Breast Cancer
A diagnosis of breast cancer is life changing. Understanding one very important point—no one dies of breast cancer in their breast—is a very important starting point in choosing your treatment plan. Women and men die of breast cancer when it has spread outside of the breast and settles in distant organs and fails to respond to chemotherapy or radiation. Becoming educated about your personal situation is of the utmost importance.
- What type of breast cancer do I have?
- What is the grade of the tumor? (How aggressive it looks under a microscope?)
- What is my receptor status (Prognostic indicators)? (ER, PR, Her-2-neu)
- What is the stage of the tumor?
- Has the tumor spread outside of my breast?
- What are my treatment surgical options?
- What is my risk of the cancer coming back with each treatment? (Recurrence)
- Can you check my Oncotype DX score?
- What is my risk of swelling in my arm? (Lymphedema)
- Do I need chemotherapy?
- Do I need radiation therapy?
- Am I a candidate for the shortened course of radiation therapy ( APBI- Accelerated Partial breast irradiation) ?
- What can I do to decrease the risk of my cancer returning?
- Do I have the breast cancer gene?
- AM I a candidate for clinical trials?
- Should I get a second opinion?
- What are the Current Treatment Options for Breast Cancer?
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Learning You Have Breast Cancer
You wake one morning and find a lump in your breast or you go for a screening mammogram and get recalled for additional views.
Welcome to the roller coaster of breast disease. However, this process need not be frightening, as you are in control and you determine where you are going. What you need now is information.
Where do you begin this daunting task?
The most important thing to do is to get the answers to all of your questions. A mass in your breast or an abnormality on your mammogram will require further evaluation. An ultrasound is often required to further characterize a mass as solid (requiring biopsy) or cystic (which may or may not require aspiration).
There are also microscopic findings on mammograms called calcifications that may require spot magnification views. Depending upon the findings of your radiologic studies, you may be referred to a surgeon or radiologist for a biopsy.
Most procedures to biopsy the breast can be performed in an outpatient setting, which will allow you to have the procedure performed more quickly. Oftentimes, an ultrasound or mammogram is used to guide your surgeon to the abnormal area of your breast. If the lump in your breast is not apparent on any studies, it still needs to be evaluated and likely require a biopsy to determine whether or not it is cancerous. Remember, 20 percent of all cancers are not seen on mammograms or ultrasounds; therefore, palpable masses with negative X-ray studies need to be thoroughly evaluated.
The bottom line with an abnormal mammogram or ultrasound, or a palpable mass is that a tissue biopsy is the gold standard to determine whether the mass is benign (not cancer) or malignant (cancer). If your questions are not adequately answered, get a second opinion.
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Your Pathology Report
Now that I have had my breast biopsy what does the pathology mean?
Benign – A category of breast lesions that do not need to be removed and do not increase a woman’s risk of developing breast cancer. Lesions that fall into this category are fibroadenomas, papillomas, fibrous mastopathy, sclerosing adenosis, PASH (pseudoangiomatous stromal hyperplasia) and various other noncancerous growths.
Atypical or high-risk lesions – A breast lesion that is not cancer, but requires surgical removal due to an association with breast cancer. Having one of these lesions increases a woman’s chances of developing breast cancer, and therefore is considered a risk factor. The tissue that is atypical can turn into cancer if certain things, such as estrogen, influence it. Lesions that fall into this category include, ADH (atypical ductal hyperplasia), LCIS (lobular carcinoma in situ), FEA (flat epithelial atypia), atypical papillary lesions, radial scars and phyllodes tumors.
Lobular carcinoma in situ (LCIS) – Occurs when cells grow faster than normal in the lobules of the breast. This is not cancer, although the word “carcinoma” is in the name. It is more appropriately called lobular neoplasia or lobular newgrowth. It is like atypia, in that when it is found on a biopsy, it increases the risk of the person developing breast cancer in the future.
Ductal carcinoma in situ (DCIS) – The very earliest stage of breast cancer where the cancer cells are confined to the ducts of the breast. The grade of the DCIS (how fast the cells divide) is extremely important when determining the treatment. The Van Nuys Prognostic Index may be used to help your doctors determine the best treatment for your DCIS.
Invasive breast cancer – The disorderly growth of cells when left untreated can spread outside of the breast to other organs of the body. The cells from which the cancer originates name it. It is referred to as invasive ductal carcinoma when it originates in the ducts and invasive lobular carcinoma when it begins in the lobules.
How to Read Your Initial Pathology Report
Your initial pathology report will contain important information, but not all of the information that you will need. The initial report will tell you the type of cancer.
The Basic Types of Cancer
Ductal carcinoma in situ – Cancer confined to the ductal structure that has not invaded the surrounding breast tissue
Invasive ductal carcinoma – Cancers originating in the ducts
Invasive lobular carcinoma – Cancers originating in the lobules
The Grade of the Tumor
The grade of the tumor is determined by how aggressive it appears under the microscope
Grade I – Low grade or slow dividing cells
Grade II – Intermediate grade moderate cell division
Grade III – High grade or rapidly dividing cells
- ER (Estrogen receptors) determine the tumors response to estrogen stimulation
- PR (Progesterone receptors)
- Her 2 neu
- Ki67
- s-phase
Your Final Pathology Report
In addition to the information on the initial report, the final report will contain information about the pathologic stage of the cancer:
- Stage I to IV
- T – For the tumor size
- N – Nodal status (whether or not the breast cancer cells have spread to the lymph nodes)
- M – Will likely be reported as “Mx” unless the pathologist has knowledge that the tumor was not identified elsewhere in the body; then it will be reported as “M0.” “M1” means that the cancer has spread to a part of the body away from the breast and lymph nodes under the arm.
