These pages have been developed to help you gather and understand the information needed to make decisions about your breast cancer treatment. The task is difficult not only because the subject is complex but also because this is a time of anxiety and stress. The purpose of these pages are to also provide a framework to make the process easier. It begins with an explanation of the nature of cancer in general and breast cancer in particular, then continues with a review of surgery, radiation, and chemotherapy. The main emphasis is on the decisions that must be made pertaining to the surgical phase of your treatment. This brief discussion of the major issues is meant to be foundational as you add to your understanding of this disease through your study and experience. The pages conclude with references to more detailed and comprehensive sources which are also available.
In order to discuss breast cancer and the treatment options available one must have a fundamental understanding of cancer. It is a disease that has more than 100 forms, can arise in any tissue in the body, and is essentially a disease of disordered cell growth. The cell is the basic unit of our bodies. The process of building a body begins with the conjugation of the sperm and the egg, leading to cellular proliferation and differentiation into bone, muscle, skin, nerves, etc. Each cell retains the genetic information to reproduce the entire organism but only expresses the characteristics needed to performs its function. The 30 trillion cells of the normal, healthy body live in a complex, interdependent community, regulating one another's proliferation. Indeed, normal cells reproduce only when instructed to do so by other cells in their vicinity. Such unceasing collaboration ensures that each tissue maintains a size and architecture appropriate to the body's needs.
This process is defined by our DNA which is copied every time the cell divides. Cellular division and DNA replication is going on constantly and is comprised of a series of complicated but remarkably reliable biochemical reactions. However, with millions and millions of divisions, mistakes are inevitable even in the most dependable system. Nearly all of these errors are inconsequential but because of the shear numbers involved they sometimes become significant and the cell loses it’s normal regulation and proceeds to divide and proliferate independent of the normal constraints. This process is going on constantly in each of us but most of these cells die because they are simply not viable or are destroyed by a competent immune system. Unfortunately some of these rogue cells are viable and in fact develop characteristics that make them quite virulent and they thrive. At this point they are malignant--cancerous. These cancer cells can invade surrounding tissues and disrupt the normal function of nearby cells leading to organ dysfunction and even spread to other sites and cause more widespread disease.
Because the cancer cells arise from all cell types in the body, they behave differently from one another and therefore respond to varied treatments. There is considerable variability even within the same kind of cancer. When the cancer cells metastasize (spread) to other organs they retain many of their original characteristics. It is a common misunderstanding to think that breast cancer which spreads to the bone is bone cancer or that colon cancer that spreads to the liver is liver cancer. This needs to be recognized as metastatic breast cancer in the bone or metastatic colon cancer in the liver. The differences are important because they help determine behavior of the tumor and the treatment.
There are many factors that increase the chance of a problem with the DNA that could lead to the development of the cancer cell. Many of them are random mistakes. Inherited genetic defects can make an individual more prone to these errors. Environmental factors such as toxic chemicals or radiation can damage the DNA. These factors can have an effect either alone or together. Some cancers have a clear association with certain of these causes, whereas most do not.
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Breast cancer is caused by genetic mutations in the cells that line the milk ducts or the cells that make up the milk producing lobule. The cancer begins because a problem arises in the DNA of the cell that causes it to lose the normal controls on growth. Although there is not a “cause” of breast cancer, several risk factors have been identified:
It is interesting to note that if a woman has one or more of these risk factors she would have more menstrual cycles than someone who doesn’t. This association may occur because each menstrual cycle causes proliferation of the ductal and lobular elements of the breast creating the potential for more genetic mistakes. One factor that is emphasized in the media is the tendency of breast cancer to occur in families. The family history is only important for 5-10% of women with breast cancer. Most women with breast cancer have no women in their family who have breast cancer. This indicates most of the genetic errors that lead to breast cancer are spontaneous (occur in the breast tissue and not passed on to the children) and not heritable (error must be in the all the cells and therefore is passed on in the sperm or egg). Some heritable factors have been identified as associated with the development of breast cancer and certainly others will be found.
The treatment of breast cancer is multi-modal. This means that it usually involves surgery, radiation, and chemotherapy/hormonal therapy. Patients have options and must be informed enough to make decisions about their treatment. While this involvement in choosing therapy is a good thing, it can provoke anxiety because there is so much to learn in so little time. The following discussion will help you start the information gathering and decision making process.
In order to simplify a complicated subject, this discussion will review the treatment of breast cancer by breaking the subject into three parts.
Most of the discussion in this pamphlet will pertain to local control and staging because this is the primary role of surgery in the treatment of breast cancer. Systemic therapy is usually managed by the medical oncologist and so will not be discussed in as much detail.
