) arising from the cells of the breast. Although breast cancer predominantly occurs in women it can also affect men. This article deals with breast cancer in women.

What are the different types of breast cancer?

There are many types of breast cancer. Some are more common than others, and there are also combinations of cancers. Some of the most common types of cancer are as follows:

Ductal carcinoma in situ: The most common type of noninvasive breast cancer is ductal carcinoma in situ (DCIS). This type of cancer has not spread and therefore usually has a very high cure rate.

Invasive ductal carcinoma: This cancer starts in a duct of the breast and grows into the surrounding tissue. It is the most common form of breast cancer. About 80% of invasive breast cancers are invasive ductal carcinoma.

Invasive lobular carcinoma: This breast cancer starts in the glands of the breast that produce milk. Approximately 10% of invasive breast cancers are invasive lobular carcinoma.

The remainder of breast cancers are much less common and include the following:

Mucinous carcinoma are formed from mucus-producing cancer cells.

Mixed tumors contain a variety of cell types.

Medullary carcinoma is an infiltrating breast cancer that presents with well-defined boundaries between the cancerous and noncancerous tissue.

Inflammatory breast cancer: This cancer makes the skin of the breast appear red and feel warm (giving it the appearance of an infection). These changes are due to the blockage of lymph vessels by cancer cells.

Triple-negative breast cancers: This is a subtype of invasive cancer with cells that lack estrogen and progesterone receptors and have no excess of a specific protein (HER2) on their surface. It tends to appear more often in younger women and African-American women.

Paget's disease of the nipple: This cancer starts in the ducts of the breast and spreads to the nipple and the area surrounding the nipple. It usually presents with crusting and redness around the nipple.

Adenoid cystic carcinoma: These cancers have both glandular and cystic features. They tend not to spread aggressively and have a good prognosis.

The following are other uncommon types of breast cancer:

Papillary carcinoma Phyllodes tumor Angiosarcoma Tubular carcinoma

Picture of the anatomy of the breast

What causes breast cancer?

There are many risk factors that increase the chance of developing breast cancer. Although we know some of these risk factors, we don't know how these factors cause the development of a cancer cell.

What are breast cancer risk factors?

Some of the breast cancer risk factors can be modified (such as alcohol use) while others cannot be influenced (such as age). It is important to discuss these risks with your health-care provider anytime new therapies are started (for example, postmenopausal hormone therapy).

The following are risk factors for breast cancer:

• Age: The chances of breast cancer increase as you get older.
• Family history: The risk of breast cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman's risk.
• Personal history: Having been diagnosed with breast cancer in one breast increases the risk of cancer in the other breast or the chance of an additional cancer in the original breast.
• Women diagnosed with certain benign breast conditions have an increased risk of breast cancer. These include atypical hyperplasia, a condition in which there is abnormal proliferation of breast cells but no cancer has developed.
• Menstruation: Women who started their menstrual cycle at a younger age (before 12) or went throughmenopause later (after 55) have a slightly increased risk.
• Breast tissue: Women with dense breast tissue (as documented bymammogram) have a higher risk of breast cancer.
• Race: White women have a higher risk of developing breast cancer, but African-American women tend to have more aggressive tumors when they do develop breast cancer.
• Exposure to previous chest radiation or use of diethylstilbestrol increases the risk of breast cancer.
• Having no children or the first child after age 30 increases the risk of breast cancer.
• Breastfeeding for one and a half to two years might slightly lower the risk of breast cancer.
• Being overweight or obese increases the risk of breast cancer.
• Use of oral contraceptives in the last 10 years increases the risk of breast cancer.
• Using combined hormone therapy after menopause increases the risk of breast cancer.
• Alcohol use increases the risk of breast cancer, and this seems to be proportional to the amount of alcohol used.
• Exercise seems to lower the risk of breast cancer.

What are breast cancer symptoms and signs?

The most common sign of breast cancer is a new lump or mass in the breast. In addition, the following are possible signs of breast cancer:

• Nipple discharge or redness
• Breast or nipple pain
• Swelling of part of the breast or dimpling

You should discuss these or any other findings that concern you with your health-care provider.

How is breast cancer diagnosed?

Although breast cancer can be diagnosed by the above signs and symptoms, the use of screening mammography has made it possible to detect many of the cancers early before they cause any symptoms.