- Margin status – Tells you how far the tumor was from the edge of the specimen (i.e., the tissue surgically removed)
We encourage you to visit www.breastcancer.org and type in your pathology to obtain an understanding of your personal pathology report.
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Staging
The initial reaction to being diagnosed with breast cancer is one filled with fear — fear of dying, fear of losing your hair, fear of losing your breasts and the fear that you have lost control of your life. Knowledge is how you release fear and regain your power.
Once your cancer has been proven by a biopsy, you may go through a series of tests that are meant to define the extent of the breast cancer and help to tailor your treatment plan. The initial tests are called a “metastatic survey” and are intended to prove that the cancer is only in your breast and nowhere else in your body. This process is important in allowing you to let one of the “black clouds” that hang over you to float away once it is determined that the tumor has not spread beyond your breast.
Your doctors will determine which of the following tests you will receive. If one or more are not ordered for you, that may be due to information about your tumor that your doctor is using to specialize your treatment plan. He or she may not feel a particular test is necessary. (Non-invasive cancers do not require many tests before surgery, where some invasive cancers require many tests). Do not be afraid to ask your doctor specific questions about your diagnosis or treatment plan. If your doctor is unwilling to answer your questions, then you may want to find a physician team that is willing to partner with you.
Bone scan – A radioactive tracer is injected into your body and allowed to circulate for several hours. The whole body is then imaged and the radiologist interprets the scans. Areas of previous trauma to the bones, arthritis and degenerative changes are often found, so do not panic if you see black spots in the films. The kidneys also light up on the scan. Additional plain X-ray films or an MRI may be needed to determine the cause of the tracer uptake.
Chest X-ray – CXR is a two view regular X-ray of your chest cavity looking for lung nodules and abnormal shadows in your chest. If something is not normal in the study, often times a CT (computerized axial tomography) scan of the chest is required.
Liver function tests – A blood test that is a screening study for abnormalities of the liver. If the liver functions are elevated, a CT scan of the abdomen may be indicated.
PET scan – Positron emission tomography uses glucose (sugar) that is tagged or so called “labeled” with a radioactive substance to identify areas of the body that have a love (or affinity) for glucose. Since cancers are fast dividing cells, they tend to take up glucose very rapidly and therefore, this test can potentially identify regions of the body that have fast dividing cells. A positive finding on this type of scan may prompt a further study.
CT scan – Computerized axial tomography is a study that is performed with or without an injection of contrast (be certain to tell the technologist if you are allergic to iodine or shell fish). It evaluates the body for areas of abnormal growth and compares the normal tissue to what may appear abnormal.
PET–CT – A PET-CT scan is the combination scan of the PET and the CT that utilizes the best of both imaging techniques and allows specific organ systems to be viewed with more precision then either technology alone.
Breast MRI – Magnetic resonance imaging uses powerful magnetic fields to create images that allow for the evaluation of the breasts and to look for the extent of the cancer and for second cancers in the same breast and abnormal areas in the other breast. There are many arguments for and against the routine use if breast MRI in the pre-op evaluation of breast cancer patients.
MRI of specific body regions – An MRI may be ordered of the spine, hip, liver, etc. to determine if a finding on another study is real or represents a normal finding.
The scans that we use to look for disease outside of the breast are highly sensitive and sometimes pick up findings that are not cancer, but normal variations found in the body. Our goal is not to create more tests and more fear, but to make certain that if cancer has spread outside of the breast at diagnosis, that we are aware of its presence and treat it appropriately.
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AJCC Staging
The American Joint Committee on Cancer (AJCC) staging system provides a strategy for grouping patients with respect to prognosis. Therapeutic decisions are formulated in part according to staging categories, but primarily according to lymph node status, estrogen- and progesterone-receptor levels in the tumor tissue, menopausal status and the general health of the patient.
The AJCC has designated staging by TNM classification.
TNM definitions
Primary tumor (T):
- TX: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- Tis: Carcinoma in situ, intraductal carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with no associated tumor (Note: Paget’s disease associated with a tumor is classified according to the size of the tumor)
- T1: Tumor 2.0 cm or less in greatest dimension
- T1mic: Microinvasion 0.1 cm or less in greatest dimension
- T1a: Tumor more than 0.1, but not more than 0.5 cm in greatest dimension
- T1b: Tumor more than 0.5 cm, but not more than 1.0 cm in greatest dimension
- T1c: Tumor more than 1.0 cm, but not more than 2.0 cm in greatest dimension
- T2: Tumor more than 2.0 cm, but not more than 5.0 cm in greatest dimension
- T3: Tumor more than 5.0 cm in greatest dimension
- T4: Tumor of any size with direct extension to the chest wall or skin (Note: Chest wall includes ribs, intercostal muscles and serratus anterior muscle, but not pectoral muscle)
- T4a: Extension to chest wall
- T4b: Edema (including peau d’orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast
- T4c: Both T4a and T4b
- T4d: Inflammatory carcinoma (Note: Inflammatory carcinoma is a clinicopathologic entity characterized by diffuse brawny induration of the skin of the breast with an erysipeloid edge, usually without an underlying palpable mass. Radiologically, there may be a detectable mass and characteristic thickening of the skin over the breast. This clinical presentation is due to tumor embolization of dermal lymphatics with engorgement of superficial capillaries)
Regional lymph nodes (N):
- NX: Regional lymph nodes cannot be assessed (e.g., previously removed)
- N0: No regional lymph node metastasis
- N1: Metastasis to movable ipsilateral axillary lymph node(s)
