Breast Cancer -- October 4, 2010 -- Dr. Laura Lawson & Dr. Carl - | Nashville News, Weather & Sports

Breast Cancer -- October 4, 2010 -- Dr. Laura Lawson & Dr. Carl Willis


Laura Lawson, MD: breast surgeon
Carl Willis, MD: medical oncologist
TOPIC: Medical & Surgical Treatments for Breast Cancer
Monday, October 4, 2010

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Breast Cancer FACTS

First, let's find out how breast cancer begins. Cells in the body normally divide (reproduce) only when new cells are needed. Sometimes, cells in a part of the body grow and divide out of control, which creates a mass of tissue called a tumor. If the cells that are growing out of control are normal cells, the tumor is called benign (not cancerous). If however, the cells that are growing out of control are abnormal and don't function like the body's normal cells, the tumor is called malignant (cancerous).

Cancers are named after the part of the body from which they originate. Breast cancer originates in the breast tissue. Like other cancers, breast cancer can invade and grow into the tissue surrounding the breast. It can also travel to other parts of the body and form new tumors, a process called metastasis.

What Causes Breast Cancer?

We do not know what causes breast cancer, although we do know that certain risk factors may put you at higher risk of developing it. A person's age, genetic factors, personal health history, and diet all contribute to breast cancer risk.

Who Gets Breast Cancer?

Breast cancer is the most common cancer among American women, after skin cancer. Today, approximately 1 in almost every 8 women (13.4%) will develop breast cancer in her lifetime. Breast cancer is the second-leading cause of cancer death in women after lung cancer -- and is the leading cause of cancer death among women ages 35 to 54. The American Cancer Society estimates that in 2009, approximately 192,370 women will be diagnosed with invasive breast cancer and approximately 40,610 will die. Although these numbers may sound frightening, research reveals that the mortality rate could decrease by 30% if all women age 50 and older who need a mammogram had one.

Only 5% to 10% of breast cancers occur in women with a clearly defined genetic predisposition for the disease. The majority of breast cancer cases are "sporadic," meaning there is no direct family history of the disease. The risk for developing breast cancer increases as a woman ages.

What Are the Symptoms of Breast Cancer?

The symptoms of breast cancer include:

  • Lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle.
  • A mass or lump, which may feel as small as a pea.
  • A change in the size, shape, or contour of the breast.
  • A blood-stained or clear fluid discharge from the nipple.
  • A change in the feel or appearance of the skin on the breast or nipple (dimpled, puckered, scaly, or inflamed).
  • Redness of the skin on the breast or nipple.
  • A change in shape or position of the nipple
  • An area that is distinctly different from any other area on either breast.
  • A marble-like hardened area under the skin.

What Are the Types of Breast Cancer?

The most common types of breast cancer are:

  • Invasive ductal carcinoma . This cancer starts in the milk ducts of the breast. Then it breaks through the wall of the duct and invades the fatty tissue of the breast. This is the most common form of breast cancer, accounting for 80% of invasive cases.
  • Ductal carcinoma in situ (DCIS) is ductal carcinoma in its earliest stage (Stage 0). In situ refers to the fact that the cancer hasn't spread beyond its point of origin. In this case, the disease is confined to the milk ducts and has not invaded nearby breast tissue. If untreated, ductal carcinoma in situ may become invasive cancer. It is almost always curable.
  • Infiltrating (invasive) lobular carcinoma. This cancer begins in the lobules of the breast where breast milk is produced, but has spread to surrounding tissues or the rest of the body. It accounts for about 10% of invasive breast cancers.
  • Lobular carcinoma in situ (LCIS) is cancer that is only in the lobules of the breast. It isn't a true cancer, but serves as a marker for the increased risk of developing breast cancer later, possibly in both breasts. Thus, it is important for women with lobular carcinoma in situ to have regular clinical breast exams and mammograms.

In addition, there are several other less common types of breast cancer.

What Are the Stages of Breast Cancer?

  • Early stage or stage 0 breast cancer is when the disease is localized to the breast with no evidence of spread to the lymph nodes (carcinoma in situ).
  • Stage I breast cancer: The cancer is two centimeters or less in size and it hasn't spread anywhere.
  • Stage IIA breast cancer is a tumor smaller than two centimeters across with lymph node involvement or a tumor that is larger than two but less than five centimeters across without underarm lymph node involvement.
  • Stage IIB is a tumor that is greater than five centimeters across without underarm lymph nodes testing positive for cancer or a tumor that is larger than two but less than five centimeters across with lymph node involvement.
  • Advanced breast cancer (metastatic) results after cancer cells spread to the lymph nodes and to other parts of the body.
  • Stage IIIA breast cancer is also called locally advanced breast cancer. The tumor is larger than five centimeters and has spread to the lymph nodes under the arm, or a tumor that is any size with cancerous lymph nodes that adhere to one another or surrounding tissue.
  • Stage IIIB breast cancer is a tumor of any size that has spread to the skin, chest wall or internal mammary lymph nodes (located beneath the breast and inside the chest).
  • Stage IIIC breast cancer is a tumor of any size that has spread more extensively and involves more lymph node invasion.
  • Stage IV breast cancer is defined as a tumor, regardless of size, that has spread to places far away from the breast, such as bones, lungs, liver, brain, or distant lymph nodes.

How Is Breast Cancer Diagnosed?

During your regular physical exam, your doctor will take a careful personal and family history and perform a breast exam and possibly one or more other tests:

  • Mammography
  • Ultrasonography

Based on the results of these tests, your doctor may or may not request a biopsy to get a sample of the breast mass cells or tissue.