The American Cancer Society has the following recommendations for breast cancer screenings:

Women age 40 and older should have a screening mammogram every year and should continue to do so as long as they are in good health.

Mammograms are a very good screening tool for breast cancer. As in any test, mammograms have limitations and will miss some cancers. The results of your mammogram, breast exam, and family history should be discussed with your health-care provider.

Women in their 20s and 30s should have a clinical breast exam (CBE) as part of regular health exams by a health-care professional about every three years for women in their 20s and 30s and every year for women 40 years of age and over.

CBE are an important tool to detect changes in your breast and also trigger a discussion with your health-care provider about early cancer detection and risk factors.

Breast self-exam (BSE) is an option for women starting in their 20s. Women should report any breast changes to their health-care professional.

If a woman wishes to do BSE, the technique should be reviewed with her health-care provider. The goal is to feel comfortable with the way the woman's breast feels and looks and therefore detect changes.

Women at high risk (greater then 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderate risk (15%-20%) should talk to their doctor about the benefits and limitations of adding MRI screening to their yearly mammogram.

How is breast cancer staging determined?

Staging is the process of determining the extent of the cancer and its spread in the body. Together with the type of cancer, staging is used to determine the appropriate therapy and to predict chances for survival.

To determine if the cancer has spread, several different imaging techniques can be used.

Chest X-ray: It looks for spread of the cancer to the lung.

Mammograms: More detailed and additional mammograms provide more images of the breast and may locate other abnormalities.

Computerized tomography (CT scan): These specialized X-rays are used to look at different parts of your body to determine if the breast cancer has spread. It could include a CT of the brain, lungs, or any other area of concern.

Bone scan: A bone scan determines if the cancer has spread (metastasized) to the bones. Low level radioactive material is injected into the bloodstream, and over a few hours, images are taken to determine if there is uptake in certain bone areas, indicating metastasis.

Positron emission tomography (PET scan): A radioactive material is injected that is absorbed preferentially by rapidly growing cells (such as cancer cells). The PET scanner then locates these areas in your body.

Staging system:

This system is used by your health-care team to summarize in a standard way the extent and spread of your cancer. This staging can then be used to determine the treatment most appropriate for your type of cancer.

The most widely used system in the U.S. is the American Joint Committee on Cancer TNM system.

Besides the information gained from the imaging tests, this system also uses the results from surgical procedures. After surgery, a pathologist looks at the cells from the breast cancer as well as from the lymph nodes. This information gained is incorporated into the staging as it tends to be more accurate than the physical exam and X-ray findings alone.

TNM staging:

T: describes the size of the tumor. It is followed by a number from 0 to 4. Higher numbers indicate a larger tumor or greater spread:

TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ T1: Tumor is 2 cm or less across T2: Tumor is 2 cm-5 cm T3: Tumor is more than 5 cm T4: Tumor of any size growing into the chest wall or skin.

N: describes the spread to lymph node near the breast. It is followed by a number from 0 to 3.

NX: Nearby lymph nodes cannot be assessed (for example if they have previously been removed). N0: There has been no spread to nearby lymph nodes. In addition to the numbers, this part of the staging is modified by the designation "i+" if the cancer cells are only seen by immunohistochemistry (a special stain) and "mol+" if the cancer could only be found using PCR(special detection technique to detect cancer at the molecular level). N1: Cancer has spread to one to three axillary lymph nodes (underarm lymph nodes) or tiny amounts of cancer are found in internal mammary lymph nodes (lymph nodes near breastbone). N2: Cancer has spread to four to nine axillary lymph nodes or the cancer has enlarged the internal mammary lymph nodes.N3: Any of the conditions below
• Cancer has spread to 10 or more axillary lymph nodes with at least one cancer spread larger than 2 mm
• Cancer has spread to lymph nodes under the clavicle with at least area of cancer spread greater than 2 mm

M: This letter is followed by a 0 or 1, indicating whether the cancer has spread to other organs.

MX: Metastasis can not be assessed. M0: No distant spread is found on imaging procedures or by physical exam. M1: Spread to other organs is present.

Once the T, N, and M categories have been determined they are combined into staging groups. There are five major staging groups, stage 0 to stage IV, which are subdivided into A and B, or A and B and C, depending on the underlying cancer and the T, N, and M scale.

Cancers with similar stages often require similar treatments.

What is the treatment for breast cancer?