- N2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures
- N3: Metastasis to ipsilateral internal mammary lymph node(s)
Pathologic classification (pN):
- pNX: Regional lymph nodes cannot be assessed (not removed for pathologic study or previously removed)
- pN0: No regional lymph node metastasis
- pN1: Metastasis to movable ipsilateral axillary lymph node(s)
- pN1a: Only micrometastasis (none larger than 0.2 cm)
- pN1b: Metastasis to lymph node(s), any larger than 0.2 cm
- pN1bi: Metastasis in 1 to 3 lymph nodes, any more than 0.2 cm and all less than 2.0 cm in greatest dimension
- pN1bii: Metastasis to 4 or more lymph nodes, any more than 0.2 cm and all less than 2.0 cm in greatest dimension
- pN1biii: Extension of tumor beyond the capsule of a lymph node; metastasis less than 2.0 cm in greatest dimension
- pN1biv: Metastasis to a lymph node 2.0 cm or more in greatest dimension
- pN2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures
- pN3: Metastasis to ipsilateral internal mammary lymph node(s)
Distant metastasis (M):
- MX: Presence of distant metastasis cannot be assessed
- M0: No distant metastasis
- M1: Distant metastasis present (includes metastasis to ipsilateral supraclavicular lymph nodes)
AJCC stage groupings:
Stage 0
- Tis, N0, M0
Stage I
- T1 (includes T1mic), N0, M0
Stage IIA
- T0, N1, M0 T1 (includes T1mic), N1 (the prognosis of patients with pN1a disease is similar to that of patients with pN0 disease), M0 T2, N0, M0
Stage IIB
- T2, N1, M0
- T3, N0, M0
Stage IIIA
- T0, N2, M0 T1 (includes T1mic), N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0
Stage IIIB
- T4, Any N, M0
- Any T, N3, M0
Stage IV
- Any T, Any N, M1
Clinical and Pathological Staging
Clinical Stage
The clinical stage of you tumor is often written on your medical record or is told to you by your surgeon as your “working” stage. In your medical record, it is denoted as a small “c” in front of the T, N and M that is used to describe your cancer. It is based upon the “clinical” appearance or what the doctor can tell by looking at your tests and using your physical exam as an indicator of your tumors stage. It will be updated as more information is obtained and your surgery or chemotherapy is completed.
For example cT1b, cN0, cM0 would be a clinical stage I breast cancer where the tumor was between 0.5 cm and 1.0 cm based upon ultrasound or physical exam and there were no lymph nodes palpable during the clinical breast exam and there is no suspected spread outside of the breast.
Pathological Stage
The pathological stage of the breast cancer is determined after the definitive breast cancer surgery is performed and we have the actual “pathology” reports to determine size, whether or not the lymph nodes have tumor and so on.
For example, if the above cancer was actually 1.2 cm in maximum diameter and the lymph nodes were negative for metastatic cancer cells, then the pathologic stage would be pT1c, pNo, cM0 of Stage I breast cancer.
This may all seem very confusing, but your doctor can help you to understand what your stage means.
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Sentinel Lymph Node Biopsy
Axillary lymph node evaluation has been the standard of care in breast cancer treatment. This procedure involves the removal of two levels of lymph nodes from the axilla (armpit) to determine if the cancer has spread locally. This is considered part of the staging of the breast cancer and is routinely done at the time of the definitive breast cancer surgery.
One of the debilitating side effects of axillary dissection has been lymphedema (arm swelling). This occurs in approximately 8 to 12 percent of patients. The arm may also become numb above the elbow at the level of the triceps muscle. You must protect your arm from cuts and scrapes for the rest of your life to prevent lymphangitis (an infection in the lymphatics of the arm).
In an attempt to better diagnose lymph node metastasis and decrease complications associated with axillary dissection, a method of lymph node mapping adopted from melanoma treatment has been used to identify the sentinel (the first line of defense) lymph node. This lymph node can be evaluated for microscopic metastasis through various procedures from a frozen section done in the operating room to high tech evaluation called cytokeratin staining. It generally takes 7 days to receive the results and is far more sensitive than the naked eye of the pathologist. (It is unclear what the implication of cytokeratin positive cells in the sentinel lymph node means; therefore, many centers have abandoned this as part of their standard practice).
We know that women previously thought to be node negative; and therefore, have local disease, have died of distant metastasis. This may be related to our previous inability to find these microscopic metastatic deposits and treat them aggressively with chemotherapy.
The absolute answers to these questions still have not been completely resolved.
Sentinel lymph node identification is indicated in nearly all breast cancers and is appropriate in both lumpectomy and mastectomy patients. Parameters may vary from surgeon to surgeon and will be based upon your individual tumor characteristics. The procedure to identify the node starts with an injection of radioactive tracer called technetium sulphur colloid. It may be injected the day before surgery, the morning of surgery or as we do it in our practice in the operating room when you are asleep. It must remain in the breast for at least 8 to 12 minutes but can remain for 24 hours.
At the time of surgery, after you are asleep, a vital blue dye may be injected around the tumor bed. These two tracers act as guides that allow us to identify the sentinel lymph node (first line of spread) in >90 percent of patients. When a sentinel lymph node is found at surgery, a frozen section (quick diagnoses) is performed. Once the sentinel node is identified, your surgeon will feel for other lymph nodes in your armpit that may have tumor in them. Lymph nodes filled completely with cancer cells may not have the ability to pick up the radioactive tracer and blue dye; therefore, this is also an important part of the process.
If the frozen section reveals spread of cancer cells to the lymph node, additional lymph nodes (level I and II axillary node dissection) are removed. If the frozen section is negative for spread of the cancer, then no further lymph node surgery is performed at that time. At your postoperative visit, you will discuss your final pathology, which will include the results of your margins of tumor resection and the H & E staining and cytokeratin staining (high tech evaluation for spread) for tiny areas of tumor spread.
