Breast Cancer

What is Breast Cancer ‘Staging’?

If the normal cells of the breast grow out of control they form a lump or tumour. The cells change in appearance and function and become abnormal.  

A breast lump is considered benign if it is limited to a few cell layers and does not invade surrounding tissues or organs. A benign lump is not cancer.  But if the tumor spreads to the surrounding tissues or organs, it is considered malignant, or cancerous. 

The breasts are, in essence, a collection of fatty tissue and glands that have been adapted to secrete milk after a woman gives birth. The glands that produce milk are called lobules and the tubes that connect them to the nipples are called ducts. Cancer of the breast develops when malignant changes occur in the cells that line the lobules or, more commonly, the ducts.

Carcinoma is the term used to describe the cancers that arise from the surface or lining cells. 

There are two major types of breast cancer:

• lobular carcinoma, and
• ductal carcinoma.

Cancer can be either invasive (spreading) or noninvasive (generally known as ‘in situ’ – confined to the original site). The majority of breast cancers (70% – 80%) arise from the ducts, which make up the bulk of breast tissue. Since lobular and ductal cells are found in the glandular tissues of the upper, central, and outer regions of the breast, this is where most breast cancers occur. Breast tumors rarely arise in the fatty or nonglandular tissues. Such tumors, when they appear, are usually sarcomas.

Cells from the tumor may break away, travel, and grow within other parts of the body. This process is known as metastasis. Breast cancer often metastasizes to sites such as the lung, bone, liver, and brain. If breast cancer is detected at an early stage – for example, before metastasis – it usually can be cured; however, as the disease progresses, the possibility of effective treatment is diminished. Fortunately, though, many breast “lumps” are caused by benign breast diseases that do not spread beyond the breasts and are not life-threatening.

Men can also develop breast cancer.

Facts About Breast Cancer: A diagnosis of breast cancer is alarming, but the good news is that most women recover from it. Improvements in breast cancer detection have helped to limit the harmful potential of this disease. In fact, during the last decade, the majority of breast cancers reported in the U.S. were small, very treatable, early-stage tumors. Overall, about 83% of women survive breast cancer, as shown by recent 5-year survival statistics. Although these numbers don’t guarantee that a person will be in the ‘favorable’ statistical group, they do show that the likelihood of beating breast cancer is good. If breast cancer is detected and treated in the early stages, the chances of complete recovery are even better. With the exception of skin cancer, breast cancer is the most common cancer among American women. Recent findings from the National Cancer Institute (NCI) indicate that an American woman has a one in eight chance of developing breast cancer during her lifetime. The American Cancer Society estimates that about 230,480 new cases of invasive breast cancer were diagnosed in the year 2011, as well as 57,650 new cases of in situ breast cancer. Nearly 40,000 American women died from breast cancer in 2011, making it the second leading cause of cancer death after lung cancer.  Breast cancer also can strike men, although cancer of the male breast accounts for only 1% of all diagnosed breast cancers. in 2011, more than 2,000 men were diagnosed with breast cancer, and 450 men died from the disease. Over the last 5 years, patients have benefited from many advances in breast cancer treatment. Breast conservation – the saving of the breast – has increased enormously because of early diagnosis and the widespread use of mammograms (x-rays of the breast). In addition, new anti-cancer drugs such as paclitaxel (Taxol®) and trastuzumab (Herceptin®) have been approved by the Food and Drug Administration (FDA) and show promise in the treatment of people with advanced disease. The progress made in breast cancer detection and treatment is perhaps best reflected by mortality (death rate) figures. U.S. statistics show that breast cancer mortality decreased significantly between 1990 and 2007, at a rate or 2.2% per year. The largest decline seen in younger women, in whom the mortality rate decreased by 3.2 percent per year. This suggests that, although breast cancer remains a major concern among American women, it can be managed successfully. However, white non-Hispanic women appear to have benefited the most from advances in screening and treatment. While decreases in mortality were significantly less for all ethnic groups other than whites, the most striking disparity is seen between white and Black women. In 2007, the breast cancer mortality rate for Black women was 41 percent higher than for white women. The following sections will explain the causes and treatment of breast cancer, as well as some of the methods used to overcome the far-reaching effects of this disease.

 

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Breast Anatomy

The breasts are composed of fatty tissue that contains the glands responsible for milk production in late pregnancy and after childbirth. Within each breast, there are about 15 to 25 lobes formed by groups of lobules, the milk glands. Each lobule is composed of grape-like clusters of acini (also called alveoli), the hollow sacs that make and hold breast milk.

The lobules are arranged around ducts that funnel milk to the nipples. About 15 to 20 ducts come together near the areola (dark, circular area around the nipple) to form ampullae – cavities that store the milk before it reaches the nipple surface. Montgomery’s glands are small oil glands that are located around each areola. They release a lubricant that protects the nipples during nursing.

Breast Size And Shape

The breasts are not always exactly the same size or shape. They are incompletely developed at birth and – in men – remain small and undeveloped unless subjected to abnormal hormonal stimulation. In general, breast formation is complete within a year or two after the start of menstruation; however, the acini keep growing, and fibrous and fatty tissues are continually added during adolescence. Pregnancy andnursing cause further increases in breast size. As a woman ages, the fatty tissue of the breasts may become more prominent than the glandular tissue, and the breasts may feel softer. The breasts gradually atrophy (shrink) after menopause (the end of menstruation).

Breast Position

The breasts cover a large part of the chest wall. In front, the breast tissue may extend from the clavicle (collarbone) to the middle of the sternum (breastbone). On the side, breast tissue may continue into the axilla (armpit) and reach as far as the latissimus dorsi (muscle extending from the lower back to the humerus bone of the upper arm).

In fact, the anatomic relationship between the breasts and the underlying muscle is a very important consideration in surgical therapy. The breasts overlay vital chest wall muscles such as the pectoralis major (the ‘pecs’), the pectoralis minor (thin, triangular muscle beneath the pecs), and the intercostals (muscles between the ribs). The breasts also may cover some of the serratus magnus (also called the serratus anterior; a slender muscle that is attached to the ribs/ rib muscles and connects with the shoulder blade) and the rectus abdominis (long, flat muscle that stretches up the torso from the pubic bone to the ribs).

Lymphatic System

Lymph is a clear, tan fluid that contains lymphocytes (white blood cells that fight disease). Lymph is drained from the breast tissues by a rich supply of vessels. Such lymphatic vessels connect with a network of lymph nodes that are located around the breasts’ edges or in nearby tissues of the armpits and collarbone. The breasts’ lymph nodes are not linked in a straight line. Instead, they are staggered and fixed within fat pads – an arrangement that complicates lymph node removal during breast cancer surgery.

Lymph nodes play a central role in the spread of breast cancer. The axillary (underarm) lymph nodes are particularly important, as they are among the first places that cancer is likely to be found if it metastasizes (spreads) from the breast. This lymph node cluster is often referred to as the ‘tail,’ or level I nodes. Level II nodes are located underneath the pectoralis minor muscle, and level III nodes are found near the center of the collarbone.

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What Causes Breast Cancer?

The exact cause or causes of breast cancer remain unknown. Yet scientists have identified a number of risk factors that increase a person’s chance of getting this disease. Certain risk factors, such as age, are beyond our control; whereas others, like drinking habits, can be modified.

Age

The risk of breast cancer increases with age. For example, annual breast cancer rates are 8-fold higher in women who are 50 years old, in comparison with women who are 30. Most breast cancers (about 80%) develop in women over the age of 50. In one age group (40 to 45 years), breast cancer is ranked first among all causes of death in women. Breast cancer is uncommon in women younger than 35, with the exception of those who have a family history of the disease.

Previous Breast Cancer

If a woman has already had breast cancer, she has a greater chance of developing a new cancer in the other breast. Such a new, or ‘second,’ cancer arises from a completely different location and should not be confused with a cancer that has recurred (come back) or metastasized (spread) from another site. The likelihood of a new cancer increases by 0.5% to 0.7% each year after the original diagnosis. After 20 years, a woman has a 10% to 15% chance of developing a new breast cancer.

A previous diagnosis of lobular carcinoma in situ (a localized tumor) is associated with a 10% to 30% greater breast cancer risk, and a previous diagnosis of ductal carcinoma in situ is associated with a 30% to 50% greater risk.

Family History Of Breast Cancer

Approximately 85% of women with breast cancer do NOT report a history of breast cancer within their families. Of the remaining 15%, about one-third appear to have a genetic abnormality. The risk of breast cancer is about two times higher among women who have a first-degree relative (mother, sister, or daughter) with this disease. The risk is increased 4- to 5-fold if the relative’s cancer was found before menopause (the end of menstruation) and involved both breasts. The risk also is increased if breast cancer occurs in several family generations.

In addition, an increased risk of breast cancer has been found in families with other inherited disorders, such as ataxia telangiectasia (a progressive disease of the motor system) and Li-Fraumeni syndrome.

Genetic Mutations

About 5% to 10% of all breast cancers are hereditary. Scientists have identified certain genetic mutations (permanent changes in genetic material) that place people at increased risk of breast cancer. To date, the genes that have been most studied include BRCA1 and BRCA2. Some American women – many of whom are descendants of Ashkenazi Jews from Eastern and Central Europe – have an inherited BRCA1 mutation. Each will have up to a 90% lifetime risk of developing breast cancer. More than half will be diagnosed with breast cancer by age 50. In some BRCA1 families, there is a likelihood of developing both breast and ovarian cancers. The BRCA2 genetic mutation also is prevalent among families with Ashkenazi backgrounds.

In addition, many other genes may be associated with breast cancer, including the genes named p53, AT, the GADD repair group, the RB suppressor gene, and the HER-2/neu oncogene (a gene that contributes to cancer). Some of these genes directly influence breast cancer risk, whereas others are involved in the general processes of cancer growth and metastasis.

Hormones

Breast cancer risk is increased in women with the longest known exposures to sex hormones, particularly estrogen (female sex hormone). Therefore, breast cancer risk is increased in women who have a history of

• early first menstrual period (before age 12),
• late menopause (end of menstruation),
• no pregnancies,
• late pregnancy (after age 30), or use of
• birth control pills (the ‘Pill;’ oral contraceptives – ‘OCs’).

It should be mentioned that the Pill’s exact hazards are difficult to assess, since risk apparently disappears in women who have not used oral contraceptives for more than 10 years.