Patients with breast cancer have many treatment options. Most treatments are adjusted specifically to the type of cancer and the staging group. Treatment options should be discussed with your health-care team. Below you will find the basic treatment modalities used in the treatment of breast cancer.

Surgery

Most women with breast cancer will require surgery. Broadly, the surgical therapies for breast cancer can be divided into breast conserving surgery and mastectomy.

Breast-conserving surgery

This surgery will only remove part of the breast (sometimes referred to as partial mastectomy). The extent of the surgery is determined by the size and location of the tumor.

In a lumpectomy, only the breast lump and some surrounding tissue is removed. The surrounding tissue (margins) are inspected for cancer cells. If no cancer cells are found, this is called "negative" or "clear margins." Frequently, radiation therapy is given after lumpectomies.

Mastectomy

During a mastectomy (sometimes also referred to as a simple mastectomy), all the breast tissue is removed. If immediate reconstruction is considered, a skin-sparing mastectomy is sometimes performed. In this surgery, all the breast tissue is removed as well but the overlying skin is preserved.

Radical mastectomy

During this surgery, the surgeon removes the axillary lymph nodes as well as the chest wall muscle in addition to the breast. This procedure is done much less frequently than in the past, as in most cases a modified radical mastectomy is as effective.

Modified radical mastectomy

This surgery removes the axillary lymph nodes in addition to the breast tissue.

Depending on the stage of the cancer , your health-care team might give you a choice between a lumpectomy and a mastectomy. Lumpectomy allows sparing of the breast but usually requires radiation therapy afterward. If lumpectomy is indicated, long-term follow-up shows no advantage of a mastectomy over the lumpectomy.

Radiation therapy

Radiation therapy destroys cancer cells with high energy rays. There are two ways to administer radiation therapy:

External beam radiation

This is the usual way radiation therapy is given for breast cancer. A beam of radiation is focused onto the affected area by an external machine. The extent of the treatment is determined by your health-care team and is based on the surgical procedure performed and whether lymph nodes were affected or not.

The local area will usually be marked after the radiation team has determined the exact location for the treatments. Usually the treatment is given five days a week for five to six weeks.

Brachytherapy

This form of delivering radiation uses radioactive seeds or pellets. Instead of a beam from the outside delivering the radiation, these seeds are implanted into the breast next to the cancer.

Chemotherapy

Chemotherapy is treatment of cancers with medications that travel through the bloodstream to the cancer cells. These medications are given either by intravenous injection or by mouth.

Chemotherapy can have different indications and may be performed in different settings as follows:

Adjuvant chemotherapy: If surgery has removed all the visible cancer, there is still the possibility that cancer cells have broken off or are left behind. If chemotherapy is given to assure that these small amounts of cells are killed as well, it is called adjunct chemotherapy.

Neoadjuvant chemotherapy: If chemotherapy is given before surgery it is referred to as neoadjuvant chemotherapy. Although there seems to be no advantage to long-term survival whether the therapy is given before or after surgery, there are advantages to see if the cancer responds to the therapy and by shrinking the cancer before surgical removal.

Chemotherapy for advanced cancer: If the cancer has metastasized to distant sites in the body, chemotherapy can be used for treatment. In this case, the health-care team will need to determine the most appropriate length of treatment.

There are many different chemotherapeutic agents that are either given alone or in combination. Usually these drugs are given in cycles with certain treatment intervals followed by a rest period. The cycle length and rest intervals differ from drug to drug.

Hormone therapy

This therapy is often used to help reduce the risk of cancer reoccurrence after surgery, but it can also be used as adjunct treatment.

Estrogen (a hormone produced by the ovaries) promotes the growth of a few breast cancers, specifically those containing receptors for estrogen (ER positive) or progesterone (PR positive).

The following drugs are used in hormone therapy:

Tamoxifen (Nolvadex): This drug prevents estrogen from binding to estrogen receptors on breast cells.

Fulvestrant (Faslodex): This drug eliminates the estrogen receptor and can be used even if tamoxifen is no longer useful.

Aromatase inhibitors: They stop estrogen production in postmenopausal women. Examples are letrozole (Femara), anastrozole (Arimidex), andexemestane (Aromasin).

Targeted therapy

As we are learning more about gene changes and their involvement in causing cancer, drugs are being developed that specifically target the cancer cells. They tend to have fewer side effects then chemotherapy (as they target only the cancer cells) but usually are still used in adjunct with chemotherapy.