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Local control involves treatment of the cancer within the breast. The goal is to reduce the chance of local recurrence (recurrent tumor in the affected breast) and preserve the breast if possible (and if desired by the patient). Studies have indicated that when the cancer is simply removed as a lumpectomy, the cancer has a 30-40% chance of recurring in that breast within five years. In most cases this is an unacceptably high recurrence rate. Additional therapy with radiation will reduce that local recurrence risk to an acceptable rate (7-8% in five years) that is nearly equal to a mastectomy.
Lumpectomy combined with radiation is referred to as breast conserving therapy. Researchers have compiled more than 20 years of carefully controlled clinical trials that indicate breast conservation is as effective as mastectomy in eradicating the cancer. Several criteria must be met to achieve successful breast conserving therapy:
When these criteria are met, breast conservation is a good option and in most cases will result in local recurrence rates and long term survival equal to mastectomy.
Radiation is considered an important part of breast conservation because without it the local recurrence rate is too high. Many people have preconceived notions about radiation because they know someone that received radiation to the brain, lungs, or abdomen and became quite ill. Breast radiation is carefully controlled and delivered to minimize exposure to nearby organs. It will not make you sick or make your hair fall out. It will cause a variable amount of a sunburn like reaction in the breast. It is also important to know that the breast will not be “normal” (just like it was before treatment) after the radiation. There will be a variable amount of pigment change in the skin, skin and breast thickening, increased firmness, and tenderness. Most women have a good to excellent cosmetic outcome with preservation of nipple sensation. Consultation with the radiation therapist can be arranged before you make your decision in order to answer any specific questions you may have.
Mastectomy is also an option for local control. Radical mastectomy is a disfiguring and disabling operation that is not done anymore. Now only the breast is removed leaving the chest muscles intact and functional. Some women choose this option because of particular characteristics of their cancer and sometimes because of personal reasons. This can be combined with immediate or delayed reconstruction to achieve an excellent cosmetic result. The surgical risks, pain, and length of recovery are essentially the same for mastectomy and lumpectomy.
The main decision facing women in the early part of breast cancer treatment is whether to pursue breast conservation or have the breast removed. The issue is local control and not systemic therapy. It is important to realize that this decision will not impact the choice to take chemotherapy or not. Radiation and chemotherapy (and hormonal therapy) have separate purposes and cannot be substituted one for the other.
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Staging is the process of categorizing an individual’s cancer in order to help determine optimal therapy and prognosis. Each type of cancer has a unique staging system that has been developed and accepted by cancer specialists throughout the country. The main elements of breast cancer staging are size of the tumor in the breast, involvement of axillary lymph nodes, and whether distant metastases are present. Statistical predictions of prognosis and treatment recommendations can then be made which are based on the Stage.
Evaluation of the axillary lymph nodes remains an important part of staging for breast cancer.
Physical exam, x-rays, and blood tests are not sufficiently accurate to determine whether tumor has spread to these lymph nodes. Therefore several of the lymph nodes need to be removed and examined under a microscope by the pathologist. In the past the operation involved removing a mass of fatty tissue under the arm that contain the lymph nodes. Then the pathologist picks through the tissue and finds a variable number of lymph nodes (5-20). Extensive removal of the axillary lymph nodes can result in swelling of the arm which is painful, disfiguring, and increased the vulnerability of the arm and hand to infection. The standard lymph node dissection causes lymphedema in 5-10% of patients and when it occurs it is nearly always controllable with physical therapy and massage techniques. Truly disabling lymph edema is very unusual.
Surgeons are now using a technique called sentinel lymph node biopsy that identifies the lymph node(s) most likely to contain the cancer cells if they have spread beyond the breast. A combination of radioactive tracer and blue dye are injected into the breast and then flow into the first draining lymph node. This can be identified and removed. The sentinel node technique is best suited to patients that have small tumors because only 5 to 15 percent of them have tumor in their lymph nodes. One disadvantage of the procedure is that if tumor is found in any of the sentinel lymph nodes the patient will need to return to the operating room on another day and have the standard axillary dissection. Patients with larger tumors should consider having the standard axillary dissection done at the time of the initial operation.
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On the day of your operation you will have a small amount (5 - 8 cc, which is approximately 1/8 - 1/4 ounce) of radioactive technetium sulfur colloid injected into the breast. This is usually done in the nuclear medicine department of the hospital. If the tumor is not palpable it may be done with ultrasound or x-ray guidance. The injection will be done with a needle smaller than those used to draw blood. You will then be taken to the operating room and undergo general anesthesia. After you are asleep the isosulfan blue dye may also be injected into the breast. The surgery will then proceed and the lymph nodes with increased radioactivity and/or blue dye will be identified using a sensitive Geiger counter and seeing blue dye in nodes.
