Treatment

Breast Cancer & Treatment Options

Breast cancer is the most common type of cancer in American women. According to the American Cancer Society, in 2008 an estimated 182,460 women and almost 2,000 men will be diagnosed with invasive breast cancer.

Risk Factors

Most women who are diagnosed with breast cancer do not have any known risk factors, but some factors may increase the chance of developing this disease. Some of these risk factors include:

• Gender: main risk factor; while men can also develop breast cancer, it is much more common in women than men.
• Age: more than 75 percent of women diagnosed with breast cancer are over the age of 50.
• Family history: history of breast cancer in your mother, sister or daughter almost doubles a woman's risk.
• Personal history of breast cancer
• Race: although slightly more common in white women, African-American women are more likely to die of the disease. Asian, Hispanic and American Indian women have a lower risk of getting breast cancer.
• Early abnormal breast biopsy: certain types of abnormal biopsy results can be linked to a slightly higher risk of breast cancer.
• Menstrual cycles: early onset of menstruation (before age 12) or late menopause (after age 55) may be associated with a slightly increased risk of breast cancer.
• Hormone replacement therapy with estrogen and progesterone may slightly increase the risk of breast cancer. Estrogen alone does not seem to increase the risk.
• Breast feeding, especially if it lasts 1½ to 2 years, may slightly lower the risk.
• Alcohol: increased risk associated with women who average 2 to 5 drinks daily.
• Diet: being overweight (especially for women later in life and if the extra fat is in the waist area) have a higher risk.
• Exercise: regular exercise, possibly as little as 1 to 2½ hours of brisk walking per week can significantly reduce the risk.
• Prior radiation: women who have had previous radiation to their chest (i.e. Hodgkin's disease) are at increased risk for developing breast cancer.
• Genetic risk: 5 to 10 percent of breast cancers are linked to mutations in the BRCA1 or BRCA2 genes.

 

Diagnosis

Breast tumors are often, but not always, painless. Therefore it is important to have any breast or underarm lump checked. If you notice breast swelling, thickening of the skin, discoloration (including redness) of the breast or nipple discharge, you should be examined by your doctor or health care provider immediately. Many times abnormalities cannot be felt, but are seen only on mammogram or ultrasound. These changes may also need to be examined. Several methods can be used to determine if a lump or change in the breast is breast cancer. These may include:

• Fine Needle Aspiration (FNA) or tru-cut biopsy: Removing tissue or cells from the lump that can be felt, by inserting a small needle into the area. Usually performed in a surgeon's office.
• Stereotactic or core needle biopsy: a radiologist uses a needle under mammography or ultrasound targeting to pinpoint smaller areas that cannot be felt. This permits the removal of a small amount of tissue for diagnosis.
• Needle or wire localization: using mammography or ultrasound guidance, the radiologist places a thin wire into the breast directing the surgeon to the suspicious area in the breast. The surgeon then removes that area along with the wire in surgery.
• Excisional or incisional biopsy: your surgeon removes the lump that can be felt to see if you have cancer

 

Types of Breast Malignancies
Breast tissue is formed by ducts and lobules surrounded by fatty tissue so there are several different types of breast cancer depending on the area of the breast affected. The pathologist who looks at the cells under the microscope will determine the specific type of breast cancer from the tissue removed during the biopsy. Among them are:

• Non Invasive: Ductal carcinoma in situ (DCIS) refers to malignant cells confined within a duct. The risk of recurrence (the malignancy returning) is within the breast of origin. At the time of recurrence it may convert to an invasive cancer.
  Lobular carcinoma in situ (LCIS) refers to abnormal lobular cells confined to lobules. LCIS confers a risk for an invasive breast cancer that can occur in both breasts. It is not necessarily confined to the breast of origin.

• Invasive: When tumors break through the wall of the duct or lobule, they are called infiltrating or invasive ductal or lobular cancers.

• Inflammatory: Inflammatory breast cancer usually presents with specific skin changes and swelling and may involve the entire breast.

There are also different cell types, tumor size, grades and other features that the pathologist will use to describe your tumor. These characteristics are important in determining the most appropriate course of treatment for you.

Treatment

The main treatments for breast cancer are surgery, chemotherapy and radiation therapy. Depending on the location and stage of the cancer your doctor may recommend two or more of these types of treatments. They order in which they are administered may vary.           

Surgery

The initial treatment for most individuals with breast cancer is surgery: breast conserving surgery (removal of the tumor and a rim of surrounding breast tissue) or mastectomy (removal of the entire breast). In certain situations, chemotherapy can be given before surgery (neoadjuvant chemotherapy). This can cause large tumors to shrink small enough to allow women to have breast conserving surgery instead of mastectomy.

• Breast-Conserving Surgery :*( also called lumpectomy, partial mastectomy, segmental resection, quadrantectomy or tylectomy).  Your surgeon removes the tumor and a small amount of surrounding breast tissue.  Sometimes a second operation, called a re-excision is required if examination under the microscope finds tumor cells at or near the edge of the tissue that was removed.  During this surgery, your doctor may also remove one or several lymph nodes from under your arm (called a sentinel lymph node biopsy or an axillary dissection). If cancer is found in any of these lymph nodes, more nodes may be removed.
• Mastectomy: Depending on the stage of the disease, your surgeon may perform either:
  • Simple mastectomy, which is removal of the entire breast without removal of lymph nodes or muscle of the chest wall, or
  • Modified radical mastectomy which involves removal of the entire breast including one or several lymph nodes from under the arm (sentinel lymph node biopsy or axillary dissection).