Targeting HER2/Neu protein

Monoclonal antibody: Trastuzumab is a engineered protein that attaches to the HER2/Neu protein on breast cancer cells. It helps slow the growth of the cancer cell and may also stimulate the immune system to attack the cancer cell more effectively.

It is given IV either once a week or every three weeks.

Drugs that target new tumor blood vessels

Tumors need new blood vessels to grow. The process of blood vessel growth is known medically as angiogenesis. New drugs are being developed to target this growth and fight certain cancers, including breast cancer.

Bevacizumab is a monoclonal antibody directed against vascular cells. Newer study results seem to indicate that this drug slows the cancer growth in some patients but did not improve survival. The use of this medication should be discussed with your health-care team.

Alternative treatments

Whenever a disease has the potential for much harm and death we search for alternative treatments. As a patient or the loved one of a patient you want to try everything and leave no option unexplored. The danger in this approach is usually found in the fact that the patient might not avail themselves of existing, proven therapies. You should discuss your interest in alternative treatments with your health-care team and together explore the different options.

What is the prognosis of breast cancer?

Survival rates are a way for health-care professionals to discuss the prognosis and outlook of a cancer diagnosis with their patients. You have to determine if you want to know this number or not and should let your health-care provider know.

The number most frequently discussed is five-year survival. It is the percentage of patients who live at least five years after they are diagnosed with cancer. Many of these patients live much longer, and some patients die earlier from causes other then breast cancer. With a constant change in therapies, these numbers also change. The current five-year survival statistic is based on patients who were diagnosed at least five years ago and may have received different therapies than are available today.

All of this needs to be taken into consideration when interpreting these numbers for yourself.

Below are the statistics from the national cancer database and reflect patients who were diagnosed with breast cancer in 2001 and 2002:

Stage	Five-year survival rate
0	93%
I	88%
IIA	81%
IIB	74%
IIIA	67%
IIIB	41%
IIIC	49%
IV	15%

Can breast cancer be prevented?

There is no guaranteed way to prevent breast cancer. Reviewing the risk factors and modifying the ones that can be altered (increase exercise, keep a good body weight, etc.) can help in decreasing the risk.

Following the American Cancer Society's guidelines for early detection can help early detection and treatment.

There are some subgroups of women that should consider additional preventive measures:

Women with a strong family history of breast cancer should be evaluated by genetic testing. This should be discussed with your health-care provider and be preceded by a meeting with a genetic counselor who can explain what the testing can and cannot tell and then help interpret the results after testing.

Chemoprevention is the use of medications to reduce the risk of cancer. The two currently approved drugs for chemoprevention of breast cancer are tamoxifen (a medication that blocks estrogen effects on the breast tissue) andraloxifene (Evista), which also blocks the effect of estrogen on breast tissues. Their side effects and whether these medications are right for you need to be discussed with your health-care provider.

Aromatase inhibitors are medications that block the production of small amounts of estrogen usually produced in postmenopausal women. They are being used to prevent reoccurrence of breast cancer but are not approved at this time for breast cancer chemoprevention.

Preventive surgery: For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

Some of the reasons for this approach may include

• mutated BRCA genes found by genetic testing,
• a strong family history,
• a personal history of cancer in one breast.

What research is being done on breast cancer? Should I participate in a clinical trial?

Without research and clinical trials there would be no progress in our treatment of cancers.

Research can take many forms, including research directly on cancer cells or using animals.

Research that a patient can be involved in is referred to as a clinical trial. In clinical trials, different treatment regimens are compared for side effects and outcomes including long-term survival. Clinical trials are designed to find out whether new approaches are safe and effective.

Whether you should participate in a clinical trial is your decision and should be based upon a full understanding of the advantages and disadvantages of the trial. You should discuss the trial with your health-care team and ask how this trial might be different from the treatment you would usually receive.

You should never be forced to participate in a clinical trial or be involved in a trial without your full understanding of the trial and a written and signed consent.

I may have breast cancer, what questions should I ask my doctor?

If you have received a positive or possible diagnosis of breast cancer, there are a number of questions that you can ask your doctor. The answers you receive to these questions should give you a better understanding of your specific diagnosis and the corresponding treatment. It is usually helpful to write your questions down before you meet with your health-care provider. This gives you the opportunity to ask all your questions in an organized fashion.

