What Is Breast Cancer?

Any uncontrolled growth of breast tissue cells, which has the capacity to spread, is breast cancer. "Early" breast cancer is confined to the breast and the tumor is not larger than 5 cm (about 2 inches) across. It may also involve the lymph glands under the armpit, called the"axillary lymph nodes." It has not spread to any distant sites in the body, as far as can be told with todays technology. "Locally Advanced" Breast Cancer is noted by a tumor greater than 5 cm across, or a fixed lump in the axilla representing cancer, ulceration of the skin from cancer, or involvement of the deep chest muscles."Inflammatory Breast Cancer" is a hot, tender breast with skin looking like an orange peel, called "peau de orange" and almost always has spread to the axilla. "Metastatic" breast cancer means the disease has spread to other areas of the body, such as the lung, liver, brain, skin or bone.

Breast cancer, like other cancers, starts in just a single cell . Normally, breast cells divide infrequently after breast growth is completed; only to replace those cells lost through old age or injury. The production of new breast cells from pre-existing ones is under tight control by the genetic code, or "genes," of each cell. When this code becomes damaged, a cell may start dividing out of control. The breast cancer cell is genetically damaged, but otherwise it looks very similar to normal body tissue. This is why our immune system may fail to detect it as abnormal. These cells can pile up to form a local "tumor." A tumor simply means a swelling; it is not necessarily cancerous . Less than 1/3 of new breast lumps and bumps are cancer. A tumor which only grows in it's place or origin, and cannot spread distantly, is called "benign"and is not cancer. However, a tumor which has the capacity to spread (whether it actually does or not) is called "malignant," this is cancer. The actual process of spread is called "metastasis." It is this ability to spread to any organ in the body which makes cancers so dangerous.

How Common is Breast Cancer?

Breast cancer is the most common cancer in women, after skin cancer, with 185,000 new cases estimated for 1997 in the U.S.A . It causes 45,000 deaths per year, which makes it second leading cause of cancer death after lung cancer in women. The number of annual deaths from breast cancer has remained about the same for the past 50 years, although the number of cases is increasing. This shows the benefits of early detection, which impacts survival. Also, effective treatment is increasing survival in all breast cancer patients. One in nine women will get breast cancer in the U.S.A. during their lifetimes . Two thirds to 75% of cases are "Early Breast Cancer", 20% are "Advanced Breast Cancer" (including Metastatic), and 5% are the"Inflammatory" subtype. Initial "Early Breast Cancer" which was thought cured may be detected as the "Advanced Metastatic" type decades after the initial diagnosis and treatment. Advanced Breast cancer can "smolder" along, slowly growing in the bone, for many years before detection.

What Causes or Increases the Risk for Breast Cancer?

Like any other cancer, the exact reason why one woman gets breast cancer and another doesn't remainsunknown. However, certain "risk factors" have been identified:

1) Being female (only 1% of cases are in males).
2) Family history of breast cancer in mother and aunts; BRCA-1 gene. The BRCA-1 gene stands for breast cancer, and although the risk is increased with the gene, not all patients with it get breast cancer. Also, genes for rare diseases like ataxia-telangectasia ("A-T") (lack of repair of skin to sun damage) associated with breast CA.
3) Getting older-- average age is 60 to get breast cancer.
4) Lots of estrogens-- including start of menstrual periods at a young age, completion of menstrual periods at an old age, no children or first child after age 30, being obese (fat cells produce estrogen).
5) Low dose radiation exposure-- can take 10 to 50 years afterward to develop breast cancer, among others. About 6 per 1 million women are estimated to get breast cancer from the mammogram radiation, but this is believed worthwhile owing to the many early cancers found.
6) High fat in the diet. This many also be related to obesity above.

Tobacco smoking, alcohol or birth control pills do NOT seem to increase risk!

Is Breast Cancer Preventable?