*Breast-conserving surgery is appropriate for many patients so it is important to talk with your doctor to discuss the best procedure for you.           

Chemotherapy and/or Hormone Therapy

After surgery, chemotherapy and/or hormone therapy (drugs which have the effects of estrogen and progesterone) is often recommended to keep the cancer from returning. There are several different chemotherapeutic drugs, hormonal agents and combinations of these used to treat breast cancer. It is important to discuss this treatment with your medical oncologist.

Radiation Therapy

Radiation therapy plays a major role in the management of breast cancer at all stages. It is usually delivered after healing from breast conserving surgery (sometimes after mastectomy) and recovering from chemotherapy (when chemotherapy is indicated) has occurred. There are several methods by which the radiation therapy treatments can be given after breast-conserving surgery: external beam radiation therapy or partial breast irradiation.

External beam radiation therapy involves the accurate delivery of radiation to the entire breast through a series of painless, daily (Monday through Friday) outpatient treatments over five to seven weeks. Usually only the breast is treated, but sometimes the lymph nodes around the collarbone or the underarm are also included in the treatment field. The two main techniques for delivering external beam radiation are:

• 3-dimensional Conformal Therapy (3-D Conformal) refers to a method of treatment delivery that incorporates 3-dimensional computer planning and treatment systems to produce a high-dose area of radiation that conforms to the shape of the area to be treated. This technique allows the delivery of precise doses of radiation to the breast through multiple treatment fields while sparing surrounding tissues.
• Intensity Modulated Radiation Rherapy (IMRT) uses a sophisticated dose calculation to design and deliver precisely targeted radiation. This is accomplished by using computer controlled small radiation shields in a linear accelerator. Dozens of uniquely shaped radiation fields are delivered to the patient using various angles and approaches.

The difference between 3-D conformal radiation and IMRT is that IMRT can create high dose volumes that are concave in shape, sparing critical normal issues that are extremely close to and surrounded by the tumor. During each field of treatment, the dose delivered is being modulated or adjusted by the multi-leaf collimator (a device that consists of a number of “fingers” or “leaves” which project into the primary beam to create the required shape). However, in order to spare some areas, other areas will receive more radiation. It is the job of the radiation oncologist and the radiation physicist to critically evaluate the trade-offs between avoiding normal tissues and adjusting radiation doses to the tumor.

IMRT is useful in treating small, fairly stationary targets surrounded by a large volume of normal tissue and/or critical structures that are especially close to the targeted tumor. Types of tumors that may be treated with IMRT include brain, head & neck cancer, prostate, spinal cord or tumors very close to radiosensitive normal tissues, such as the optic nerve (e.g., pituitary or nasopharyngeal cancer). Many tumors are too large or too mobile to be treated with IMRT.

Internal Radiation (Brachytherapy) involves the temporary or permanent placement of a radioactive source either on or within body tissues or cavities. Also called internal radiation therapy or implant therapy, the process allows the delivery of a high dose of radiation to a small area while sparing the amount of surrounding normal tissue that is irradiated.

• Accelerated Partial Breast Irradiation or APBI, is a new alternative for some women who have breast conserving surgery is partial-breast irradiation. It works by delivering radiation from inside the lumpectomy cavity (the space left after the tumor is removed) directly to the tissue surrounding the cavity where the cancer is most likely to recur. APBI is a 2-stage process: balloon placement and radiation delivery. After the surgeon performs the lumpectomy, an uninflated balloon connected to a catheter, is placed inside the cavity where the tumor was. A portion of the catheter remains outside of your breast. Once in place, the balloon is inflated with a sterile salt water solution to fit snugly into your lumpectomy cavity. The balloon remains inflated for the entire time you are receiving radiation therapy (usually 5 days). After the balloon is in place, that area of the breast is cleaned and bandaged and you may go home.

APBI is given under the direction of a radiation oncologist who will determine the amount of radiation needed. It is delivered on an outpatient basis twice a day for 5 days. During radiation therapy, the portion of the catheter that remains outside your breast will be connected to a computer-controlled machine. A form of X-ray radiation is delivered to the breast via the catheter. Once completed, the machine is disconnected from the catheter. No radiation will remain in your breast between treatments or after your final treatment. Usually on the same day as your final radiation treatment, the balloon will be deflated and easily removed. Partial breast irradiation is not appropriate for all patients. Long term results of this treatment are still being studied.

• High-dose Rate Brachytherapy (HDR) uses a small amount of radioactive material that is passed through thin, plastic tubes (called catheters) that are placed in the lumpectomy area. These catheters are connected to a machine so high doses of radiation can be delivered to a small area of the breast. The radiation is removed at the end of each treatment, but the catheters remain in the breast until the radiation treatments are comple

After Mastectomy Radiation

Several factors including tumor size, the number of lymph nodes involved and surgical margins will determine whether or not radiation therapy will be recommended after the breast has been surgically removed.

Treatment Side Effects

Side effects from radiation therapy may include mild to moderate skin dryness, irritation and itching (similar to sunburn), mild to moderate breast swelling, breast tenderness and fatigue.  Lymphedema (swelling of the arm and/or hand) can develop after surgery when lymph nodes are removed from under the arm and/or radiation therapy is delivered to the axilla. This may occur shortly after treatment or many years later.