If the cytokeratin stains are positive and a micro-metastasis >.2 mm is found, you may need to go back to the operating room for more lymph nodes to be removed (the completion of level I and II axillary node dissection) to complete your staging. The need for further surgery will be discussed with your surgeon and medical oncologist
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Frequently Asked Questions
1. If you identify a sentinel lymph node, does that mean that the cancer has spread?
NO. Finding a sentinel lymph node only means that we are able to find a node or nodes that has taken up the tracer or blue dye. It only identifies the lymph node that is at the highest risk to have metastatic cancer in it.
2. Is the sentinel lymph node identification full proof?
NO. We believe that it is approximately 98 percent accurate in finding the first line of cancer spread. That means we could potentially miss 1 to 2 percent of cancer metastasis.
3. Can there be more than one sentinel lymph node?
YES. You can have several nodes show up with radioactive tracer. Usually only one is blue. On average, 2 or 3 nodes are removed.
4. Can I have an axillary node dissection if I want one?
YES. Even if there is no evidence of spread in the sentinel lymph node, you are entitled to have levels I and II removed. It is still considered the standard of care.
5. What happens if you can’t find a sentinel node or if more than one lights up?
It is the surgeon’s judgment that determines if a node dissection needs to be completed. When in doubt, it is still the safest course and the surgeon should remove level I and II lymph nodes.
6. Why wouldn’t a sentinel lymph node show up?
Some tumors take a different route out of the breast and do not drain via the axillary lymphatics and therefore cannot be identified. Not finding a sentinel lymph node may also help the oncologist to determine the need for chemotherapy. Lymph nodes that are replaced completely with tumor may not take up the tracer.
7. What happens to the radio-labeled tracer and the blue dye?
It is excreted in the urine and therefore you will see blue urine for 24 to 48 hours after surgery. Your skin may also have a blue discoloration on the breast and systemically.
8. Do I have to spend the night in the hospital?
If you require an axillary node dissection, you will have a drain and will be kept overnight. If your node(s) are negative, you should be able to go home the same day.
Allergic reactions to the Isosulfan BLUE
- The incidence of allergic reactions in our series was 2.0 percent.
- Severe life threatening reactions to the blue dye have been reported.
- Anaphylaxis and “blue hives” after injection with isosulfan blue. Patients with anaphylaxis experienced cardiovascular collapse, erythema, perioral edema, urticaria and uvular edema.
Axillary Node Dissection
Axillary node dissection refers to the staging procedure performed in conjunction with lumpectomy for breast conservation or mastectomy. The procedure involves an axillary incision below the hairline when performed with a lumpectomy and is performed through the mastectomy incision with removal of the breast.
Removal of level I and II lymph nodes includes the tissue between the axillary portion of the breast and the area above the axillary vein underlying the pectoral muscles. The axillary nodes (level III nodes) lying above the pectoral major muscle are preserved to decrease the incidence of arm swelling (lymphedema). It may also remove a small nerve in the process resulting in numbness to the posterior aspect of the arm. Determining whether the lymph nodes are involved with the tumor will stage the cancer to determine if chemotherapy will be needed.
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Lumpectomy
This procedure removes the tumor plus a wedge of normal tissue surrounding the cancer. Occasionally, the skin and the lining of the chest muscle below the tumor will need to be removed to obtain clear margins. A margin of normal tissue must be removed to ensure the tumor has been completely removed. (A 5 mm margin of normal tissue is optimal, but a 2 mm margin can decrease the risk of local recurrence after radiation therapy.) It is followed by approximately six weeks of radiation therapy.
Advantages – If a woman is large breasted, most of the breast is preserved. There is little possibility of loss of muscle strength or arm swelling.
Disadvantages – If a woman has small or medium-sized breasts, the procedure may noticeably change the breast’s shape. There is a possibility of arm swelling if an axillary lymph node dissection is performed.
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Radiation Therapy
Radiation therapy as a primary treatment is an excellent treatment choice for women who have early stage breast cancer. This procedure allows a woman to keep her breast and involves lumpectomy followed by radiation (X-ray) treatment.
The treatment consists of high-energy rays or particles that destroy cancer cells (fast dividing cells). Radiation therapy may be used to kill any cancer cells that remain in the breast, chest wall or underarm area after breast-conserving surgery. Radiation may also be needed after mastectomy in patients with either a cancer larger than 5 cm in size, or when cancer is found in more than three of the lymph nodes.
External beam radiation
This is the most common type of radiation therapy for women with breast cancer. The radiation is focused from a machine outside the body on the area affected by the cancer.
Accelerated breast irradiation
The standard radiation approach of five days a week over many weeks can be inconvenient for many women. Some doctors are now using other schedules, such as giving slightly larger daily doses over only three weeks, which seems to work about as well. Giving radiation in larger doses using fewer treatments is known as hypofractionated radiation therapy. Newer approaches now being studied give radiation over an even shorter period of time. In one approach, larger doses of radiation are given each day, but the course of radiation is shortened to only five days.
Accelerated Partial Breast Irradiation. (Brachytherapy)
In another approach, known as intraoperative radiation therapy (IORT), a single large dose of radiation is given in the operating room right after lumpectomy (before the breast incision is closed).
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Whole Breast XRT (Radiation Therapy)
Once a biopsy has been done and breast cancer has been diagnosed, radiation treatment usually involves the following steps:
- Surgery to evaluate underarm lymph nodes to see if the cancer has spread beyond the breast, i.e. sentinel lymph node biopsy or axillary lymph node dissection
- External radiation therapy to the breast and the surrounding area (involving approximately five weeks of treatment)
- “Boost” radiation therapy to the biopsy site, which is usually marked with surgical clips to mark the tumor bed (one additional week of radiation therapy)
For external radiation therapy, a machine beams X-rays to the breast and possibly the underarm lymph nodes. The usual schedule for radiation therapy is five days a week for about 5 to 7 weeks. In some instances, a “boost” or concentrated dose of radiation may be given to the area where the cancer was located. This can be done with an electron beam. Less frequently used is a boost done internally with an implant of radioactive materials.