Estrogen replacement therapy (ERT), also known as hormone replacement therapy (HRT), is used by many older women to relieve the symptoms of menopause. Certain studies indicate that ERT may increase the risk of breast cancer after long-term use (10+ years). Yet there is no official consensus on ERT, because scientists also have found that the increase in breast cancer risk is eliminated within 5 years of stopping ERT. In addition, some researchers have reported an increased risk of breast cancer in women taking estrogen or estrogen plus progestin, whereas others have not. Because of these uncertainties – and the fact that ERT has a number of positive benefits (e.g., lowered risks of bone fractures and heart attack) – a physician should be consulted about risks and benefits before a person uses ERT.

Nice To Know: Estrogen Scientists are finding more evidence that a woman’s lifetime exposure to her sex hormones – especially estrogen – is directly related to her chance of getting breast cancer. Two key factors also appear to be involved in this association: exercise and body fat. Exercise A woman’s exposure to estrogen is lowered by exercise, which affects the menstrual cycle and can inhibit ovulation (release of an egg from the ovaries). Research suggests that the less a woman ovulates (that is, the fewer ovulation cycles she has), the lower her risk of breast cancer. This may explain why women who have had many pregnancies, or who experienced late menstruation and early menopause, are at lower risk for breast cancer than never-pregnant women and those women who menstruated early and had a late menopause. So exercise – with its apparent ability to affect estrogen and, likewise, ovulation – may indirectly lower the risk of breast cancer. Body fat Although a woman’s ovaries stop making sex hormones after menopause, her body still produces estrogen. This is possible because aromatase, an enzyme manufactured by body fat, can make estrogen from androstenedione, a steroid released by the adrenal glands. Postmenopausal women with more body fat have more aromatase. Therefore, they can convert more androstenedione into estrogen. So the high levels of circulating estrogen caused by excess body fat may be linked with an increased risk of breast cancer in postmenopausal women. The relationship between body fat and breast cancer is much more complex in younger, menstruating women; however, exercise appears to be beneficial, no matter what a woman’s body size.

Breast Disease (Benign)

Most benign breast diseases such as nonproliferative (not rapidly dividing) fibrocystic “disease” (temporary changes in the breasts that coincide with the menstrual cycle) – do NOT increase the risk of breast cancer. Yet risk is increased when the breast tissue shows specific characteristics, such as

• complex fibroadenoma (fibrous, benign tumor of glandular tissue),
• hyperplasia (abnormal increase in cell number), or
• atypia (abnormal cellular structure).

Moderate or severe hyperplasia alone may increase breast cancer risk by 1.5- to 4-fold; however, when associated with atypia, the risk may be increased as much as 5-fold. If a woman also has a family history of breast cancer in first-degree relatives, her risk may be increased 11-fold.

Alcohol Use

The risk of breast cancer is increased among women who drink. Women who consume one alcoholic beverage a day have a slightly increased risk of breast cancer. By contrast, breast cancer risk is nearly doubled in women who have more than three drinks daily. Although the basis for this association is unknown, there is a recognized relationship between the consumption of more than two drinks a day and an increased level of estrogen in the blood.

Radiation Exposure

A significantly increased risk of breast cancer has been found in women who received radiation therapy in the chest area during childhood or young adulthood. Because of former medical practices (for example, the repeated use of fluoroscopic x-rays to check the lungs for tuberculosis), women over 45 generally have more exposure to radiation than younger women. In addition, an increased risk of breast cancer has been seen in women who were exposed to atomic bomb radiation at Hiroshima and Nagasaki, Japan.

Other Potential Risk Factors

A number of variables are potential, but unproven, risk factors for breast cancer. They include:

• dietary fat

  There are conflicting results concerning the relationship between dietary fat and breast cancer. Many U.S. studies have found no association between the two; however, international findings suggest that breast cancer rates are minimal in countries where the standard diet is low in fat (particularly animal fat). It is known that fat cells play a role in estrogen production, especially in postmenopausal women. Therefore, being overweight may contribute to risky estrogen exposure in such individuals.

• environmental pollutants

  Pollutants – such as pesticides made from organochlorides (organic compounds in which chlorine is bound to carbon) – may add to a person’s risk of breast cancer, although research has not definitely established an association with such exposure.

• cigarette smoking

  Smoking has not been shown to increase the risk of breast cancer. Yet because smoking increases the risk of so many other cancers – as well as heart disease and lung emphysema – most physicians advise women to quit. In addition, smoking can limit the treatment options of breast cancer patients, since certain types ofreconstructive surgery cannot be used for women who smoke.

• abortion/miscarriage history

  Some studies have reported an increased risk of breast cancer among women who have had induced abortions. Yet a large, more recent survey disputes these findings. When the pregnancy histories of over 16,000 American women were analyzed, there was only a slight risk of breast cancer among those who had experienced either spontaneous miscarriages or induced abortions.

• above-average body height/weight

  Some researchers have suggested that above-average body height/body weight relationships may be associated with an increased risk of breast cancer. For example, the heaviest 10% of women age 50 and older may have up to a 20% higher risk of breast cancer, and the tallest 10% of women age 30 to 49 years may have a 30% higher risk. Such associations are probably the result of hormonal factors – particularly estrogen levels- in the respective subgroups.

Unproven Protective Factors

In contrast to the potentially harmful effects of a person’s lifestyle or family history, some factors actually may reduce the risk of breast cancer. Such factors are believed to have protective or preventive benefits. They include

• regular exercise
• early pregnancy, and
• breast-feeding.

Researchers at the University of Southern California School of Medicine have reported that the risk of early breast cancer is reduced by more than 50% in women (aged 40 years and younger) who exercise for four hours a week. Similarly, a recent study from the Netherlands Cancer Institute suggests that women who exercise on a regular basis may substantially reduce their risk of breast cancer. The researchers found that benefits were greatest in women who kept their weight in proportion to their height. The protective effect of exercise may result from its estrogen-lowering effects. In addition, exercise changes body fat composition, influences ovulation (egg release), and has a favorable effect upon natural immunity.

If a woman experiences a full-term early pregnancy (pregnancy before age 30), research suggests that she may reduce her risk of breast cancer; however, until menopause, a woman’s overall risk of getting breast cancer remains very low, whether or not she gives birth.

There continues to be a debate about whether or not breast-feeding prevents the development of breast cancer. Some studies suggest that young women (age 20 or less) who have breast-fed for 6 or more months protect themselves against early breast cancer (breast cancer that occurs before age 50); others claim reductions in breast cancer risk after breast-feeding for 1 ½ to 2 years. Still other studies have found no association between breast- feeding and breast cancer. Yet there seems to be some agreement that breast-feeding does not influence the development of late (postmenopausal) breast cancer.

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What is Breast Cancer ‘Staging’?

‘Staging‘ is a method that has been developed to describe the extent of cancer growth. Breast cancer is ‘staged’ by information that is obtained from surgical and other findings. Specifically, information is gathered from the pathology (disease) report that accompanies a lumpectomy (lump removal), mastectomy (breast removal), or other form of breast surgery. In addition, staging is based upon findings from imaging studies – such as chest x-ray, abdominal ultrasound (images produced by high-frequency sound waves) computed tomography (CT or CAT scan; computer-assisted technique that produces cross-sectional images of the body), and bone scans.

The physician uses all available findings to choose a stage that best describes the person’s condition. Staging helps to predict how an individual will fare over time – that is, it helps the physician to estimate how long a person will live and the risk of cancer recurrence, or relapse. Correspondingly, staging allows the physician to customize cancer treatment. In general, the lower the stage, the better the person’s prognosis (expected outcome).

The TNM System

Pathologists (disease specialists) use a specific system to stage breast cancer. This method- known as the TNM system – was devised by the American Joint Committee on Cancer (AJCC) in collaboration with the National Cancer Institute (NCI). Within the TNM system, “T” refers to tumor size, “N” refers to lymph node involvement, and “M” refers to the extent of metastasis. The primary tumor (T) is ranked within one of the following categories:

Category:	Description:
TX:	Tumor cannot be assessed
T0:	No evidence of primary tumor
Tis:	Carcinoma in situ, or Paget’s disease of the nipple, without a detectable tumor mass
T1:	Tumor two centimeters or less (< 2 cm) in greatest dimension
T2:	Tumor more than two centimeters (> 2 cm), but less than five centimeters (< 5 cm), in greatest dimension
T3:	Tumor more than five centimeters (> 5 cm) in greatest dimension
T4:	Tumor of any size, with direct spread to chest wall or skin (includes inflammatory carcinoma and ulceration of the breast skin)

The extent of lymph node (N) involvement is described by the following categories:

Category:	Description:
N0:	Regional lymph nodes are metastasis-free
N1:	Metastasis to movable, same-side, axillary (armpit) lymph node(s)
N2:	Metastasis to same-side lymph node(s) fixed to one another or to other structures
N3:	Metastasis to same-side lymph nodes beneath the breastbone (internal mammary nodes)

Metastasis (M) is specified by the categories:

Category:	Description:
MX:	The presence of distant metastasis cannot be assessed
M0:	No distant metastases are found
M1:	Distant metastases are present

To simplify this information, the TNM classifications are grouped within four basic stages, labeled stage 0 through stage IV (0-4).

Stage	TNM Classifications
Stage 0:	in situ breast cancer – Tis, N0, M0
Stage I:	T1, N0, M0
Stage IIa:	T0-1, N1, M0, or T2, N0, M0
Stage IIb:	T2, N1, M0, or T3, N0, M0
Stage IIIa:	T0-2, N2, M0, or T3, N1-2, M0
Stage IIIb:	T4, N (any), M0, or T(any), N3, M0
Stage IV:	T(any), N(any), M1

The lower the stage number, the less the cancer has grown and spread. For example, a “stage I” breast cancer is relatively small and has not yet spread to the lymph nodes or other sites. By contrast, a “stage IV” cancer is much more serious, as it has already metastasized to the lymph nodes as well as another location(s).

Women with low-stage tumors have a better chance of surviving breast cancer than women with high-stage tumors. Recent findings from the National Cancer Institute (NCI) indicate that 5-year survival rates are 96% for limited, low-stage breast cancers (stage 0, stage I, and some stage II cancers), 75% for breast cancers that have invaded the surrounding tissue (stage II & III cancers), and only 20% for breast cancers that have metastasized (stage IV cancers). Unfortunately, survival rates are lower and breast cancer stages tend to be higher among women from low socioeconomic backgrounds.

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Are There Different Kinds Of Breast Cancer?