Most of the risk factors for getting Breast Cancer are not in a woman's control. In the past, women with a very high risk sometimes had both breasts removed as a preventative measure, called "prophylactic mastectomy." This is very infrequent today, given the earlier detection and better treatment of breast cancer. Reducing fat in the diet, getting pregnant in her early 20's, appropriate screening, and prompt treatment can reduce cancer deaths.

How is Breast Cancer Screened For?

There are two common ways of screening for breast cancer. Every woman can do a Breast Self Exam"one week after her menstrual period each month, feeling for lumps. After menopause, it can be done at any standard time each month. This should also be done if a patient with a history of breast cancer has kept a breast. The American Cancer Society recommends a"baseline" mammogram at age 35 - 40 with an "every other year" mammogram from ages 40 to 50. After age 50, women should get a mammogram every year. Women at higher risk may get this test more frequently, as should women who have had breast cancer but kept their breast. In spite of the recent controversy for how often to get mammograms, the main point is to get them on a regular basis, especially as a women gets older than age 40.

What are the Symptoms of Breast Cancer?

Early breast cancer usually has no symptoms, but is picked up with screening tests. It is important to note that most new breast lumps are not cancer, but it must be "ruled out" anyway. The first symptom is usually a new lump or bump in the breast, which is of "dominant" character. This means that it is single, hard, non-movable, non-tender, and in only one breast . Occasionally (3%) breast cancer results in a nipple discharge, while 50% of watery discharges are from cancer, only 1% of milky or pussy discharges are cancerous. In more advanced breast cancer, the breast may have a large tumor, or have a lump in the armpit. Inflammatory breast cancer looks like an infection, being red and painful, and may be confused with the much more common "mastitis," which is a simple breast infection. Breast cancer spread to bones can cause pain and fractures, and to the brain can result in symptoms of imbalance, confusion, headache and local weakness or numbness. Rarely, it spreads to the eyes to cause blindness. Most commonly, however, it stays localized in the breast for many years. If it spreads, it is most commonly to bone where it may remain inapparent for many years. About 5% of patients develop cancers in both breasts, called "bilateral" breast cancer.

How Does Breast Cancer Spread?

It generally starts inside the milk ducts of the breast, then invades through the wall ofthe breast. If it invades, then it grows locally to form a tumor, and the first spread is to the lymph glands in same sided armpit (called the "axilla" ). When the tumor is 1 inch across, there is a 30% chance that it has spread to the axillary lymph glands; when it is 2 inches across, the chance of the axilla being involved, or "positive" is about 60%. Once the axilla is involved, the cancer is considered "systemic", that is likely to have spread to other areas of the body through the bloodstream. The most common places for it to spread, in order, are the bones, liver, lung, skin and brain.

What are the Types of Breast Cancer?

The most common type is called "Invasive Ductal Carcinoma," that is, the cancer starts in the milk duct and invades through it. This accounts for 70% of breast cancers,and is the only type found in men. It accounts for most of the locally advanced and inflammatory cancer, too. The next most common type is called "lnvasive Lobular Carcinoma." It arises from the lobules in the breast and accounts for 10% of cases. Alternatively, the either the "Ductal" or the "Lobular" type of cancers may not invade, but stay locally within the ducts or lobules and grow to a large size there. "Non- invasive" or "in Situ" disease accounts for about 10% of breast cancer, it does not spread to the axilla or elsewhere, and in general patients do better than with invasive disease. It is also important because local recurrence of breast cancer (after breast conservation therapy) may be of this "non-invasive" type and so less dangerous. "Ductal Carcinoma in Situ," or "DCIS " for short, is becoming more common since it often can only be detected with a mammogram. Interestingly, "Lobular Carcinoma in Situ," or "LCIS" for short, is a "marker" for the development of later invasive ductal cancer, which happens in 30% of patients. Uncommon types of breast cancer include "medullary," "mucinous," and "tubular" forms, which all tend to occur in older women and are less aggressive, and "Paget's Disease of the Nipple," which appears as a scaly irritation but has an underlying lump in the breast 70% of the time. Rarely, cancer may arise from the sweat glands of the breast ("apocrine") from the immune cells in the breast ("lymphoma") or from the muscle("sarcoma"). The treatment for these cancers is different that the typical ductal or lobular types, and discussed in other transcripts. There may be a mixture of types 10% of cases.