If you are having radiation therapy as primary treatment for early stage breast cancer, a qualified, board certified radiation therapist who is experienced in this form of treatment should do it.
Advantages – The breast is not removed. Lumpectomy with radiation therapy as a primary treatment for breast cancer appears to be as effective as mastectomy for treating early stage breast cancer. Because this is a new treatment procedure, researchers are continuing to collect information on long-term results. Usually there is not much deformity of surrounding tissues. The skin usually regains a normal appearance.
Disadvantages – A full course of treatment requires short daily visits to the hospital as an outpatient for approximately five weeks. Treatment may produce a skin reaction like sunburn, and may cause tiredness. Itching or peeling of the skin may also occur. Radiation therapy can sometimes cause a temporary decrease in white blood cell count, which may increase the risk of infection. You maintain your breast and, therefore, have a variable risk of local recurrence, which would necessitate mastectomy should cancer return. Post-mastectomy reconstruction options are limited after radiation therapy to the breast.
What is IMRT?
Intensity Modulated Radiation Therapy is a radiation delivery technique. It allows the radiation oncologist to decrease the amount of harmful radiation to normal tissues. The anterior border of the heart and the left lung were particularly vulnerable to radiation exposure. This new technique can spare the normal tissues while adequately treating the breast.
Left sided breast cancers are the ones that will benefit most from this form of radiation therapy.
Ask your radiation oncologist if IMRT would be correct for you.
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APBI (Accelerated Partial Breast Irradiation)
What is APBI?
In the past there have been several methods of radiation therapy delivery to treat breast cancer. Most involve treatment of the entire breast as well as a boost to the tumor bed to decrease the risk of local recurrence. Small catheters were inserted into the breast to deliver the boost to the tumor bed.
These catheters had several problems with cosmesis and patient tolerance. At the present time, we are revisiting the use of partial breast irradiation for the treatment of small stage I breast carcinomas.
This treatment involves the use of HDR (high dose radiation) to treat the tumor bed in women whose cancers have a low risk of local recurrence. Brachytherapy treatment lasts one week as opposed to six weeks for convention external beam radiation.
A catheter is inserted either with ultrasound guidance in an outpatient setting or thorough an open procedure in the operating room. Once the position is confirmed by CT scan (called simulation) images the treatment is given twice a day for a week. The Radiation Oncologist in can easily remove the catheter.
Am I a candidate for this procedure?
Clearly you must discuss your particular case with your care management team to determine if you are eligible for this form of radiation.
General accepted treatment criteria:
- Age >55
- Tumor size <2 cm
- Lymph node status negative
- Breast size (varies with tumor size)
- ER+, PR+ Her 2 – tumors
- Clinical trial criteria vary
- Infiltrating lobular cancers are excluded
- Extensive DCIS are excluded
- Lympho-vascular invasion excluded
Ask your surgeon and or radiation oncologist if you are a candidate.
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Mastectomy
Mastectomy is the medical term for surgical removal of the breast. It refers to a number of different operations, ranging from those that remove the breast, chest muscles and underarm lymph nodes, to those that remove only the breast lump.
The different types of breast surgery are described below. Based on the size and location of the lump, your doctor will recommend the type of surgery that offers you the best chance of successful treatment.
Most medical and surgical procedures carry some risk. The risks are categorized small or serious, frequent or rare. Because there is such a wide range of potential risks and benefits from various treatments for the different stages and kinds of breast cancer, you should discuss with your doctor the particular benefits and risks of treatment methods suitable for you.
Modified Radical Mastectomy or Total Mastectomy with Axillary Node Dissection
This procedure removes the breast, the underarm lymph nodes and the lining over the chest muscles. It is also called “total mastectomy with axillary (or underarm) dissection.” Today, it is the most common treatment of early stage breast cancer where lymph node involvement has been proven.
Advantages – Keeps the chest muscle and the muscle strength of the arm. Swelling is less likely, and when it occurs, it is milder than the swelling that can occur after a radical mastectomy. It leaves a better appearance than the radical mastectomy. Survival rates are the same as for the radical mastectomy when cancer is treated in early stages. Breast reconstruction is easier and can be planned before surgery.
Disadvantages – The breast is removed. In some cases, there may be swelling of the arm because of the removal of the lymph nodes (8 to 10 percent risk of lymph edema).
Total or Simple Mastectomy
This type of surgery removes only the breast. Ideally, a few of the underarm lymph nodes closest to the breast are removed to assure complete removal of the axillary tail of the breast. This is most often used to treat noninvasive breast cancers or in prophylactic mastectomies.
Advantages – Most or all of the underarm lymph nodes remain, so the risk of swelling of the arm is greatly reduced. Breast reconstruction is easier.
Disadvantages – The breast is removed. If cancer has spread to the underarm lymph nodes, it may remain undiscovered.
Skin Sparing Mastectomy
The mastectomy is performed through a small keyhole using the nipple/areola complex as the only skin that is removed. It allows for excellent cosmetic results from reconstruction and does not increase the risk of local recurrence, as long as the skin is not involved by tumor.
Advantages – Cosmetic results are superior to a standard mastectomy scar.
Disadvantages – The skin flap may lose adequate blood flow to remain alive.
Nipple Sparing Mastectomy
This procedure essentially removes the breast tissue and leaves the skin and nipple complex in place. It may be ideal for patients undergoing prophylactic surgery and women with cancers that are located away from the nipple complex.
Advantages – Cosmetically, in the appropriate patient, the results are superior to other reconstruction options.