Each question is followed by a brief explanation as to why that particular question is important. We will not attempt to answer these questions in detail here because each individual case is just that, individual. This outline is designed to provide a framework to help you and your family make certain that most of the important questions in breast cancer diagnosis and treatment have been addressed. As cancer treatments are constantly evolving, specific recommendations and treatments might change and you should always confer with your treatment team regarding any questions. You obviously should add your own questions and concerns to these when you have a discussion with your doctor.

Is the doctor sure I have breast cancer?

Certain types of cancer are relatively easy to identify by standard microscopic evaluation of the tissue. This is generally true for the most common types of breast cancer. This obviously implies that you have had a biopsy that was then reviewed by a pathologist.

However, as the search for earlier and rarer forms of breast cancer progresses, it can be difficult to be certain that a particular group of cells is malignant (cancerous). At the same time, benign conditions may have cells which are somewhat distorted in appearance or pattern of growth (known as atypical cells or atypical hyperplasia). For this reason, it is important that the pathologist reading the slides of your breast biopsy be experienced in breast pathology. Most good pathology groups have multiple pathologists review questionable or troublesome slides. In more difficult cases, the slides will often be sent to recognized specialists with considerable expertise in breast pathology.

What type of breast cancer do I have?

Breast cancer is not a single disease. There are many types of breast cancer, and they may have vastly different implications. Breast cancers range from localized cancers such as ductal carcinoma in situ (DCIS) to invasive cancers that can rapidly spread (metastasize). In the middle of the spectrum are breast cancers, such as colloid carcinomas and papillary carcinomas, which have a much more favorable outlook (prognosis) than the other more typically invasive breast cancers. Sometimes, noninvasive DCIS is found around invasive breast cancers.

The treatment team should be able to explain what type of cancer you have, how they determined this, and the treatment they recommend.

What difference does a precise diagnosis make?

The importance of an accurate diagnosis cannot be overstated. It is the precise diagnosis that determines the recommended treatment. Treatment must be specifically tailored to the specific type of breast cancer as well as to the individual patient.

Your doctor should be able to give you a clear description of your type of breast cancer along with the treatment options that are appropriate to your case.

What has been done to exclude cancer in other areas of the same breast or in my other breast?

Unfortunately, there are some patients who may have more than one area of malignancy in the same breast or even an additional malignancy in the other breast. If this does occur, it can greatly change the recommendations for treatment.

Therefore, it is critically important that your doctors carefully investigate beyond the immediate site of the tumor to make certain there are no other areas with possible malignancy.

Sometimes discovering these "secondary" areas requires careful review of yourmammograms. It may also require the addition of special views from different angles and specialized examination of your breasts by ultrasound, MRI, or other imaging techniques. Sometimes imaging techniques will be used to evaluate the rest of your body as well.

What type of medical team do I need for the most accurate diagnosis?

A well-coordinated team which includes input from the pathologist, surgeon, and radiologist is usually the best way to approach treatment decisions. Advice from the entire team must be available during biopsies and any tumor-clearing surgery to ensure the best chance of a favorable outcome for the patient.

How important is the role of the pathologist reading my slides?

The pathologist evaluating the slides made from fine-needle aspiration biopsies, core biopsies, and tissue slides of the breast must have a great deal of experience and special training. It is important that the pathologist reliably determine the presence or absence of cancer and distinguish cancer from other conditions such as hyperplasia with atypia (an overgrowth with unusual-looking but benign cells). The pathologist also orders and interprets special studies (see below) on your cancer tissue to determine the precise characteristics of the cancer cells, such as whether the cancer expresses hormone receptors. These results are used to further specify the type of breast cancer and optimize treatment decisions. The remainder of the treatment will be based on the pathologist's diagnosis.

Have my slides been reviewed by more than one pathologist?

A review by more than one pathologist is optimal. There are many subtleties which can be overlooked when reviewing microscope slides. These can lead to both over-reading (making a false-positive diagnosis) and under-reading (making a false-negative diagnosis). When slides are read a second time by another pathologist followed by a discussion of the conclusions, most diagnostic problems are resolved.

There are almost always several pathologists available who can review the pathology of your slides (this is termed a "double reading"). The added safeguard of double reading may not be necessary in most cases of breast cancers but can be a critical factor in some cases.

Can I have my biopsy reviewed by a pathologist at another diagnostic center?