After the sample is removed, it is sent to a lab for testing. A pathologist -- a doctor who specializes in diagnosing abnormal tissue changes -- views the sample under a microscope and looks for abnormal cell shapes or growth patterns. When cancer is present, the pathologist can tell what kind of cancer it is (ductal or lobular carcinoma) and whether it has spread beyond the ducts or lobules (invasive).

Laboratory tests such as hormone receptor tests (estrogen and progesterone) can show whether the hormones help the cancer to grow. If the test results show that hormones help the cancer grow (a positive test), the cancer is likely to respond to hormonal treatment. This therapy deprives the cancer of the estrogen hormone.

Breast cancer diagnosis and treatment are best accomplished by a team of experts working together with the patient. Each patient needs to evaluate the advantages and limitations of each type of treatment, and work with her team of physicians to develop the best approach.

How Is Breast Cancer Treated?

If the tests find breast cancer, you and your doctor will develop a treatment plan to eradicate the breast cancer, to reduce the chance of cancer returning in the breast, as well as to reduce the chance of the cancer traveling to a location outside of the breast. Treatment generally follows within a few weeks after the diagnosis.

The type of treatment recommended will depend on the size and location of the tumor in the breast, the results of lab tests done on the cancer cells and the stage or extent of the disease. Your doctor usually considers your age and general health as well as your feelings about the treatment options.

Breast cancer treatments are local or systemic.

  • Local treatments are used to remove, destroy, or control the cancer cells in a specific area, such as the breast. Surgery and radiation treatment are local treatments.
  • Systemic treatments are used to destroy or control cancer cells all over the body. Chemotherapy; hormone therapy such as tamoxifen; aromatase inhibitors such as Arimidex, Aromasin, Femara; and biologic therapies such as Herceptin are systemic treatments. A patient may have just one form of treatment or a combination, depending on her needs.


What Happens After Treatment?

Following local breast cancer treatment, your doctors will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with the surgeon, may advise the use of tamoxifen or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

How Can I Protect Myself From Breast Cancer?

Follow these three steps for early breast cancer detection:

  1. Annual screening mammography starting at age 40 or 50. Breast cancer experts don't agree when women need to begin getting mammograms. Ask your doctor.
  2. Women in high-risk categories should have screening mammograms every year and typically start at an earlier age. MRI or ultrasound screening can also be given in addition to mammograms. Discuss the best approach with your doctor.   
  3. Have your breast examined by a health care provider at least once every three years after age 20, and every year after age 40. Clinical breast exams can complement mammogram.


Choosing the Right Breast Cancer Treatment

The primary treatment for breast cancer is surgery to remove the cancer. There are three main types of surgery:

Breast cancer patients with early-stage cancer may opt for breast-conserving surgery -- either a lumpectomy -- removal only of the "lump" of tumor as well as the normal breast tissue closely surrounding the tumor, or partial mastectomy -- removal of the tumor and a larger portion of surrounding breast tissue. This is usually followed by radiation therapy.

If the cancer is advanced or if there is a high risk of recurrence, the surgeon may recommend a mastectomy, which is complete removal of the breast. The woman should also be informed about her options for breast reconstruction, which sometimes is done right after mastectomy.

At the time of surgery, most patients also have either axillary node dissection or sentinel node biopsy to see if breast cancer has spread to the lymph nodes. These procedures remove lymph nodes from the armpit to test them for cancer cells. Sentinel node biopsies have largely replaced axillary node dissection.

Surgery is often combined with additional treatments, known as adjuvant therapy, to destroy any remaining cancer cells. Sometimes, the additional treatment may be given before surgery (called neoadjuvant therapy) when the breast cancer has been found to have already spread widely. These methods of treatment include:

Treatment for breast cancer will depend on a woman's:

  • Personal preferences.
  • Overall health.
  • Stage of the breast cancer, including whether cancer has spread to the lymph nodes.
  • The type of cancer and whether the cancer is an aggressive type.
  • Whether she has gone through menopause.
  • Whether the cancer she has depends on female hormones to grow. If it is "sensitive" to the female hormones, then the cancer is called "estrogen-receptor positive" (ER positive). If not, it is ER negative. This can usually be determined by testing a tissue sample in the lab.
  • The presence of other markers suggestive of aggressive cancer behaviors, such as progesterone receptors and the HER2 oncogene.

Most doctors who treat cancer patients in the U.S. follow national guidelines set by the National Comprehensive Cancer Network (NCCN) or the American Society of Clinical Oncology (ASCO), which have helped improve patient care. Still, treatment will vary from one doctor to the next or from one hospital to the next, depending on the woman's needs and circumstances.

Breast Cancer Treatment With Chemotherapy

Chemotherapy refers to the use of anti-cancer drugs to kill breast cancer cells. The doctor who determines which drugs will be used, and in what dosage is known as an oncologist. Chemotherapy can be used for three major purposes:

  1. Adjuvant therapy: The goal is to prevent or postpone cancer from coming back after the initial surgery and radiation. Even when the cancer seems to be confined to the breast and lymph glands under the arm, there is a chance that cells may have already spread to other areas that cannot be seen. Chemotherapy is given to try and kill these cells.
  2. Neo-adjuvant therapy. Sometimes the cancer in the breast is so big that shrinking it first with chemotherapy may make it easier to do surgery.
  3. To treat metastatic disease. If the cancer shows up in parts of the body other than the breast and lymph glands under the arm, it is called metastatic disease. Chemotherapy can be one of the main ways to kill cancer cells that have spread to other parts of the body, and help women live longer with a good quality of life.When to start chemotherapy, what drugs to use, and what side effects to expect varies from woman to woman. Women should discuss this with their doctors.
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