Although the majority of breast lumps are benign, nearly one-quarter will be cancerous. But not all breast cancers are the same. Most are carcinomas – that is, cancers that arise from epithelial (surface or lining) tissues – and most develop in the breast lobules (glands that produce milk) or tissues known as terminal ductolobular units (TDLU). Such cancers include ductal carcinomas and lobular carcinomas. Paget’s disease (cancer of the areola and nipple) and inflammatory carcinoma (a highly malignant cancer) account for nearly all remaining types of breast cancer.

Non-invasive Carcinomas

Often breast tumors are discovered at an early stage, when they are still small and confined. In such cases, cancer cells have not grown into the surrounding tissues and remain within the borders of a duct or lobule. These tumors are known as non-invasive, in situ tumors (tumors that remain ‘in the site’ of origin).

In situ tumors are too tiny to have formed a ‘lump,’ and so they usually are not felt or detected during a physical exam. They are diagnosed by mammography (breast x-ray). Non-invasive carcinomas include

• ductal carcinoma in situ (DCIS), and
• lobular carcinoma in situ (LCIS).

Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma or non-invasive ductal carcinoma) contains breast duct cells that have malignant characteristics when viewed under a microscope. Therefore, this tumor is very difficult to grade (an evaluation that reflects a cell’s tendency to divide). Although, by definition, DCIS has not yet invaded the surrounding tissues, the abnormal cells within DCIS may be the forerunners of invasive breast cancer. Each year, about 1% of women with high-grade DCIS develop invasive breast cancer after lumpectomy. Thus, DCIS is a potential marker for invasive carcinoma.

The treatment of DCIS is a topic of great debate. Experts continue to argue about whether to treat DCIS by some form of breast-conserving surgery, with or without radiation, or by mastectomy.

Lobular carcinoma in situ (LCIS; also known as non-invasive lobular carcinoma) usually occurs in women who have not undergone menopause. LCIS is a multifocal (located in more than one area) disease that typically affects both breasts. This is in direct contrast to DCIS, which generally is unifocal (confined to one location) or at least limited to one region of the breast. Because of the multifocal character of LCIS, women with this disease should receive careful examinations of both breasts. Fortunately, though, most people with LCIS (over 99%) do not develop invasive breast cancer.

Paget’s disease is a slow-growing cancer of the nipple. It usually strikes middle-aged women and may occur in association with an underlying in situ or invasive ductal carcinoma of the breast. Paget’s disease arises in the ducts beneath the nipple and then grows onto the nipple itself. Because the tumor may cause crustiness, oozing, and itching of the areola and nipple, sometimes it is incorrectly diagnosed as eczema or another skin condition. Yet Paget’s disease is distinguished by the fact that it does not involve the surrounding skin and typically is limited to one breast.

Invasive Carcinomas

If breast cancer penetrates the membrane that surrounds the lobules or ducts, it is called an infiltrating or invasive carcinoma. Invasive carcinomas – like ductal carcinoma and lobular carcinoma – can grow into the supporting tissue between the ducts, blood vessels, lymph nodes, and other structures with the breasts. Therefore, there is a greater chance that invasive carcinoma will metastasize, spreading throughout the body.

About 75% percent of all invasive breast cancers are ductal carcinomas. Under the microscope, ductal carcinoma looks like a mass with poorly defined edges that have begun to extend into the surrounding tissue. As the cancer invades the fatty tissue around a duct, it causes the formation of fibrous, scar-like tissue. Such scar formation may make ductal carcinoma appear larger than it actually is. Depending upon the location of the tumor, the symptoms of invasive ductal carcinoma may include retraction (drawing inward) of the nipple or nipple discharge and skin changes such as wrinkling or dimpling.

Lobular carcinomas make up approximately 5% to 10% of all invasive breast cancers. Lobular breast cancer is more difficult to detect by mammography because it may not occur as a distinct lump. Instead, lobular carcinoma may appear as an irregular thickening in the breast. A small proportion of women (~5%) may develop lobular carcinoma in both breasts.

In addition to ductal and lobular carcinoma, three well recognized types of invasive breast cancer are:

• tubular cancers (slow-growing, tube-shaped cancers)
• medullary cancers (cancers that look like the medulla [gray matter] of the brain), and
• mucinous cancers (cancers that contain a mucous protein).

Inflammatory carcinoma is a very serious, rapidly spreading type of tumor that accounts for about 1% of all breast cancers. It produces symptoms like swelling, redness, and skin warmth, which result from blockage of the skin’s lymphatic vessels by cancer cells. Because of such symptoms, inflammatory carcinoma sometimes is confused with mastitis – a breast infection that may or may not be associated with breastfeeding and can be cured by antibiotics. In the past, a diagnosis of inflammatory carcinoma was particularly grim, since the majority of people died from the disease within a year. However, new, aggressive forms of chemotherapy have greatly improved the chance of survival for most people with inflammatory cancer.

Rare Breast Cancers

Although most breast cancers are carcinomas – tumors that develop from epithelial (surface or lining) tissues – a very small number of breast cancers may arise from the muscle, fat, or connective tissues of the breast. Such cancers are known as sarcomas. The rare types of sarcoma that occasionally are diagnosed within the breast include:

• angiosarcoma (also known as hemangiosarcoma; a cancer that is composed of cavity-lining and fiber-producing cells), and
• cystosarcoma phylloides (a cancer that primarily affects middle-aged women who have histories of recurring fibroadenomas).

In addition, cancer can directly strike the lymphatic tissue within the breast, resulting in a primary lymphoma.

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Treatments For Breast Cancer

The treatment of breast cancer is determined by many factors, such as

• tumor stage
• tumor type
• tumor characteristics
• the person’s general health
• medical conditions that may influence treatment.

After breast cancer has been staged, a comprehensive treatment plan will be developed by a team of physicians, including an oncologist (cancer specialist). The treatment plan typically involves some form of surgery to remove as much of the cancer as possible.

In addition to surgery, the treatment plan may call for adjuvant (assisting) therapy such as

• radiation therapy
• chemotherapy, and/or
• hormone therapy

Other treatment options that may be used for aggressive or late-stage breast cancers are

• high-dose chemotherapy with bone marrow transplantation and
• immunotherapy

Finally, the physician team will try to predict the likelihood of breast cancerrecurrence (coming back). Specific tumor characteristics that help to determine the risk of recurrence include breast cancer

• size
• estrogen and progesterone (ER/PR) receptor status (presence or absence of hormone ‘receptors’ [lock-like molecules] – in cancer cells)
• phase (whether or not tumor cells are actively dividing)
• HER2/neu protein status (presence or absence of an oncogene-related protein found in some aggressive breast cancers),
• grade (indicator of malignant change in the tumor), and
• ploidy (number of sets of genetic material within tumor cells).

Surgery

A number of surgical procedures are used to treat breast cancer. Apart from removal of the tumor itself, operations may be performed to improve the appearance of the chest after breast surgery, to discover whether or not cancer has spread to the lymph nodes, or to relieve some of the symptoms of late-stage disease.

The most recent trend in breast cancer surgery is the use of breast-saving lumpectomy (removal of the tumor and its margins) plusradiation therapy for the treatment of early breast cancer. This method has been found to be as effective as mastectomy (complete removal of the breast), while sparing the breast. In addition, sentinel lymph node biopsy – a more exacting, less invasive form of lymph node biopsy – is becoming an acceptable alternative to axillary (armpit) dissection during surgical staging.

The most common surgeries for breast cancer are listed below:

• Lumpectomy

  Lumpectomy removes the cancer, a surrounding border of cancer-free tissue (roughly 3/4 in), and the nearby lymph nodes. Lumpectomy is, by definition, a form of breast-conserving surgery (BCS).

• Partial mastectomy

  Partial mastectomy is a non-specific term for surgery in which part of the breast is removed. If the tumor is located in the upper breast, the incision often is made in a curved line, close to the areola (dark, circular area around the nipple). If the tumor is located in the outer breast near the armpit, the tumor and nearby lymph nodes may be taken out through the same incision. If the tumor is located in the lower breast, the surgeon usually makes a radial incision (one that extends from the center of the breast outward towards the edges). The axillary (underarm) lymph nodes are removed through the original incision or via a separate incision in the armpit itself. In general, between 10 and 15 lymph nodes are removed during partial mastectomy.

  Quadrantectomy (also known as segmentectomy or tylectomy) is the term used to for a partial mastectomy in which about one-quarter of the breast is removed together with the tumor.

• Total (simple) mastectomy

  Total mastectomy – also known as simple mastectomy – removes the entire breast, without removing the underam lymph nodes or muscular tissue beneath the breast. This procedure is being used increasingly for women who have carcinoma in situ (for example, DCIS) that has not yet spread to surrounding tissues.

• Modified radical mastectomy

  Modified radical mastectomy (also known as Patey mastectomy) removes the entire breast and some of the underarm lymph nodes. In certain cases, the pectoralis minor (an upper chest muscle) may be removed if it is cancerous or if it hampers the removal of lymph nodes. This procedure is now the most frequently performed breast cancer surgery in the U.S., since it has a record of the best long-term results with the fewest complications.

• Radical mastectomy

  Radical mastectomy, also known as the Halsted procedure, is a very invasive surgical procedure that involves extensive removal of chest tissue. In addition to the entire breast and axillary lymph nodes, this operation removes the chest muscles under the breast and the surrounding skin. After radical mastectomy, the natural contour of the chest is deformed, arm movement may be impaired, breast reconstruction is complicated, and skin grafting may be needed. Radical mastectomy is rarely justified or performed, since modified radical mastectomy has proven to be an equally effective technique with less disfigurement.

• Skin-sparing mastectomy

  Skin-sparing mastectomy – a new surgical procedure – is a variation of total mastectomy. During this operation, the breast tissue is removed through a tiny circular incision that is made around the nipple. This technique, which minimizes disfigurement, leaves the skin undamaged and enables immediate breast reconstruction by means of an implant or natural tissue. Skin-sparing mastectomy is now being performed at a number of cancer centers throughout the U.S.

• Subcutaneous mastectomy

  Subcutaneous mastectomy removes most, but not all, breast tissue via a small surgical incision that leaves the breast skin and nipple unchanged. This operation is rarely performed, since breast cancer often recurs due to cancerous tissue that has been left behind in the breast and nipple.

• Axillary dissection

  Axillary dissection is used to determine whether or not cancer has spread to the lymph nodes under the arm. During this procedure, a section of underarm fat and adjoining lymph nodes are removed for microscopic analysis by a histopathologist (specialist in diseases of tissues). Axillary dissection may be conducted as part of a modified radical mastectomy or as a separate underarm incision that is made during lumpectomy.