Disadvantages – The remaining nipple complex will usually lose its sensation. There is a 20 percent chance that the nipple will lose a portion of its skin due to lack of blood flow. We currently have no means of imaging the remaining tissue of the nipple. The nipple is considered part of the breast, and therefore there is a slightly higher risk that a cancer could grow in the nipple complex.
Radical Mastectomy
This type of surgery removes the breast, the chest muscles, all of the underarm lymph nodes, and some additional fat and skin. It is also called a “Halsted Radical” (after the surgeon who developed the procedure). A radical mastectomy was the standard treatment for breast cancer for over 70 years and is now rarely used for treatment.
Advantages – Cancer can be completely removed if it has not spread beyond the breast or nearby tissue. Examination of the lymph nodes provides information that is important in planning future treatment.
Disadvantages – Removes the entire breast and chest muscles, and leaves a long scar and a hollow chest area. May also cause lymphedema (swelling of the arm), some loss of muscle power in the arm, restricted shoulder motion, and some numbness and discomfort. Breast reconstruction is also more difficult. This procedure is rarely done for treatment of primary breast cancer.
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Reconstruction Options
Breast Reconstruction
Modern surgical technology makes it possible to construct a natural-looking breast after mastectomy (breast removal) for cancer or other diseases. The procedure is commonly begun and sometimes completed immediately following mastectomy, so that the patient wakes with a new breast mound. Alternatively, reconstruction may begin years after mastectomy. There are several ways to reconstruct the breast, both with and without implants; your surgeon(s) should work together with you in deciding which is the best option for you. Breast reconstruction has no affect on the recurrence of cancer or other diseases, chemotherapy or radiation treatment.
Post mastectomy reconstruction can take place immediately after the mastectomy or may be delayed to a separate surgery. There are medical reasons to delay the reconstruction. If your breast surgeon recommends the delay, make certain that you understand why a delay is necessary.
As you consider mastectomy as a treatment option, you should be aware of breast reconstruction, a way to recreate the breast’s shape after a natural breast has been removed. This procedure is gaining in popularity, although many women are still unaware of it and many women are not offered reconstruction. Sixty-five percent of women in the United States are not offered reconstruction by their surgeon!
Today, almost any woman who has had a mastectomy can have her breast reconstructed. Successful reconstruction is no longer hampered by radiation-damaged, thin skin, tight skin or the absence of chest wall muscles. The options for immediate reconstruction after mastectomy will be discussed with your surgeon and again when you consult with a plastic and reconstructive surgeon.
Reconstruction is not for everyone and may not be right for you. After mastectomy, many women prefer to wear artificial breast forms or prostheses inside their surgical bras. Our consultants and survivors Heather and Diane at The Profile Shop evaluate our patients preoperatively. Both a general surgeon and a plastic surgeon may help you decide whether to have breast reconstruction.
You should discuss breast reconstruction before your surgery because the position of the incision may affect the reconstruction procedure. A procedure called a skin-sparing mastectomy has been able to greatly enhance the final reconstruction results and should also be discussed with your surgeon prior to the operation.
Having breast reconstruction at the time of your cancer surgery can lead to better cosmetic results, decreased risks from additional anesthesia and added psychological benefits to you. All of these benefits can result from immediate reconstruction, without compromising the curative aspects of your cancer operation.
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Implants
Implant Reconstruction
Following skin sparring mastectomy, breast reconstruction often begins during the same surgical operation. One form of reconstruction uses breast implants to reconstruct the breast mound. If there is adequate skin after the mastectomy, the implants can be inserted immediately. If there is not enough skin to create a breast of the desired size, a temporary tissue expander can be placed to stretch the skin over a few weeks to months. The implants are placed behind the muscle to recreate the breast mound. The surgery is well tolerated and adds only 1 to 2 hours of additional surgical time. If radiation therapy is anticipated, reconstruction may be delayed to allow for treatment. The decision to use silicone of saline (salt water) will be made with your reconstructive surgeon.
Immediate Implant Placement
Your breast surgeon and reconstructive surgeon, will determine if you are a candidate for placement of permanent implants at the time of your mastectomy.
Several factors determine whether or not this is possible:
- Type of you cancer
- Size of your native breast
- Looseness of you skin
- Desired size of you reconstructed breast
- Need for radiation therapy
Tissue Expanders
For many women, tissue expanders are required to stretch the skin to achieve the desired cosmetic results after mastectomy. When there is a discrepancy in size of the breasts, radiation therapy is indicated or a larger breast mound post mastectomy is desired, then expanders may be required.
Several factors determine whether or not this is possible:
- Small native breasts
- Desire for larger reconstructed breasts
- Radiation therapy planned
- Delayed reconstruction
Nipple Areola Reconstruction
Nipple areola reconstruction is completed at a later stage regardless of the type of reconstruction that is chosen. The areola nipple complex surgery is an outpatient procedure and the final touch is tattooing of the areola complex.
Risks of Implant Reconstruction
- Skin necrosis
- Infection
- Hematoma/seroma
- Asymmetry
- Capsular contracture
- Implant extrusion
- Deflation
- Rupture
- Pain
- Delayed wound healing
Tissue Reconstruction
An alternative to implant reconstruction is the use of a muscle flap to recreate the breast.
To learn more about autologous tissue reconstruction, visit our colleagues’ website at The University of Pennsylvania.
Latissimus Flap – The latissimus muscle from the back can be used in conjunction with a small implant. The surgery is longer than implant alone, but is an excellent choice to reconstruct a previously radiated breast or chest wall.
TRAM Flap – The trans rectus abdominis myocutaneous (TRAM) flap uses the lower abdominal skin, muscle and fat to recreate the breast. The skin, fat and muscle are disconnected from the lower portion of the abdomen and then a tunnel is made under the upper abdomen and is attached to the chest where the breast previously resided. The flap remains attached to its original blood supply. This procedure adds 4 to 5 hours to the surgery and adds significant postoperative recovery time for the patient. Patients who smoke, have midline lower abdominal incisions, are morbidly obese or have other health issues may not be candidates for this reconstruction.