How is Breast Cancer Detected and Evaluated?

Monthly breast "self-exam" by women can pick up about 30% of breast cancers, both new ones and recurrences after breast conservation therapy. Others are too small to be felt, or "palpated," but 85% of breast cancers can be detected with a mammogram. The radiation dose from a modern mammogram is 0.2 centigray, about the same as an ordinary chest X-ray. Worrisome findings on a mammogram include lots of little calcium deposits, called "microcalcifications," especially in irregular or "starburst" patterns. About 1/3 of these will represent cancer. Sometimes, a "dominant" mass may be felt in the breast, but the mammogram doesn't show anything. any dominant mass must be biopsied (sampled) to rule out cancer! That's because 15% of even large cancers will remain invisible on a mammogram. If a suspicious area is found, either on exam or mammogram, the National Cancer Institute recommends a "2 part approach." Firstly, a biopsy (sampling procedure) is done to confirm or deny cancer, then secondly, a surgery is performed to remove any cancer detected. The quickest, easiest way to sample a suspicious area is called a "fine needle aspiration" in which a thin needle is placed into the tumor using radiographic guidance. Some cells are sucked up, or "aspirated," and sent to a "pathologist," who is a doctor who specializes in making diagnoses from tissue specimens. This test is over 90% accurate at detecting cancer. If it is"positive" (that means cancer is found) then surgery is done. Either the entire breast is removed (called a mastectomy ), or just the area of the tumor with a surrounding safety margin (called a lumpectomy). The cancer removed is submitted for various tests, to classify it and see how likely it is to be aggressive. These include the following "Prognostic Factors" :

Grading the tumor -- the pathologist looks at the cells in the tumor to see how closely they resemble normal breast cells. He assigns a grade, called the "Bloom-Richardson" grade, from 1 to 3. A grade of 1 means that the tumor closely resembles normal breast, that is "well-differentiated", and probably isn't very aggressive while a grade of 3 means the tumor looks very cancerous, that is "poorly differentiated"and is likely aggressive. A grade of 2 means "moderately differentiated" so is of intermediate behavior.

Estrogen and Progesterone Receptor Studies ("ER" and"PR" for short) look to see how likely the tumor is to respond to these female hormones. The chances of them being positive increases with the age of the patient. If both "ER" and "PR" are positive, the tumor is less aggressive and has an 80% chance of responding to "anti-estrogen" drugs like tamoxifen. If both are negative, their is only a 10% chance of response Positive "PR" with Negative "ER" is better than vice-versa.

The "DNA activity measurements" of"S-phase" (which tells how quickly the cells are dividing--higher "S-phase" is more aggressive ) and "Ploidy" which also tells how similar the cancer cells are genetically to normal breast cells. "Diploid" is normal and is better than"aneuploid" which is more cancerous.

Cathepsin D -- is a cellular "enzyme", a high level suggests positive lymph glands .

"Oncogenes" look genetically at the tumor, if the "Breast Cancer" ("BCA-1") or a gene called"HER-2/neu" are increased, these tumors are more aggressive.