• Sentinel lymph node biopsy

  Sentinel lymph node biopsy uses a radioactive substance to target the lymph nodes that are likely to be affected by breast cancer. A radioactive tracer is injected into the tumor and is eventually carried by the lymph to the first ‘sentinel’ node in the tumor’s lymphatic pathway. If the cancer has spread, this node is most likely to contain cancer cells. Therefore, the surgeon will biopsy the sentinel node and have it analyzed for malignancy. If it does not contain cancer cells, the removal of additional lymph nodes may be unnecessary.

• Reconstructive or breast implant surgery

  Strictly speaking, breast reconstruction is NOT a breast cancer treatment. It is a surgical procedure that is performed to restore a woman’s appearance after breast surgery. To ensure the best results, a person should decide about breast reconstruction before mastectomy. This enables the surgeon to plan for reconstruction or even perform reconstruction at the time of mastectomy. The advantages of immediate reconstruction include:

  • lessening of grief over breast loss,
  • completion of both procedures with one anesthetic risk, and
  • preservation and immediate use of uninvolved breast skin.

  Delayed reconstruction is preferable if:

  • the person is unsure about having the operation,
  • prolonged anesthesia will increase the risk of the operation, or
  • postoperative radiation therapy is being considered.

  A reconstructed breast may differ in shape and/or size from the remaining normal breast. Therefore, some women choose to have plastic surgery performed on the normal breast so that both breasts appear similar.

Breast implants (artificial cushions that are filled with a soft, breast-like substance – usually saline [salt water] or gel) have been used extensively for breast reconstruction. Breast implants are not placed under the skin, but rather are inserted under the pectoral (chest) muscle in a surgically-made pouch. Sometimes the chest muscle must be pre-stretched by a temporary device before placement of the permanent implant.

The major advantage of using an implant is that it can be inserted easily and quickly. The disadvantages are the continual risk of implant failure in the form of infection, rupture, breakdown, capsular contraction (tissue hardening around an implant), and the need for tissue pre-stretching. The lifespan of implants beyond 10 to 20 years is still unknown, as is the relationship – if any – to autoimmune disease.

For these reasons, the use of the woman’s own tissue has become the method of choice for breast reconstruction. Specifically, surgeons have begun to use skin and fat from elsewhere in the woman’s body (e.g., the abdomen) to create a more natural-looking breast.

In some cases – especially if the chest muscles have been removed during radical surgery – myocutaneous (skin and muscle) “flaps” may be transferred from a donor site to the chest wall. Such flaps include the

• latissimus dorsi (back muscle), or “LD” flap,
• transverse rectus abdominis (abdominal muscle)myocutaneous, or “TRAM” flap, and
• gluteus maximus flap, which is a “free” or unattached flap made from the tissue of the buttocks or thigh.

Nipple and areola reconstruction usually is conducted a few months after breast reconstruction so that the nipple can be positioned correctly. A variety of methods are used to create the nipple projection and areola. The tissue often is darkened by tattooing to achieve a good color match.

For more specific information about breast surgery or mastectomy, contact the American Cancer Society or the National Cancer Institute.

Radiation Therapy

Radiation therapy, also known as radiotherapy, uses high-energy rays

(x-rays, gamma rays) to destroy cancer cells. Cancer cells are targeted by radiation therapy because, unlike normal cells, they are unable to repair radiation-induced damage. Radiation therapy is delivered by means of linear accelerators – machines that generate x-rays and electrons and direct them as an external beam. Another device, the cobalt machine, gives off gamma rays from a radioactive source of cobalt. Radiation therapy usually is given after breast-conserving surgery, that is, after

• lumpectomy or
• partial mastectomy for early-stage cancers.

Such treatment helps to eliminate any cancer cells that may remain in the breast. Radiotherapy is used to preventlocal recurrence (regrowth of breast cancer at the original site) and to avoid the need for mastectomy. Recent follow-up studies indicate that women who undergo lumpectomy with radiotherapy survive as long as women who undergo mastectomy. Unfortunately, women who develop a local recurrence usually require mastectomy, because a cancerous breast cannot be irradiated twice without damaging side effects (for example, death of normal breast tissue, skin ulceration, or radiation-induced cancer).

Radiation therapy usually is not needed after a complete mastectomy. Some exceptions include breast cancer that is:

• advanced, with a high risk of recurrence in the chest wall (for example, cancer with four or more cancerous lymph nodes),
• very large (> 5 cm),
• not able to be removed with awide enough margin, and
• recurrent after mastectomy (for example, a small cancer that returns to grow upon the skin).

In such cases, radiotherapy may be employed to destroy cancer cells in a wider area of the chest and to prevent recurrence. Chemotherapy and/or hormone therapy may be given before or after radiotherapy.

Computer simulation is used to establish the fields (parts of the body to receive radiation) and angles of radiation that will be used. The simulator helps to ensure that radiation therapy is limited to the breast, with little exposure of other tissues. To confirm the treatment area for radiation therapy, the person’s skin is marked with indelible ink or small tattoos.

External beam radiation therapy – which usually delivers a total dose of about 4500-5000 rad (a unit of absorbed dose of radiation) – often is performed in an outpatient facility. A typical schedule is 5 days of therapy per week over a period of about 6 weeks. Each session lasts a few minutes and is painless. A boost dose (another type of radiation specifically directed at the tumor site) may be given over a period of 5 to 14 days.

An internal boost of radiotherapy may be used as an alternative treatment. During this procedure, a radioactive isotope like iridium (Ir192) is implanted into the breast cancer by means of hollow plastic tubes. The implants remain in place for about 2 days, after which they are removed. In some cases (for example, cancers deep within the breast), the internal boost may be given during the removal of the tumor, before the surgical incision is closed.

Lymph nodes may be treated by external beam radiation under certain circumstances. For example, if breast cancer has spread to the axillary (armpit) lymph nodes, then the supraclavicularlymph nodes (above the collarbone) are at high risk and may need to be irradiated. Also, if breast cancer is located near the middle of the body, then the internal mammary lymph nodes may require radiation therapy. Radiation therapy should NOT be performed upon the axillary lymph nodes if surgery has been conducted in the underarm region, since it is likely that lymphedema (swelling of the arm caused by fluid retention) will occur after the operation or at some time in the future.

Radiation therapy can cause side effects such as:

• fatigue,
• sunburn-like reddening and peeling of the breast skin,
• loss of underarm hair, and
• ‘pins and needles’ sensation in the treatment area.

After a while, the ‘sunburn’ effect usually fades into a light tan. Temporary relief from mild burning sensations may be provided by gentle creams, the use of baby powder, and the wearing of light, non-binding cotton clothing. The breast skin may thicken, causing the breast to become firmer to the touch and slightly smaller in size. Occasionally, the breast may become larger if fluid builds up within the breast tissue due to a damaged lymphatic system. Other uncommon side effects are costochondritis (arthritic pain in the rib/breastbone junction), hairline fractures in ribs made brittle by radiation, radiation pneumonitis (lung inflammation), and radiation damage of the nerves, muscles, or heart.

Radiotherapy is NOT RECOMMENDED for women who have connective tissue diseases such as scleroderma or systemic lupus erythematosus (SLE) . Their tissues respond abnormally to radiation and may form considerable scars or non-healing skin ulcers. Radiotherapy also may be problematic for women with large breasts. If radiation equipment cannot be adjusted to deliver the radiation dose required for a large tissue mass, the woman may need to be referred to another facility that has suitable equipment.

Chemotherapy

Chemotherapy is the use of anticancer drugs to destroy cancer cells. Chemotherapeutic drugs are given with the hope that micrometastases (small groups of cancer cells) will be eliminated before they spread to other tissues. Many chemotherapeutic drugs interfere with cell division or other metabolic processes. Therefore, they are most harmful to rapidly-dividing cancer cells, although normal cells also may be damaged.

Chemotherapy typically is delivered in the form of shots or pills. It may be the only treatment used if breast cancer has spread to other parts of the body. More commonly, though, chemotherapy is given as an adjuvant (assisting therapy) to reduce the chance of cancer recurring after surgery, radiation therapy, or both. Adjuvant chemotherapy, like hormone therapy, usually is started about 4 weeks after surgery. Neoadjuvant chemotherapy is given before surgery to shrink the breast tumor and make it easier to remove. Specific schedules are followed during chemotherapy, so that periods of treatment are accompanied by periods of recovery. Most treatment schedules are completed within 3 to 6 months.

The following drugs are commonly used for breast cancer chemotherapy:

Brand name	Generic (common) name
Cytoxan®	Cyclophosphamide
(Methotrexate)	Methotrexate
5-Fluorouracil (5-FU)	5-Fluorouracil
Adriamycin®	Doxorubicin
(Prednisone)	Prednisone
Nolvadex®	Tamoxifen
Taxol®	Paclitaxel
(Leucovorin)	Leucovorin
Oncovin®	Vincristine
Thioplex®	Thiotepa
Arimidex®	Anastrozole
Taxotere®	Docetaxel
Navelbine®	Vinorelbine tartrate
Gemzar®	Gemcitabine

 

As illustrated by the table above, many anticancer drugs are available to treat breast cancer. Combination chemotherapy – a mix of two or more drugs – often is more effective than a single medication. Some proven, first-line drug combinations include:

Drug	Combination
CMF	cyclophosphamide, methotrexate, and 5-fluorouracil. This mixture, which has been studied for more than 20 years, is very effective in mastectomy patients who have cancerous lymph nodes. Both premenopausal and postmenopausal women respond well to CMF therapy.
‘classic’ CMF	oral cyclophosphamide plus methotrexate and 5-fluorouracil
CAF	cyclophosphamide, adriamycin® (doxorubicin), and 5-fluorouracil. When the dose of adriamycin is increased, this regimen is called FAC.
AC	Adriamycin® and cyclophosphamide
ACT	Adriamycin® plus cyclophosphamide and tamoxifen
AC taxol	Adriamycin® plus cyclophosphamide and paclitaxel (Taxol®)
FACT	5-fluorouracil plus adriamycin®, cyclophosphamide, and tamoxifen
A-CMF	4 cycles of adriamycin® followed by 8 cycles of CMF; also known as Adria/CMF or the Milan regimen.
CMFP	CMF plus prednisone.
CMFVP	CMF plus vincristine and prednisone.
CAFMV	CAF plus methotrexate and vincristine.
CMFVATN	CMF plus vincristine, adriamycin®, thiotepa, and tamoxifen.
MF	methotrexate plus 5-fluorouracil and leucovorin (a B-vitamin relative used to temper the activity of antimetabolite drugs).