It should always be possible to send slides from your biopsy to a pathologist at another diagnostic center. First of all, there should not be a rush to treatment; breast cancer is almost never an emergency. Developing the best treatment plan depends on a good, thorough pathologic evaluation as well as a complete workup of both breasts, as noted above. You should discuss this with your treatment team or primary-care giver as they can help you arrange for this.

Second, good pathologists are never offended by a request for an outside opinion. They also usually know the names of some of the finest breast pathologists in the country and should be willing to arrange a consultation with one of these doctors.

In most cases of breast cancer, it is not necessary to obtain this in-depth consultation. However, if there are any unusual aspects of your case, it can be important in your decision-making process. The matter of obtaining additional consults may take a week or more.

Is my family history relevant to my breast cancer diagnosis?

If you have a strong (positive) family history for breast cancer, ovarian cancer, or evenprostate cancer, this information is relevant to your diagnosis. A strong family history in this case usually means that a mother, sibling, child, or father has had a related malignancy. Information about other family members (aunts, nieces, etc.) is also important. This is especially significant if the diagnosis of breast cancer was made at an early age or involved both breasts or a breast and an ovary in the same individual. A positive family history may necessitate a more comprehensive diagnostic workup, more involved treatment, and consideration of genetic testing, not only for you but for other family members.

What other studies should be done on my tissue biopsy?

Microscopic evaluation of the slides made from involved tissue provides critical information about the tumor. A reasonably accurate prediction of tumor behavior can be made based on the appearance of the cancer cells, their size and similarity to one another, and the presence or absence of these cells in the lymphatic and blood vessels immediately adjacent to the tumor. This type of evaluation is a standard part of the diagnostic process.

However, there are additional relevant data which the laboratory should obtain, and this analysis is directed by the pathologist at the time of diagnosis. This information includes, at a minimum, an assessment of the estrogen and progesterone receptors on the malignant cells and the status of at least one oncogene, called her-2-neu. An oncogene is a gene that plays a normal role in cell growth but, when altered, may contribute to abnormal cell division and tumor growth.

Currently, these tests (estrogen and progesterone receptors and her-2-neu) have an accurate enough predictive value that their status should be determined in all cases of breast cancer. Test results are available within a few days to a week after removal of the tumor tissue. The results of these tests should then be taken into account in the final decision-making about treatment. These tests are constantly evolving and changing, and your treatment team will be able to discuss the current standard and advanced testing available.

How urgent is it that I make decisions and begin treatment?

It is extremely rare that a patient must be rushed into treatment. The biology of breast tumors is established fairly early in their development, and by the time the tumors are detectable, most have been growing undetected for considerably more than a year. This means that if you take a few weeks to complete a thorough evaluation, obtain appropriate consultations, understand the situation, discuss the alternatives and initiate a treatment plan, it is not likely to add any significant risk. This time frame, however, should allow the facts of your case to be carefully sorted out and errors to be minimized. Your treatment team should be able to help you in this process and specifically advise you on the urgency to start certain treatments.

Are there controversies in the recommended treatments among reputable experts?

Doctors may differ in their recommendations if they weigh the risks differently. There will always be uncertainties in any given case. These issues are rarely "right versus wrong." They can be compared with decisions such as "how do I balance my desire to have the largest and safest care with the need to have convenience and economy?" There are tradeoffs. For example, certain breast-cancer treatment options may favor cosmetic appearance but slightly increase the risk of recurrence in the affected breast. If you have concerns, a second opinion by a different treatment team can often be helpful.

How might my treatment affect future risks and follow-up treatment?

There are often indirect consequences of treatment decisions. For example, breast-conservation therapy achieves, as its goal, treatment of the breast cancer along with preservation of the breast. This is clearly a highly desirable objective. However, in doing so, it leaves the possibility that cancer may recur in that breast. The risk is small but is definitely there. Most of the time, the recurrence will be recognized and the new tumor treated early but not always.

These risks mean that a patient choosing breast-conservation therapy must have the treated side (and the other breast as well) carefully monitored with regular examinations and imaging tests. Occasionally, tissue abnormalities develop which may suggest a new or recurrent cancer, thereby necessitating further evaluation with more tests or even another biopsy. The majority of these abnormalities turn out to be benign, perhaps caused by benign breast disease or changes from the surgery and radiation therapy. But the psychological impact of having to repeat such an evaluation may be very upsetting to some patients. Breast conservation is not appropriate for every breast-cancer patient or breast-cancer type.