Free Flap Reconstruction – A free flap means that the tissue is dissected from where it was attached and the blood vessels are then reattached to the vessels in the axilla (armpit). The flaps can come from the latissimus muscle, the rectus muscle and also the gluteal muscle. Free flap reconstruction has an increased risk of the flap dying or becoming compromised due to the microscopic vascular connection and the surgery time will be longer than in implant reconstruction.
DIEP Flap – Subsequently, the deep inferior epigastric perforator (DIEP) flap was described. The DIEP flap uses the same skin island as the TRAM flap, but preserves all of the rectus muscle and anterior rectus fascia, potentially reducing the risk for abdominal wall weakness and subsequent hernia formation or lower abdominal bulge. The skin island in the DIEP flap is based on one or more perforating branches off the deep inferior epigastric artery and vein.
SIEA – More recently, the superficial inferior epigastric artery (SIEA) flap was described as the true abdominoplasty flap for breast reconstruction. It is based on the superficial inferior epigastric vessels, which arise from the common femoral vessels and course through the subcutaneous tissues. The harvest of this flap does not violate the anterior abdominal wall fascia or musculature and as a result, patients experience less post-operative pain, quicker recovery and no chance of hernia formation. Unfortunately, clinical experience has shown that the superficial inferior epigastric vessels are either absent or too small to adequately perfuse a free flap transfer of abdominal tissue in the majority of patients. These vessels are only adequate for use in approximately 20 to 30 percent of patients and are smaller than the deep inferior epigastric vessel system with less blood volume flow as a result.
Nipple areolar reconstruction is completed at a later stage regardless of the type of reconstruction that is chosen. The areolar nipple complex surgery is outpatient procedure and the final touch is tattooing of the areolar complex.
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Chemotherapy
No one has ever died of breast cancer in their breast! They die of breast cancer when it has spread beyond the breast, therefore chemotherapy plays a crucial role in breast cancer care as its target is the entire body, not just the breast.
In breast cancer treatment, chemotherapy refers to the use of various medicines to kill or halt the growth of rapidly multiplying cells.
Chemotherapy usually includes a combination of drugs, since this is more effective than a single drug given alone. Many combinations of drugs are used to treat breast cancer and your doctors will determine which combination of chemotherapy is appropriate for you.
Recent studies have shown that women with early stage breast cancer may benefit from adjuvant (additional) therapy following primary treatment (mastectomy or lumpectomy with radiation therapy). These studies indicate that many breast cancer patients whose underarm lymph nodes show no signs of cancer (known as node negative) may benefit from chemotherapy or hormonal therapy after primary treatment.
Prior to the initiation of your chemotherapy, your doctors may want a test to evaluate your heart function as some of the drugs can affect your heart ability to pump blood (using multigated acquisition, or MUGA, scan or echocardiography)
You may also be requested to have a catheter or infusaport placed to administer the drugs, which may be toxic to your arm veins and to allow for ease of blood drawn for testing.
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Adjuvant Chemotherapy
Adjuvant chemotherapy refers to the use of drugs to kill cancer cells that may be present in the body, but outside of the breast. It is given after surgery and the duration of treatment. Types of drugs selected and interval between treatments will be determined by several factors.
When breast cancer cells have spread to the lymph nodes under the arm, chemotherapy is offered to treat the cancer. They may be given through the vein or occasionally just by mouth. Factors such as age, underlying medical conditions and tumor biology are used to create your treatment plan.
The use of chemotherapy in node negative patients will be determined by your age at diagnosis, stage of the cancer, tumor markers, tumor biology and future risk of systemic recurrence. (These findings do not apply to women with pre-invasive or in-situ breast cancer).
For years, women whose underarm lymph nodes were free of cancer usually received no additional therapy because they have a relatively good chance of surviving the disease after primary treatment. However, scientists know that cancer may return in about 30 percent of these women. Adjuvant therapy can potentially prevent or delay the return of cancer.
The type of chemotherapy and duration of chemotherapy are determined by your health care team and there are many factors that they will take into consideration:
- Stage – size of the tumor, lymph node involvement, spread to other body regions
- Grade – aggressiveness of the tumor
- Prognostic indicators – whether your tumor expresses estrogen and progesterone sensitivity
- Her 2 neu over expression – A sign of aggressiveness of the tumor
Oncotype DX
Tumors that are referred to as estrogen receptor positive of ER+, that have no evidence of spread to the lymph nodes, can be evaluated by a genomic (genetic footprint) test that can help us determine what patients may benefit from chemotherapy.
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Neo-adjuvant Chemotherapy
The term neo-adjuvant means that the chemotherapy is being given before the surgical treatment of the breast cancer to shrink a tumor. This may be done to allow for breast preservation or if your doctors feel your surgery may positively impacted by shrinking your tumor.
Your surgeon will discuss the pros and cons of performing a sentinel lymph node biopsy prior to the initiation of your chemotherapy or may perform an ultrasound-guided fine needle biopsy of the lymph node.
Will I be able to continue working?
Yes. Most people are able to continue working while they are being treated with chemotherapy for their breast cancer. It may be possible to schedule your treatments later in the day or right before the weekend so they don’t interfere as much with your work schedule. You may have to adjust your work schedule while receiving chemotherapy, especially if you have side effects.
Is the chemotherapy working?
Chemotherapy given while the tumor is in place will cause the tumor to shrink. You may undergo repeat ultrasound or breast MRI in addition to clinical breast exams. Some people may think that their chemotherapy treatment is not working if they do not experience side effects, but this is not the case. If your tumor does not appear to be responding by shrinking, your doctors may decide to change drugs, or re-biopsy the tumor and send it for evaluation for chemotheraputic sensitivity. Alternatively, surgery may be indicated.