Chemotherapy may cause significant side effects, depending upon the

type of medication taken, the dose, and the length of treatment. Some temporary conditions include:

• nausea and vomiting
• hair loss
• diarrhea
• mouth sores
• fatigue
• excess stomach acid
• bone marrow damage
• leukopenia (shortage of white blood cells)
• infection

Less common, but notable side effects are:

• heart muscle damage
• phlebitis (vein inflammation)
• neuropathy (nerve damage)
• arthritic pain
• increased blood sugar
• changes in skin color
• bladder wall damage
• prolonged fever
• thrombocytopenia (shortage of blood-clotting cells)

Medicines are available to help relieve some of the side effects caused by chemotherapy. These include anti-nausea drugs (for example, reglan), anti-anemia drugs (for example, epoetin alfa [Procrit®, Epogen®] – a synthetic hormone that stimulates the manufacture of red blood cells), and cell-protecting drugs like amifostin (Ethyol®), which lessens some of the toxic effects of cisplatin chemotherapy.

Most temporary side effects disappear after chemotherapy has ended. Unfortunately, the permanent side effects of chemotherapy in premenopausal women are:

• impaired function of the ovaries, and
• sterility.

Some oncologists believe that no chemotherapeutic program should last for more than 6 months; however, longer programs have been effective in some women, particularly when combined with hormone therapy (e.g., tamoxifen).

Nice To Know: Chemotherapy medications and examples
Medication Type and Activity	Examples
Alkylating agents Prevent cell growth	Cyclophosphamide (Cytoxan®) Ifosphamide (Ifex®) Melphalan (L-Pam®) Thiotepa (Thioplex®) Cisplatin (Cisplatinum®, Platinol®)Carboplatin (Paraplatin®) Carmustine (BCNU; BiCNU®)
Antimetabolites Interfere with the manufacture of genetic material (DNA, RNA) and with nutrition in tumor cells	5-Fluorouracil (5-FU) Methotrexate
Antitumor antibiotics Kill tumor cells and interfere with cell genetics (DNA manufacture)	Doxorubicin (Adriamycin®) Mitomycin C (Mutamycin®)
Cytotoxics Kill tumor cells and interfere with cell genetics (DNA manufacture)	Mitoxantrone (Novantrone®)
Natural products Vinca alkaloids Kill tumor cells; are extracts of the periwinkle plant	Vincristine (Oncovin®) Vinblastine (Velban®) Vinorelbine (Navelbine®)
Taxanes Kill tumor cells; are extracts of Pacific and European yew trees	Paclitaxel (Taxol®) Docetaxel (Taxotere®)
Retinoids Vitamin A derivatives that affect cell growth, maturation, and immunologic function	Fenretinide
Hormone-related drugs
Corticosteroids Enhance the tumor-killing effects of other chemotherapeutic drugs and, possibly, interfere with cell DNA	Prednisone
Antiestrogens Interfere with the action of estrogen on cancer cells; inhibits tumor growth	Tamoxifen (Nolvadex®)
Male hormone Inhibits tumor growth	Fluoxymesterone (Halotestin®)
Investigational drugs
Topoisomerase-I (“topo-I”) compounds Extracts of the Chinese tree Camptotheca acuminata	Toptecan Irinotecan 9-amino-camptothecin [9-AC]
Anthrapyrazoles Antitumor antibiotics that are less toxic relatives of doxorubicin; they kill tumor cells and interfere with cell genetics (DNA manufacture)	Biantrazole Losoxantrone
Antimetabolites Methotrexate-like compounds that interfere with the manufacture of genetic material (DNA, RNA) and with nutrition in tumor cells	Edatrexate
Epidophylotoxins Kill tumor cells	Etoposide Teniposide

Hormone Therapy

Hormone therapy for breast cancer is based on the observation that cancer cell growth is sped up by estrogen. ‘Antiestrogen’ medications like

tamoxifen (Nolvadex®) are used to counteract this effect.

Tamoxifen is an estrogen-like compound that binds to the breasts’ estrogen receptors (ER) and makes them unavailable to estrogen’s cancer-promoting activity. Tamoxifen also may prevent breast cancer by stopping angiogenesis – the blood vessel growth required by tumors.

Hormone therapy usually begins within 4 weeks of surgery. Tamoxifen is given in pill form and is most effective when administered on a daily basis for a period of five years. Recent studies indicate that tamoxifen benefits most women with early breast cancer.

Clinical trials are now underway to evaluate the effects of another antiestrogen, raloxifene. Raloxifene, like tamoxifen, may lessen the chance of developing breast cancer; however, it is not recommended for use in women who are already have breast cancer.

Tamoxifen is likely to be given if a woman’s breast cancer is

• ‘ER/PR positive’ – that is, it contains estrogen and progesterone receptors, or if a woman’s breast cancer is
• ‘ER/PR positive’ and shows metastasis or recurrence.

If tamoxifen is not effective against an aggressive tumor, other hormonal medications may be prescribed. Such drugs include

• aromatase inhibitors (e.g., anastrozole [Arimidex®], aminoglutethimide [Cytadren®]), which block the estrogen-converting power of the enzyme aromatase and stop estrogen production
• LHRH (luteinizing hormone-releasing hormone)-inhibiting compounds (e.g., goserelin [Zoladex®], leuprolide (Lupron®), which suppress the production of pituitary hormones that cause the ovaries to make estrogen
• progestins (e.g., megestrol acetate [Megace®], medroxyprogesterone acetate [Provera®]), which are synthetic progestational (pregnancy-enhancing, abortion-preventing) drugs, and
• androgens (e.g., fluoxymesterone [Halotestin®], testolactone [Teslac®], testosterone enanthate [Delatestryl®]) synthetic male hormones that suppress the estrogen supplied to the breasts

Along with breast cancer prevention, tamoxifen has other beneficial effects such as increased bone production and the prevention of plaque buildup within the blood vessels. Tamoxifen usually is well tolerated. However, reported side effects, which are related to its estrogen-like properties, include hot flashes, nausea, vomiting, endometrial hyperplasia (overgrowth of the tissue lining the womb), and early or temporary menopause in premenopausal women.

Unlike tamoxifen, the aromatase inhibitor aminoglutethamide can cause relatively toxic side effects, such as sluggishness, ataxia (lack of motor coordination), orthostatic hypotension (low blood pressure when standing), dizziness, weakness, blood abnormalities, elevated liver enzymes, and nausea. By contrast, the progestins medroxyprogesterone acetate and megestrol acetate cause few side effects and are particularly useful in postmenopausal women (age 60+ years) who have experienced a recurrence of cancer. Androgens can cause masculinization (development of male secondary sex characteristics like a low voice and facial hair) in some women. Fortunately, fluoxymesterone (Halotestin®) is not as likely to produce masculinization as some of the other androgens. There are reports that it may be particularly effective in women who have bone metastases.

Immunotherapy

Immunotherapy – treatment that works via the immune system – usually is begun if standard therapies (chemotherapy, hormone therapy) are no longer effective. Trastuzumab (Herceptin®) – a monoclonal antibody(immune system molecule) – is a drug that binds with the HER2/neu protein found on the surface of some breast cancer cells. Trastuzumab inactivates HER2/neu, which otherwise can promote cancer growth and metastasis.

Because of how it works, trastuzumab causes fewer side effects than traditional chemotherapy. The mild side effects that have been reported include flu-like symptoms such as fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. Trastuzumab provides another treatment option for people with late-stage cancer, since it improves survival and the quality of life with minimal toxicity. Clinical studies are in progress to determine whether or not trastuzumab is beneficial when used during the first course of chemotherapy.

Transplantation Procedures

Chemotherapy for breast cancer often improves as the dose is increased. Because of this fact, oncologists (cancer specialists) have begun to practice a controversial treatment known as high-dose chemotherapy.

High-dose chemotherapy usually is given as a single, brief treatment with a dramatically increased amount of chemotherapeutic drugs. A typical program is cyclophosphamide plus cisplatin and BCNU (also called carmustine).

Unfortunately, high-dose chemotherapy temporarily destroys bone marrow – an organ essential for the production of oxygen-carrying red blood cells, clot-making platelets, and white blood cells needed to fight the serious infections that can develop following chemotherapy. Therefore, after high-dose chemotherapy, the bone marrow must be renewed by procedures such as

• bone marrow transplant (BMT), or
• peripheral blood stem cell transplant (PBSCT).

Stem cells (‘mother’ cells that can form many types of blood cells) are collected by BMT or PBSCT before chemotherapy. They are transplanted (transfused) back into the patient after chemotherapy to colonize the bone marrow with healthy, blood-making cells.

BMT requires a surgical procedure, whereas PBSCT does not. To perform BMT, a needle is used to extract stem cells from the bone marrow. To perform PBSCT, a technique known as leukapheresis(sometimes shortened to “pheresis”) is conducted to separate stem cells from the peripheral (circulating) blood. Sometimes PBSCT is preceded by injections of a ‘growth factor’ (e.g., granulocyte-colony stimulating factor, or G-CSF) to spur the production of stem cells.

PBSCT is the newest form of transplantation. It has the advantage of being performable when cancer has spread to the bone marrow. Both BMT and PBSCT usually can be carried out in an outpatient setting without general anesthesia.

High-dose chemotherapy and transplantation have been used in clinical trials to treat women who have a high risk of cancer recurrence oradvanced disease. To date, there is no conclusive proof that this method is better than standard chemotherapy. Yet because there is no confirmed cure for metastatic breast cancer, many women and their physicians feel that it is an appropriate, although experimental, therapy.

Treatment By Stage

As previously noted, treatment options are directly related to the stage of breast cancer. Yet, before deciding upon a treatment plan, the individual and her physician team must consider a number of factors. These include overall health, personal preference for therapy, anticipated length of survival, risk of another cancer, and the ER/PR (estrogen receptor / progesterone receptor) status of the tumor.

Some women develop a combination of invasive and non-invasive breast cancer. The treatment of such cases is determined by the stage of the invasive tumor.

• Stage 0 breast cancer

Ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) are both – by definition – stage 0 breast cancers. But, the similarity ends there, as these tumors are managed very differently.

LCIS

LCIS usually does not require surgery; however, it should be watched carefully, because LCIS is associated with an increased risk of cancer over time (20% incidence over 20 years). Both breasts are at risk.

• Hormone therapy with tamoxifen or raloxifene (now being tested in clinical trials) may be beneficial, along with other
• preventive measures such as exercise, dietary changes, and, in certain cases, preventive surgery (e.g., removal of both breasts in women with recurrent lumps, difficult-to-interpret mammograms, or a strong family history of breast cancer).