There are similar considerations in each treatment plan which have to be understood and carefully evaluated before committing to a particular method of therapy. You should discuss these issues thoroughly with your doctor.

Should genetic testing be part of the treatment decision process?

The majority of breast cancers occur as unconnected (sporadic) cases and are not caused by an inherited genetic abnormality (mutation) passed from parent to child. However, if you have close family members, such as a mother or sister, who have had the disease, especially if it occurred at a young age, then the possibility of a genetic predisposition to develop cancer cells should be investigated. In these situations, genetic testing may provide valuable information. The test results may affect not only recommendations for your therapy but may also have major implications for other family members as well. Gene testing should only be done after careful genetic counseling so that everyone has a thorough understanding of the potential value and also the limitations of these tests.

Should I stop taking hormone replacement therapy (HRT)?

Breast cells are programmed to respond to certain hormones as signals for growth and multiplication. The most prominent examples of these hormones are estrogens andprogesterone. Many breast-cancer cells retain hormone receptors (molecular configurations on the cell surface to which the hormones bind). The hormone receptors therefore make the cancer cells responsive to these particular hormones.

In general, taking hormones is not recommended if a diagnosis of breast cancer is under consideration. This does not necessarily mean that you can never resume hormone replacement therapy. This issue is generally reconsidered after the completion of your evaluation and treatment. You should consult with your physician before you stop or start any new medications.

Even though my breast tumor does not have hormone receptors, should I take tamoxifen to reduce the risk of a new tumor?

Following completion of your treatment for breast cancer, whether or not tamoxifen(Nolvadex) is prescribed should at least be addressed. In many cases, the primary breast cancer for which the patient is being treated may not be hormone-receptor positive. In these cases, tamoxifen (which binds to the estrogen receptor in place of estrogen) is not generally part of the treatment protocol.

However, the Breast Cancer PreventionTrial (a study of the use of tamoxifen) demonstrated a significant reduction in the development of new cancers in the opposite breast in patients who were treated with tamoxifen. So, the possible use and benefits of tamoxifen should not be ignored. A thoughtful evaluation of all the factors in a particular case will lead to a recommendation which balances the benefits of tamoxifen against the potential risks. Your treatment team should address this issue with you.

I have a ductal carcinoma in situ (DCIS), a type of localized cancer. Why have I been advised to have a mastectomy when other women with invasive cancer have lumpectomies?

Ductal carcinoma in situ (DCIS) sometimes presents a difficult dilemma. Most patients with DCIS can undergo successful breast-conservation therapy but not all. The diagnosis implies that this is an "early" form of cancer in the sense that the cancer cells have not acquired the ability to penetrate normal tissue barriers or spread through the vascular or lymphatic channels to other sites of the body. It is important to realize that breast cancer is a wide spectrum of diseases and no comparisons should be made just on the basis that someone you know has "breast cancer" and shares a different treatment approach with you.

However, the millions of cells forming the DCIS have accumulated a series of errors in their DNA programs which allow them to grow out of control. There are varying degrees of disturbance, called "grades," of the normal cellular patterns. Low grades are more favorable, and high grades are less favorable.

The DCIS cells originate from the inside of the breast gland ducts (microscopic tubes). As they multiply, the cells fill and spread through the normal ducts of the breast glandular tissue. With many DNA errors already in place and millions of these cells exposed to the usual risks of additional DNA damage, a few cells will ultimately become invasive. This invasive change is the real risk of DCIS.

Treatment which does not physically remove all of the DCIS seems to leave a substantial risk of recurrence and, therefore, invasive disease. This risk of recurrence is particularly increased in the high-grade form of DCIS. In cases where the DCIS has spread extensively through the breast ducts, even though the disease is in a sense "early" because it is not yet invasive, it may still require a large surgical resection, at times even a mastectomy (removal of all or part of the breast).

Your treatment team should be able to discuss the pros and cons of the different approaches and actively include you in the decision process.

Should I start chemotherapy before surgery?

The classical concept of breast-cancer treatment has been a sequence of tumor-removing surgery followed by chemotherapyand/or radiation therapy. The goal of surgery and radiation therapy is to destroy or remove the primary cancer. Follow-up chemotherapy is designed to eliminate any cancer cells, as yet undetectable, at remote sites.