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Hormonal Therapy
Blocking the effects of estrogen on the body in women and men who have estrogen receptor positive breast cancer is one of the mainstays to treatment and prevention of systemic breast cancer. There are two classes of medications that we use routinely—SERMs (selective estrogen receptor modulators) and AIs (aromatase inhibitors).
The best-known SERM is Tamoxifen or Nolvadex®. Tamoxifen works against the effects of estrogen on these cells. It is often called an antiestrogen.
Tamoxifen (Nolvadex®) is a drug, taken by mouth, which blocks the activity of estrogen, a female hormone. Estrogen can stimulate the development of cancer cells in the breast. Tamoxifen is approved by the U.S. Food and Drug Administration (FDA) for the prevention of breast cancer and for the treatment of breast cancer, as well as other types of cancer.
Tamoxifen has been used for more than 30 years to treat breast cancer in women and men. Tamoxifen is given in early stage breast cancer for five years or until a patient is switched to an aromatase inhibitor. It is also used when the breast cancer has spread elsewhere in the body. Tamoxifen helps prevent the original breast cancer from returning and also helps prevent the development of new cancers in the other breast. As treatment for metastatic breast cancer, the drug slows or stops the growth of cancer.
Tamoxifen has been used for almost 10 years to reduce the risk of breast cancer in women who are at increased risk of developing breast cancer. Tamoxifen is also used to treat ductal carcinoma in situ (DCIS), a noninvasive condition that sometimes leads to invasive breast cancer.
Risks:
- Blood clots
- Strokes
- Uterine cancer
- Cataracts
- Symptoms of menopause, including hot flashes, vaginal discharge, irregular periods, headaches, fatigue, nausea, vaginal dryness, decrease in sexual interest
For more information visit The National Cancer Institute
Aromatase Inhibitors
Aromatase inhibitors are a class of anticancer drugs that are used to decrease estrogen production and suppress the growth of tumors that need estrogen to grow. They work by blocking an enzyme aromatase in the adrenal gland that produces estrogen from fat substrates (androgens).
This means that less estrogen is available to stimulate the growth of hormone-receptor-positive breast cancer cells.
Aromatase inhibitors can’t stop the ovaries from making estrogen, so aromatase inhibitors only work in post-menopausal women.
There are three aromatase inhibitors:
- Arimidex (chemical name: anastrozole)
- Aromasin (chemical name: exemestane)
- Femara (chemical name: letrozole)
Each is a pill, usually taken once a day.
Benefits of Aromatase Inhibitors
A number of studies have compared aromatase inhibitors with tamoxifen to see which type of medicine was more effective in treating early-stage, hormone-receptor-positive breast cancer in post-menopausal women. Based on the results, most doctors recommend that after initial treatment (surgery and possibly chemotherapy and radiation therapy):
- An aromatase inhibitor is the best hormonal therapy to start with. When treating early-stage, hormone-receptor-positive breast cancer, aromatase inhibitors have more benefits and fewer serious side effects than tamoxifen.
- Switching to an aromatase inhibitor after taking tamoxifen for 2 to 3 years (for a total of 5 years of hormonal therapy) offers more benefits than 5 years of tamoxifen.
- Taking an aromatase inhibitor for 5 years after taking tamoxifen for 5 years continues to reduce the risk of the cancer coming back, compared to no treatment after tamoxifen.
Side Effects of Aromatase Inhibitors
Aromatase inhibitors tend to cause fewer serious side effects than tamoxifen; however, side effects include:
- Cardiac problems
- Bone loss/osteoporosis
- Broken bones
- Joint stiffness
- Joint pain
If you and your doctor are considering an aromatase inhibitor as part of your treatment plan, you may want to ask your doctor about having a bone density test to see if a bone strengthening medicine might be necessary while you’re taking the aromatase inhibitor.
If you’re experiencing side effects from taking one aromatase inhibitor medicine, tell your doctor. You may be able to take a different medicine. Arimidex and Femara have similar chemical structures, while Aromasin has a different structure.
Ask your doctor if you have specific question regarding hormone therapy.
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Will I Lose My Hair?
Will chemotherapy make me lose my hair?
Of all the treatments for breast cancer, the loss of your hair is by far the most visible. Feeling good about how you look can be maintained through chemotherapy with the right guidance.
The goal of chemotherapy is to kill rapidly dividing cells, such as cancer cells. Unfortunately, your body hair falls into the category of rapidly dividing cells. The loss of your hair is simple a sign that the chemotherapy is working.
We are fortunate to have one of our breast cancer THRIVERS available in Bucks county to help you in this process. The Grand Salon and Spa in Buckingham is worth the drive and Patty will be there to guide you along the way. She too has walked the path of hair loss and skin changes and has created an environment in her salon that is warm, welcoming and nurturing for women on their cancer journey.
The Grand Salon and Spa
The Buckingham Green Center
4920 York Road
P.O. Box 296
Holicong, PA 18928
Phone: (215) 794-3702
Email: thegrandsalonspa@gmail.com
Be prepared to lose your hair by day 14 after your first treatment. A good offense is what you need. By following these few steps you can maintain your power and take control of your treatment instead of letting your treatment take control of you.
- Accept the fact that you will lose your hair temporarily.
- Plan to cut your hair short and get a wig cut to match your new short hairdo. The change in style just before you begin to wear you wig will keep people guessing.
- Buy a wig that works for you.
- Shave your head by day 14 or visit your hairdresser and let them do it for you. Do not delay this shave as you DO NOT want your hair to fall out in clumps and give the cancer your power.
- REMEMBER your true beauty is from within and there is no hair loss or surgery that will take that away.