DCIS

DCIS is of greater concern than LCIS, since it is considered a direct forerunner of invasive breast cancer. Therefore, DCIS usually does require surgery in the form of

• mastectomy or wide excision followed by
• radiation therapy.

Mastectomy ensures a near 100% success rate for the treatment of DCIS. If breast-saving excision is chosen instead, there is a low (1%) but acceptable risk of recurrence each year.

Paget’s disease

Sometimes a tumor near the nipple will be found if there are changes in the areola or nipple surface. If Paget cells are detected during biopsy, it is likely that there is an underlying in situ or invasive ductal cancer in the breast. If the tumor affects only the nipple, Paget’s disease may be treated by removing the nipple alone and performing reconstructive surgery to replace it. Invasive breast cancers require more aggressive treatment.

Stage I breast cancer

According to breast cancer specialists, most women with stage I or stage II disease may be treated appropriately with

• breast-conserving surgery (lumpectomy, partial mastectomy) and
• axillary dissection (removal of underarm lymph nodes) or sentinel lymph node biopsy (removal of targeted lymph nodes) (see alsoSurgery), followed by
• radiation therapy.

Depending upon the individual’s specific concerns (for example, more than one cancer in the breast or a tumor near the center of the breast)modified radical mastectomy may be a better alternative, possibly followed by breast reconstruction.

When breast cancer is very small – for example, an early stage I cancer that is 0.1 to 1.0 cm in size – the treatment plan MAY NOT include systemic therapy (therapy that is given through the bloodstream, such as chemotherapy, hormone therapy, or immunotherapy). However, hormone therapy (e.g., daily doses of tamoxifen over a 5-year period) can benefit some individuals who, despite having a small tumor, are more likely to have cancer return (for example, women who are at risk due to the S-phase, HER2/neu, or ploidy characteristics of their tumors).

Stage I cancers that are between 1.0 and 2.0 cm in size often requirecombinationchemotherapy. The following are typical drug combinations:

• AC (adriamycin® and cyclophosphamide)
• CMF (cyclophosphamide plus methotrexate and 5-fluorouracil)
• classic CMF (oral cyclophosphamide plus methotrexate and 5-fluorouracil)
• FAC (5-fluorouracil plus high-dose adriamycin® and cyclophosphamide)

Hormone therapy with tamoxifen may be added to the above treatments if the woman’s tumor is positive for estrogen and progesterone receptors (“ER/PR positive”):

• ACT (adriamycin® plus cyclophosphamide and tamoxifen)
• CMFT (cyclophosphamide plus methotrexate, 5-fluorouracil, and tamoxifen)
• classic CMF+T (oral cyclophosphamide plus methotrexate, 5-fluorouracil, and tamoxifen)
• FACT (5-fluorouracil plus high-dose adriamycin®, cyclophosphamide, and tamoxifen)

Stage II breast cancer

Like women with stage I disease, most women with stage II disease initially are treated with

• breast-conserving surgery (lumpectomy, partial mastectomy) and
• axillary dissection (removal of underarm lymph nodes) or sentinel lymph node biopsy (removal of targeted lymph nodes), followed by
• radiation therapy.

If the cancer is large or has spread to many lymph nodes, the surgery of choice may be

• modified radical mastectomy, followed by
• radiation therapy.

Women who have been diagnosed with stage II breast cancer often need some form of adjuvant therapy, including chemotherapy, hormone therapy, or both.

• Chemotherapy typically is an option for women who are in good health and are expected to survive for a long time.

If the person is ‘ER/PR negative’– that is, if her breast cancer DOES NOT have estrogen or progesterone receptors – chemotherapy usually is given WITHOUT tamoxifen (hormone therapy).

• Hormone therapy may be more suitable for women who are in poor health or who have a short projected survival time.

If the person is ‘ER/PR positive’ – that is, if her breast cancer DOES have estrogen or progesterone receptors – then 5-year tamoxifen therapy is advisable.

Combination chemotherapy for stage II breast cancer is comparable to that given for stage I cancer. Below are typical drug combinations:

• AC (adriamycin® and cyclophosphamide; plus tamoxifen = ACT)
• CMF (cyclophosphamide plus methotrexate and 5-fluorouracil; plus tamoxifen = CMFT)
• classic CMF (oral cyclophosphamide plus methotrexate and 5-fluorouracil; plus tamoxifen = classic CMF+T)
• FAC (5-fluorouracil plus high-dose adriamycin® and cyclophosphamide; plus tamoxifen = FACT)

Clinical trials may offer additional treatment options for some people. If a woman’s breast cancer has spread to more than 10 lymph nodes, she may be eligible for a trial that uses high-dose chemotherapy with stem cell or bone marrow transplantation.

Stage III breast cancer

Until recently, the treatment of women with stage III breast cancer began with mastectomy (surgical removal of the breast); since there is a high risk that cancer will return in such locally-advanced disease. Yet many oncologists now begin treatment with

• neoadjuvant chemotherapy (chemotherapy before surgery) to increase the woman’s options for breast-conserving surgery (BCS). Women with large or inflammatory cancers have a particular need for neoadjuvant chemotherapy.

As with less advanced tumors, if the person is ‘ER/PR negative’– that is, if her breast cancer DOES NOT have estrogen or progesterone receptors – chemotherapy usually is given WITHOUT tamoxifen (hormone therapy). Alternatively, if the person is ‘ER/PR positive’ – that is, if her breast cancer DOES have estrogen or progesterone receptors – then 5-year tamoxifen therapy is recommended.

Combination chemotherapy programs for people with stage III cancers include:

• AC (adriamycin® and cyclophosphamide; plus tamoxifen = ACT)
• CMF (cyclophosphamide plus methotrexate and 5-fluorouracil; plus tamoxifen = CMFT)
• classic CMF (oral cyclophosphamide plus methotrexate and 5-fluorouracil; plus tamoxifen = classic CMF+T)
• FAC (5-fluorouracil plus high-dose adriamycin® and cyclophosphamide; plus tamoxifen = FACT)

Surgery – usually a modified radical mastectomy – is conducted after the tumor has shrunk.

Some individuals may be eligible to participate in clinical trials designed to lower the risk of cancer recurrence. Such trials may involve post-surgical (after surgery) therapy with high-dose chemotherapy and stem cell or bone marrow transplantation. Women with inflammatory carcinomas should be considered for bone marrow transplantation after initial therapy has been completed.

Stage IV breast cancer

When a woman is faced with stage IV cancer, either her breast cancer has recurred (returned), or it has metastasized (spread) beyond the breast.

The primary treatment for stage IV cancer is systemic therapy using

• chemotherapy, and/or
• hormone therapy.

The goal of treatment for stage IV cancer is to prolong survival and maintain thequality of life. Women with stage IV disease are often told that, although long-term management of their cancer is possible, there is no cure. Yet more and more people with stage IV cancer are defying the odds of cancer survival.

Hormone therapy usually is recommended if the woman’s tumor is

ER/PR positive and has spread only to the bones. Typical treatment involves

• oophorectomy (surgical removal of one/both ovaries),
• 5-year tamoxifen therapy, and
• anastrozole (Arimidex®) therapy to control metastatic disease.

If the woman’s tumor is ER/PR negative and has spread to the viscera (liver, lungs, brain, etc.),

• chemotherapy usually is given first if the person is able to tolerate it, followed by
• hormone therapy.

Unhealthy individuals who are ER/PR negative may be offered hormone therapy alone, with additional medicine for comfort and symptoms.

Common chemotherapy/hormone therapy programs for people with stage IV cancers include:

• ACT (Adriamycin® plus cyclophosphamide and tamoxifen)
• classic CMF+T (oral cyclophosphamide plus methotrexate, 5-fluorouracil, and tamoxifen)
• CMFT (cyclophosphamide plus methotrexate, 5-flurouracil, and tamoxifen)
• FACT (5-fluorouracil plus high-dose Adriamycin®, cyclophosphamide, and tamoxifen)
• Paclitaxel (Taxol®) plus tamoxifen
• Docetaxel (Taxotere®) plus tamoxifen
• Vinorelbine tartrate (Navelbine®) plus tamoxifen
• Gemcitabine (Gemzar®) plus tamoxifen

If the woman’s tumor is ‘HER2/neu positive’ (that is, it contains the HER2/neu protein), then

• immunotherapy with trastuzumab (Herceptin®) may be started after or instead of hormone therapy. Ongoing studies hopefully will determine whether immunotherapy is more beneficial when given alone or in combination with
• chemotherapy.

Women who are troubled by cancer-related symptoms may benefit from additional treatment with

• radiation and/or
• surgery.

Stage IV patients who otherwise are in good health may respond very well to the treatment offered in clinical trials. Such trials usually involve aggressive, high-dosechemotherapy with stem cell transplantation. A small percentage of women actually may be cured of breast cancer or may remain disease-free for long periods of time. Because promising new therapies are continuously being developed, all eligible women should be considered for treatment in clinical trials.

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Living With Breast Cancer

The unknowns that women face after breast cancer affect many aspects of their lives. There are primary issues about self-image, fear of recurrence, and the need for continued treatment, as well as issues related to daily activities, career, and relationships. Yet, after the immediate crisis of ‘the diagnosis,’ most women weather the difficulties of breast cancer without long-term psychological or sexual problems.

Psychosocial Effects Of Mastectomy

The breasts are a profound source of female self-image. Cancer of the breast may seriously affect a woman’s perception of her identity, and breast loss can be very psychologically damaging. Therefore, most breast cancer centers employ counselors. The role of the counselor is to help people adjust to the physical and psychological blow of breast cancer. About 30% of women with the disease suffer from prolonged anxiety and depression, which are natural responses to the loss of a breast or fear of the disease. Women who fail to adjust often have other life crises such as divorce or unemployment. These psychological problems can be helped by referral to a psychiatrist (specialist in mental illness), who may recommend psychotherapy or medications to aid recovery.

Physical and sexual rehabilitation can be helped by providing the woman with an adequate prosthetic device (breast form) and by encouraging the woman and her partner to discuss sexual problemsin an open way.

The decision to use a prosthesis or to undergo breast reconstruction usually is based on the woman’s own body image. Other key factors include her level of physical activity, style of clothing, and her willingness to reveal the diagnosis of breast cancer to others.

The majority of women can return to normal employment after any type of breast cancer surgery. In addition, most are able to enjoy all types of physical recreation, including swimming and golf.