Recently, there have been new findings suggesting a potential benefit in some patients when chemotherapy is started before surgery. However, initial chemotherapy (neoadjuvant chemotherapy) should be considered primarily in patients with larger tumors and those with strong evidence of lymph-node involvement at the time of initial diagnosis.

If you are enrolled in a clinical trial, the advantages and disadvantages of all protocols should have been explained to you, giving you the opportunity to make an informed decision.

If I am advised to have a mastectomy, what are the risks and benefits of immediate breast reconstruction?

If a mastectomy is necessary, immediate reconstruction offers a great psychological benefit to most women. However, as is often the case in medicine, there are trade-off risks which must be considered. If the reconstruction is done during the same surgery as the mastectomy (immediate reconstruction), the final results of the pathology tests on the removed tumor and tissue is not yet known and will not be known for at least a day or two.

There are sometimes findings on the final pathology report which make chest-wall radiation advisable in order to reduce the risk of local recurrence. If a prosthesis for the breast has been implanted, the radiation treatment will still work, but the radiation may significantly compromise the cosmetic appearance of the prosthesis. There may also be healing problems which delay chemotherapy, potentially increasing the risk of breast-cancer recurrence. These and other factors should be discussed and carefully considered before committing to immediate breast reconstruction.

Should my lymph nodes be removed?

Lymph nodes are small glandular structures that filter tissue fluids. They filter out and ultimately try to provide an immune response to particles and proteins which appear foreign to them. There are thousands of these nodes scattered in groups throughout the body. Each cluster is more or less responsible for the drainage of a particular region of the body.

The lymph nodes under the arm (axillary nodes) are the dominant drainage recipients from the breast. When cancer cells break free from a breast cancer, they may travel through the lymph tubes (vessels) to the lymph nodes. There, the cancer cells may establish a secondary growth site. The presence of cancer cells in the lymph nodes proves that cancer cells have traveled away from the primary breast tumor. Therefore, the presence or absence of cancer cells in these regional nodes is an important indicator of the future risk of recurrence. This information is often important in making decisions about whether to use chemotherapy and what type of chemotherapy should be employed.

Unfortunately, removal of the lymph nodes also carries a potential risk of lymphedema, a condition that may cause the arm to swell. Lymphedema can occur early after surgery or many years later. It can be a difficult and disabling condition. Here again, there are trade-offs in risk. When more lymph nodes are removed, more accurate the information about tumor spread is obtained and the chance for tumor recurrence is less. But there is a greater incidence of lymphedema.

There are alternatives to standard lymph-node removal (called axillary node dissection). These alternatives should be considered in each patient's situation. They include

1. replacing standard axillary-node removal with sentinel node biopsy (explained below);
2. not doing lymph-node removal in patients who will receive chemotherapy anyway based on other information; and
3. not doing lymph-node removal in patients with very small or "favorable" tumors.

Again, these alternatives must be selectively applied with the benefits and risks carefully evaluated.

What is a sentinel lymph node biopsy, and what are its benefits and risks?

A sentinel node biopsy takes advantage of a peculiar physiologic and anatomical finding. Although there may be many lymph nodes in a particular drainage region, it appears that only one or two are the first recipients of the regional fluids.

This means that if any nodes will be involved by tumor spread, the sentinel node will be the first. It also means in general that if the sentinel node is not involved, then no other nodes will be affected. Therefore, only the sentinel node needs to be removed. There are techniques for removing just the sentinel nodes. A sentinel node biopsy allows the pathologist to more intensively study this node and apply specialized techniques that are capable of detecting even a few cancer cells.

Are there any other questions I should ask my doctor?

Yes. There are surely other questions you will wish to ask. Do not hesitate to be very open about your concerns with your doctor. The foregoing questions and comments should demonstrate that the diagnosis and treatment of breast cancer may not be a simple process. Even when all the information is available, there may be difficulties in deciding a proper course of action. However, this decision-making process has a better chance of success when you and the doctor are well-informed and communicating effectively. Although the information here cannot be all-inclusive, we hope it will help you work through this process.

Previous contributing author:

Medical Author: Edward J. White, MD

REFERENCE:

Hammer, C., A. Fanning, and J. Crowe. "Overview of Breast Cancer Staging and Surgical Treatment Options."Cleve Clin J Med. 75.1 Mar. 2008: S10-6.

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