The radioactive material to be injected is called Technetium-labeled sulfur colloid (Tc99). Technetium sulfur colloid is fully approved for use in humans. It is widely used for liver/spleen scans and other diagnostic tests. It is not a new or experimental drug. The dose of radioactivity you will receive from the injection is less than what you get in a single chest x-ray. When Technetium sulfur colloid is used for bone scans, the dose is 20 times what is used in this study. There is no danger to others around you from the small amount of radioactivity. Any radioactivity not removed in the tissue with surgery will disappear over 1-2 days. No precautions are needed and no one around you will receive any radiation dose. The blue dye is isosulfan blue. Isosulfan blue is fully approved for use in humans, and is also used in the detection of lymph nodes in melanoma (a kind of skin cancer). Allergic reactions to Technetium sulfur colloid and isosulfan blue dye are exceedingly rare and consist of a rash or some bronchoconstriction. Most of the blue dye will be removed with the surgery. Some of the blue dye will be excreted in the urine turning it a light blue or green color. Any remaining blue color in the skin or breast will disappear over several weeks.
The sentinel node biopsy procedure will allow us to gain the same information and remove fewer lymph nodes. This reduces the discomfort, risk of lymphedema, and numbness in the armpit. The drain tube is usually removed more quickly. There is a 1 - 3 percent risk of a false negative test. This means that the sentinel nodes did not have any tumor in them but there is actually tumor in some of the other nodes. This is approximately the same risk of obtaining a false negative result with the standard axillary dissection. The major drawback to the procedure is that if the pathologist determines that there is tumor in the sentinel node(s) when the studies are completed 2 - 3 days after the operation, then you may need to return to the OR for a complete axillary dissection.
Beyond axillary dissection, our ability to identify metastatic disease is very limited. If systemic metastases exist, they are only present in microscopic deposits that are too small to be identified by x-ray exams or MRI. Blood tests are still too insensitive to reliably detect metastases unless the tumor is widespread. Breakthroughs in the future will allow more accurate staging which will result in more effective treatment.
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Systemic therapy involves drugs that go throughout the entire body to kill (or slow the growth of) cancer cells that may have metastasized from the primary tumor in the breast. These treatments usually consist of chemotherapy and/or hormonal therapy. This is the medical oncologist’s specialty and therefore detailed discussion of the options will be deferred to the time when you meet with him/her.
It is important (and will be reiterated here and elsewhere) to understand that decisions about systemic therapy have no impact on decisions about local control and vice versa. Choosing breast conservation or mastectomy will not obviate the need for systemic therapy. Decisions about systemic therapy cannot be undertaken until adequate staging has occurred. As noted in the previous discussion about staging, it allows for statistical predictions about the possibility that the cancer cells have spread beyond the breast. Systemic therapy is intended to target these cells and reduce the risk of distant (and probably local) recurrence. The risks and benefits of the treatment must be carefully considered and then it must be decided whether the benefits are worth the risks. Generally the more advanced the stage the more likely the patient will benefit from the systemic therapy.
The preceding discussion is an overview of the treatment of breast cancer. It should be used as an introduction or as a guide to more detailed works. The following is a list of such sources:
Dr. Susan Love’s Breast Book, Susan Love, MD
This is probably the best and most comprehensive treatment of the subject for a lay person. However, it is a large book and somewhat intimidating.
Breast Cancer Journey, American Cancer Society
This book is not as comprehensive as Susan Love’s Book, but is complete in its discussion of the major topics.
A Woman’s Decision, Karen Berger & John Bostwick, MD
Nearly half of this book is devoted to breast reconstruction. Dr Bostwick is a well-known academic plastic surgery from Emory University and a pioneer in the field of breast reconstruction.
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The internet is a relatively new source of information that can be overwhelming. Most of the web sites are trying to sell something. One must be critical of any information received over the internet and carefully consider the source and their motives. Below are some sites that are reliable and can serve as links to other sites:
National Cancer Institute
Provides access to The National Library of Medicine and information on guidelines and experimental protocols through its PDQ service (this requires registration and a fee). This site is designed more for physicians but is available to patients.
OncoLink
This is an excellent site maintained by the University of Pennsylvania.
American Cancer Society
Good source for patient education and cancer statistics
National Alliance of Breast Cancer Organizations
A central resource for other organizations. This site provides many links to other resources on the internet.
Cancer Guide
This is a web page put together by a cancer survivor. Its stated purpose is to help the cancer patient research their own illness.
Living Beyond Breast Cancer
This organization was started by a medical oncologist who has also written a book by the same name. Her emphasis is on life after the treatments are completed.
Susan Love’s Web Page
NCCN-National Comprehensive Cancer Network
This is a network of the best Academic Cancer Centers in the country. NCCN has developed some authoritative guidelines for the treatment of many kinds of cancer. Their guidelines for breast cancer are comprehensive and probably the best available. They are quite technical, but if you want the best recomendations for treatment they are available through this organization.
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