Fear Of Recurrence

Women with breast cancer often assume that changes in the treated breast or other areas of their bodies may be a sign that cancer has returned. Yet many such changes are expected side effects of treatment. For example, radiation therapy may cause changes in the breast area, such as sunburn-like reddening or peeling of the skin, ‘puckering,’ loss of underarm hair, tingling sensations, or skin thickening that causes the breast to become firmer to the touch and slightly smaller in size. Therefore, women are encouraged to contact their physicians or other members of their healthcare team to determine if their symptoms are any cause for concern.

Sexuality

Certain breast cancer myths still exist and may affect a woman’s sexuality. Some women and their husbands or partners may believe that caressing of the breast plays a role in cancer development, or that it may encourage recurrence. The woman’s partner also may have fears of “catching cancer.” Although such beliefs are unfounded, they may interfere with the reestablishment of a healthy sex life. Therefore, the partner or spouse – as well as the breast cancer patient – should be involved in discussions about breast cancer diagnosis, risk factors, treatment options, and potential side effects of therapy. Cooperation in post-treatment care often enhances the ability of the woman and her sexual partner to adjust to the disease and its treatment.

After breast surgery, many women consider themselves repulsive and may be inhibited during lovemaking. Yet men often claim that their love is not impaired by the loss of their wives’ breasts and – if anything – it increases the strength of the bond with their spouse. Therefore specificsexual counseling may be very helpful after breast cancer is diagnosed.

Important topics include:

• getting used to nudity versus concealment of surgical scars with a prosthesis (breast form) or lingerie;
• how to have comfortable sex if the treated breast or arm is tender;
• how to use lubricants to avoid the vaginal dryness and pain associated with menopause;
• how to perform sensation-focusing exercises; and
• verbal and nonverbal ways to communicate sexual preferences.

Relapse Prevention

One of the difficult problems with breast cancer is that relapses may occur, even though initial treatment appeared successful. Such a relapse may develop near the site of the original cancer or in a distant organ of the body. A recurrence of cancer many years after breast cancer surgery is more likely if the lymph nodes under the armpit were diseased at the time of the original operation. To reduce the chance of relapse, adjuvant (assertive) therapy now is widely recommended. In most cases, this entails 5 years of hormone therapy with the anti-estrogen drug tamoxifen (Nolvadex®) . Tamoxifen is a non-toxic drug that is easy to use and has been found to delay or prevent relapses if taken for at least 5 years after initial breast cancer surgery.

Alternatively, some pre-menopausal women with severely cancerous lymph nodes may benefit from a 6-month course of chemotherapy given every 3 to 4 weeks. There are a variety of programs, most of which begin about 4 weeks after surgery. The frequency of treatment will depend upon the program, drugs used, and the doses. Radiation therapy may be given before, during, or after chemotherapy.

In order to detect cancer relapse at the earliest possible time, follow-up examinations with an oncologist (cancer specialist) should be scheduled at specific intervals after breast cancer treatment.

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Frequently Asked Questions: Breast Cancer

Here are some frequently asked questions related to breast cancer.

Q: Must I really have surgery to treat my breast cancer?

A: Surgery is the best initial treatment for breast cancer in most women; however, the condition lobular carcinoma in situ (LCIS) usually does not require surgery. LCIS should be watched carefully, though, since breast cancer may develop over time. In some older individuals, LCIS may be controlled by hormone therapy (tamoxifen) alone.

Q: My breast cancer was diagnosed early, but my physician says that I need surgery. Which operation is better – lumpectomy or mastectomy?

A: Although lumpectomy (removal of the tumor and its margins) – combined with radiation therapy – has gained favor as a treatment for early breast cancer, there are some important instances in which mastectomy is a better option. For example, if the tumor lies directly behind the nipple, it may be difficult for the surgeon to remove without significantly altering the shape of the breast. If this is the case, mastectomy may be a better alternative when followed up by breast reconstruction. In addition, women with small breasts may achieve better cosmetic results with mastectomy followed by breast reconstruction.

Q: Does it matter when I have surgery?

A: If breast cancer has been diagnosed and surgery is proposed, it certainly is advisable to have the operation sooner rather than later. But breast cancer is rarely a surgical “emergency.” So it is better to explore surgical options and get a second opinion before scheduling a procedure. Such leeway will permit you to make a more informed decision about your surgery; such as having breast reconstruction at the time of mastectomy, rather than during a separate operation.

Q: I am scheduled to have a lumpectomy. How can I be sure that the surgeon will remove only the lump and not my entire breast?

A: A lumpectomy is – by definition – an operation in which only the cancerous ‘lump’ is removed, along with a small border of cancer-free tissue (roughly 3/4 in.) and the nearby lymph nodes. This is the surgery to which you have consented. If you still have any questions about surgery – for example, “What will the surgeon do if more cancer than expected is found during surgery?” – discuss them with your surgeon beforehand to avoid any misunderstandings.

Q: What will my chest look like after breast surgery?

A: Many women worry that they will have a “hollow” chest after breast cancer surgery. Fortunately, the operations that are performed these days are not likely to produce that kind of disfigurement. If you have a lumpectomy, you will probably have a small indentation in your breast. If you have a modified radical mastectomy or a simple mastectomy, your chest will be flat on the side where the breast was removed. Depending upon the location of your tumor, the scar on your chest wall may be horizontal or diagonal.

Q: I am frightened by the idea of radiation therapy. Will I lose my hair or experience any other side effects?

A: Radiation therapy for breast cancer does not affect the hair on your head, although some hair loss may occur in the armpit area. Some women develop sunburn-like redness and/or skin peeling in the treatment area, whereas others do not. You may be able to predict what to expect by your personal tolerance of sunlight.

Q: Because my cancer has spread, my physician says that I should have chemotherapy. What kind of side effects should I expect, and how long will I have them?

A: The medications that are used for chemotherapy mostly affect rapidly dividing cancer cells, but they also can injure normal cells. In particular, the rapidly dividing cells of the hair follicles and the lining of the oral/digestive tract may be damaged, causing hair loss and oral/digestive complaints, respectively. Other side effects – some of which are treatable – include nausea, anemia, repeated infections, bleeding, fatigue, and changes in the menstrual cycle. Side effects usually disappear after chemotherapy has ended.

Q: Is it safe to become pregnant during breast cancer therapy?

A: Most physicians advise women to wait at least 3 years before trying to get pregnant; however, if you are already pregnant or have special considerations, there may be a different answer to this question. There is no overwhelming evidence that pregnancy causes adverse effects in women with breast cancer. But being pregnant while taking the hormone tamoxifen may interfere with the drug’s activity and increase the likelihood that your breast cancer will return. It is especially important to practice birth control when taking tamoxifen, as use of this drug is associated with a slight risk of abnormality in the unborn child. Because many women have had normal, healthy babies during breast cancer therapy, the final decision about pregnancy remains a personal choice.

Q: Is my breast cancer curable?

A: Although a “cure” can’t be guaranteed in most cases, the majority of women with breast cancer now can expect to live longer and have a better quality of life. In fact, because of recent advances in breast cancer detection and treatment, many breast cancer survivors live a normal lifespan. Even if breast cancer returns, improved therapies may control the disease for a long time.

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Putting It All Together: Breast Cancer

Here is a summary of the important facts and information related to breast cancer.

• Breast cancer is the most common cancer among women in the United States. Recent findings indicate that an American woman has a one in eight chance of developing breast cancer during her lifetime.

• Most breast lumps are not cancerous; they are benign. Most common are fibrocystic changes, in which scar-like (fibrous) tissue combines with fluid-filled sacs called cysts to form lumps. Other benign breast tumors include fibroadenmonas and intraductal papillomas. These tumors do not spread outside the breast to other organs.

• A breast tumor that can spread to surrounding tissues or organs is considered malignant, or cancerous.

• There are two major types of breast cancer: lobular carcinoma and ductal carcinoma.

• Breast cancers can be either invasive (spreading) or noninvasive (generally known as ‘in situ’ – tumors that are confined to the original site).

• Paget’s disease (cancer of the areola and nipple) and inflammatory carcinoma (a highly malignant cancer) account for nearly all remaining types of breast cancer.

• Breast cancer cells may break away, travel, and grow within other parts of the body. This process is known as metastasis.

• If breast cancer is detected at an early stage – for example, before metastasis – it usually can be cured; however, as the disease progresses, there is less possibility of an effective treatment.

• The exact cause or causes of breast cancer remain unknown. Yet scientists have identified a number of risk factors that increase a person’s chance of getting this disease, such as:
  • age
  • previous breast cancer
  • family history of breast cancer
  • genetic mutations
  • certain benign breast diseases
  • alcohol use
  • radiation exposure
  • hormones

• Some factors may reduce the risk of breast cancer because they have protective or preventive benefits. They include:
  • regular exercise
  • early pregnancy
  • breast-feeding

• Staging helps to predict how a person with breast cancer will fare over time – that is, it helps the physician to estimate how long the person will live and the risk of cancer recurrence, or relapse. Correspondingly, staging allows the physician to customize breast cancer treatment. In general, the lower the stage, the better the person’s prognosis (expected outcome).

• The treatment of breast cancer is determined by many factors, such as
  • tumor stage
  • tumor type
  • tumor characteristics
  • the person’s general health
  • medical conditions that may influence treatment.
  • After breast cancer has been staged, a comprehensive treatment plan will be developed. The treatment plan typically involves some form of surgery to remove as much of the cancer as possible.

• In addition to surgery, the treatment plan may call for adjuvant (assisting) therapy such as radiation therapy, chemotherapy, and/or hormone therapy.

• Other treatments that may be used for aggressive or late-stage breast cancers include high-dose chemotherapy with bone marrow transplantation (BMT) or peripheral stem cell transplantation (PSCT), and immunotherapy.
• Specific characteristics help to determine the risk of breast cancer recurrence (coming back). These include breast cancer:
  • size
  • estrogen and progesterone (ER/PR) receptor status (presence or absence of hormone ‘receptors’ [lock-like molecules] in cancer cells)
  • phase (whether or not tumor cells are actively dividing)
  • HER2/neu protein status (presence or absence of a protein found in some aggressive breast cancers)
  • grade (indicator of malignant change in the tumor)
  • ploidy (number of sets of genetic material within tumor cells)

• A recent trend in surgery for early breast cancer is the use of lumpectomy (a breast-saving procedure in which only the tumorous ‘lump’ is removed), plus radiation therapy. This method spares the breast and has been found to be as effective a mastectomy (complete removal of the breast).

• Radiation therapy usually is given after breast-conserving surgery, that is, after lumpectomy or partial mastectomy.

• Chemotherapy typically is delivered in the form of shots or pills. It usually is given as an adjuvant (assisting therapy) to reduce the chance of cancer recurring after surgery, radiation therapy, or both.

• Adjuvant chemotherapy, like hormone therapy, typically is started after surgery.

• Neoadjuvant chemotherapy is given before surgery to shrink the breast tumor and make it easier to remove.

• ‘Combination chemotherapy’ – a combination of drugs – often is more effective than a single medication. The following drugs frequently are used together during chemotherapy:
  • cyclophosphamide
  • methotrexate
  • 5-fluorouracil
  • Adriamycin® (doxorubicin)
  • tamoxifen
  • Taxol® (paclitaxel)

• Hormone therapy for breast cancer is based on the observation that cancer cell growth is sped up by estrogen. ‘Antiestrogen’ medications like tamoxifen (Nolvadex®) and raloxifene are used to counteract this effect.

• Tamoxifen is likely to be given if a woman’s breast cancer is ‘ER/PR positive’ – that is, it contains estrogen and progesterone receptors.

• Immunotherapy – treatment that works via the immune system – usually is begun if standard therapies are no longer effective. A monoclonal antibody (immune system molecule) has been developed to recognize and bind with the HER2/neu protein found on the surface of some breast cancer cells. The medication made from this antibody is known as trastuzumab (Herceptin®).

• About 30% of women with breast cancer suffer from prolonged anxiety and depression, which are natural responses to the loss of a breast or fear of the disease. 

• Sexual counseling often is helpful for breast cancer patients and their partners. Important topics include:
  • getting used to nudity versus concealment of surgical scars with a prosthesis (breast form) or lingerie;
  • how to have comfortable sex if the treated breast or arm is tender;
  • how to use lubricants to avoid the vaginal dryness and pain associated with menopause;
  • how to perform sensation-focusing exercises; and
  • verbal and nonverbal ways to communicate sexual preferences.

 

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Glossary: Breast Cancer

Here are definitions of medical terms related to breast cancer.

Adjuvant therapy: Treatment given in addition to surgery, such as radiation therapy, chemotherapy, or hormone therapy.

Atypical hyperplasia: Cells that are both abnormal (atypical) and increased in number.

Axillary lymph node dissection: Surgery to remove some of the lymph nodes in the armpit.

Benign: Not cancerous or malignant.

Breast-conserving surgery (BCS): Surgery that removes only the tumor and a small amount of surrounding breast tissue. Examples are lumpectomy and segmental mastectomy.

Breast self-examination (BSE): Examination of one’s own breasts on a regular basis.

Cancer: A group of diseases in which cells are changed in appearance and function, grow out of control, and form a ‘tumor’ (mass) that tends to spread to surrounding tissues or organs.

Chemotherapy: Treatment using drugs that kill or damage cancer cells.

Estrogen replacement therapy (ERT): see Hormone replacement therapy (HRT)

Excisional biopsy: Surgery that completely removes a small breast lump during tissue sampling. The tissue is studied under the microscope to see if cancer cells are present. Excisional biopsy usually is performed if the physician suspects that a breast lump is benign (not cancerous). Excisional biopsy is NOT a lumpectomy.

Fine needle aspiration (FNA): Procedure that removes a sample of fluid and/or cells from a breast lump by means of a fine needle and syringe.

Hormone replacement therapy (HRT): Hormone therapy (estrogen and progesterone/progestins) used by older women to relieve the symptoms of menopause.

Hormone therapy: Cancer treatment in which drugs are used to slow tumor growth by blocking the effect of certain hormones; employed to prevent cancer recurrence.

Implant: Artificial device used in surgical reconstruction to restore breast shape. May be filled with saline (salt water) or silicone (gel).

Malignant: Cancerous. A growth that tends to spread to surrounding tissues or organs.

Menopause: Time when a woman’s monthly menstrual periods cease. Menopause often is referred to as the “change of life.”

Metastasis: Spread of cancer from one part of the body to another. Common sites for breast cancer metastases are the lungs, bones, liver, and brain.

Modified radical mastectomy: Surgery that removes the entire breast, including some axillary (underarm) lymph nodes; also known as Patey mastectomy. In some cases, the pectoralis minor (upper chest muscle) may be removed if it is cancerous or blocks the removal of lymph nodes.

Oncogene: Gene that contributes to cancer; e.g., HER2/neu

Partial mastectomy: Non-specific term for surgery in which part of the breast is removed. The axillary (underarm) lymph nodes are taken out through the original incision or via a separate incision in the armpit itself. In general, between 10 and 15 lymph nodes are removed during partial mastectomy.

Quadrantectomy: Partial mastectomy in which about one-quarter of the breast is removed along with the tumor; also known as segmentectomy,segmental mastectomy, or tylectomy.

Radiation therapy: Treatment for breast cancer that uses high-energy rays to destroy cancer cells.

Reconstruction: Surgery to rebuild the shape of the breast.

Recurrence: Reappearance of the cancer; also known as relapse. There are three kinds of recurrence: local – at the same site; regional – near the original site; and distant – in another site.

Segmentectomy or segmental mastectomy: see Quadrantectomy

Simple mastectomy: see Total mastectomy.

Tamoxifen: Hormonal drug used in cancer therapy. Tamoxifen blocks estrogen – a hormone necessary for the growth of some breast cancers – and therefore helps to shrink them.

Total mastectomy: Surgery to remove the entire breast, but not the axillary (underarm) lymph nodes or muscular tissue beneath the breast; also known as simple mastectomy.

Tumor: A cellular growth that forms a progressively enlarging mass. A tumor is benign unless it tends to invade surrounding tissues and organs, in which case it is malignant.

Tylectomy: see Quadrantectomy.

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Additional Sources Of Information: Breast Cancer

Here are some reliable sources that can provide more information on breast cancer.

American Cancer Society (ACS) 
Phone: (800) ACS 2345 (toll-free hotline)
www.cancer.org

The American Cancer Society (ACS) provides a national, toll-free hotline (800 ACS 2345) that has information about breast cancer and referrals for the ACS-sponsored “Reach to Recovery” program for breast cancer.

In addition, the ACS supplies pamphlets that may be obtained by calling the hotline or local ACS chapter:

• Breast Cancer Network Update and
• Breast Cancer Questions and Answers.

National Cancer Institute (NCI), Cancer Information Service 

Phone: (800) 422 CANCER

www.nci.nih.gov

The Cancer Information Service (CIS) has a regional network that provides in-depth information about cancer. The CIS offers informational brochures as well as referrals to medical centers and facilities that offer clinical trials.

Spanish-speaking staff members are available upon request.

National Alliance of Breast Cancer Organizations (NABCO) 
Phone: (212)-719-0154
Fax: (212) 768-8828
www.nabco.org

NABCO is a nonprofit resource for information about breast cancer.

Annual membership in NABCO’s information network ($40, tax deductible) entitles the participant to receive:

• Nabco News, a quarterly publication
• customized information packets
• Breast Cancer Resource List, and
• special mailings

Y-ME National Organization for Breast Cancer Information & Support (Y-ME) 
Phone: (800) 221-2141
Phone: (312) 986-8228(24-hour hotline) 
Fax: (312) 986-0020

Y-ME offers support to callers by trained volunteers, most of whom have had breast cancer. A new hotline also is available for the partners of women with breast cancer. Y-ME has chapters in 12 states besides Illinois, and it provides advice about how to start a local support group for women living with breast cancer.

Society for the Study of Breast Disease (SSBD) 
Phone: (214) 821-2962
Fax: (214) 827-7032

Susan G. Komen Breast Cancer Foundation (SGKF) 
Phone: 800-462-9273

U.S. Breast Cancer Centers

Northeast

Dana Farber Cancer Institute Breast Evaluation Center (BEC) 
44 Binney Street
Boston, MA02115
Phone: (617) 632-3000

Comprehensive Breast Center at the Lombardi Cancer Center Georgetown University Medical Center 
3800 Reservoir Road NW
Washington, DC20007
Phone: (202) 687-2122

Evelyn H. Lauder Breast Center/ Iris B. Cantor Diagnostic Center of Memorial Sloan-Kettering Cancer Center 
205 East 64th Street
New York, NY10021
Phone: (212) 639-5200

Strang-Cornell Breast Center of the Strang Cancer Prevention Center 
428 East 72nd Street
New York, NY10021
Phone: (212) 794-4900

South

University of Texas M.D. Anderson Cancer Center Breast Clinic 
1515 Holcombe Boulevard
Houston, TX77030
Phone:  (800) 392-1611

Midwest

The Mayo Clinic’s Breast Clinic 
200 First Street SW
Rochester, MN55905
Phone: (507) 284-9238

Myer L. Prentis Comprehensive Cancer Center of Metropolitan Detroit 
110 East Warren Avenue
Detroit, MI48201
Phone: (313) 833-0710

Lynn Sage Comprehensive Breast Center at Northwestern Memorial Hospital 
333 East Superior
Chicago, IL60611
Phone: (312) 908-5522

West

The Breast Center 
14624 Sherman Way, Suite 600
Van Nuys, CA 91405

Revlon/UCLA Breast Center at Jonsson Comprehensive Cancer Center 
200 UCLA Medical Plaza, Suite 510
Los Angeles, CA90095
Phone: (800) 825-2144
Phone: (310) 825-2144

Helpful Websites

OncoLink University of Pennsylvania Medical Center and Cancer Center 
http://cancer.med.upenn.edu

CancerNetNational Cancer Institute 
http://www.meb.uni-bonn.de/cancernet/cancernet.html

Books

Breast Cancer. The Complete Guide, by Yashar Hirshaut M.D., F.A.C.P. and Peter I. Pressman, M.D., F.A.C.S. (New York: Bantam Books, 1996)

This book is written by a breast cancer surgeon and an oncologist. It covers all topics from breast cancer diagnosis to life after cancer. In addition, it provides resources for advice about breast cancer centers and information services. (4 rating).

The Complete Book of Breast Care, by Niels H. Lauersen, M.D., Ph.D., and Eileen Stukane. (New York: Fawcett Columbine, 1996).

This book, by the authors of Listen to Your Body, offers professional guidance to maintain healthy breasts and to combat breast cancer. It covers breast cancer diagnosis, treatment, and recovery. This book also provides a wealth of valuable resources for concerns such as: where to find help, planning treatment, plastic surgery/reconstruction, emotional support, nutrition, medication, and other topics. (5 rating)

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