The size of the tumor - If it's less than 1 cm. across, 10 year survival is over 80% while if it's more than 7 cm. across, average 10 year survival is only 40%. The larger the cancer grows locally (the higher the"tumor burden" ), the more chance it has to spread to lymph nodes and to distant body areas. The pathologist also looks at the type of breast cells to classify the cancer as "ductal" or "lobular," and to see if it invades through these ducts or lobules. If the cancer in vades (90% of them do) then it becomes necessary to do a second small operation, called an "axillary lymph node sampling", which is not a therapeutic procedure, but merely diagnostic. There procedure isn't done if the cancer isn't invasive (i.e. "DCIS" or "LCIS"). If the axilla's lymph glands are "negative" (not involved) then 10 year survival is over 75%, while if more than 4 lymph nodes are "positive" (involved) 10 year average survival drops to only 25%. The main point of checking the axilla is to see if chemotherapy will be necessary, if its involved, this suggests that the cancer cells may have spread through the body, and chemotherapy will be necessary.For any Locally Advanced or Inflammatory cancer, chemotherapy is essential .

Other Standard Tests: Include"bone-scan" where a small quantity of radioactive dye is injected into a vein, and a special X-ray is then taken to see if the cancer has gone to bone. Breast cancer has a predilection to go to bone, where it may lie dormant for many years. A "baseline" scan is obtained for any invasive cancer, to make later scans easier to compare and interpret. If "something" is seen on a bone scan, it may or may not be cancer. Old fractures, inflammation, or infections can make bone scans "light up" in those areas. The two ways of seeing if cancer is causing the increased "uptake" is to do a bone biopsy, or do another bone scan several months later to see if the area has "progressed." In practice, bone biopsy is difficult and may still miss an area of cancer spread, giving a false sense of security. Repeat scans and the expertise of the radiologist in determining whether cancer is causing the abnormal bone scan are relied upon.Chest X-ray and Chest and Abdominal CT scans ("Computerized Axial Tomography"). A contrastsolution may be injected into an arm vein, which helps highlight blood vessels in a CT scan. Insist upon"omnipaque" brand or equivalent contrast; it is more expensive but also more comforable and less likely to cause allergic reactions or kidney failure. These scans are obtained to help rule out spread, or"metastasis" of cancer to the lungs and liver. CT scan of the Brain or Bone Marrow Biopsy are only done if their is suspician that the cancer has spread to these organs, or if a bone-marrow transplant is considered. Routine blood tests of "complete blood count" (CBC ) and "chemistry panel" (SMA ) are obtained prior to any therapy.

How is the Extensiveness of Breast Cancer Gauged?

Like any cancer, the extensiveness of Breast Cancer is given by the "Stage." The American Joint Cancer Committee ("AJCC") has stages given by Roman numerals:

"Stage 0" means the cancer does not invade, such as "DCIS" or "LCIS"
"Stage I" means the cancer is less than 1 inch across, and is invasive.
"Stage II" means the cancer is between 1 and 3 inches across, or the lymph glands in the axilla are involved (or both).
"Stage III" means that the cancer is greater than 3 inches across and the lymph glands in the axilla are involved and may even be hard and "fixed".
"Stage IV" means that the cancer has spread to other organs, like bone or brain. This may be as little as a single lymph node involved above the collar- bone ("supraclavicular node") or as much as massive cancer spread ("dissemination") throughout the body.

What is the Survival of Breast Cancer?

This depends upon many factors, including the cancer type, grade and stage, the general condition of the patient, and the treatment(s) selected. The textbook figures are:

It is crucial to note that many patients live many productive years with their cancer! The figures given above include death from all causes, including heart attack, accidents, or a different cancer. Many patients with breast cancer are elderly and have other serious medical problems ("comorbid conditions") leading to their demise.

What is the Conventional Treatment for Early Breast Cancer?

For both invasive and non-invasive Breast Cancer, the historical treatment has been mastectomy. The pioneer of this operation was a surgeon named Halstead, who advo cated radical mastectomy. In this operation, not only is the entire breast removed, but so are the underlying muscles of the chest wall (called the "pectoralis muscles") and the lymph glands in the axilla. Halstead believed that the lymph nodes in the axilla acted as as "trapping stations" for cancer, which would only spread after the axilla was involved. In the 1950's, an even more radical operation, called an extended radical mastectomy where the lymph glands under the breastbone, (called the "internal mammary nodes") were also removed. When more drastic operations were NOT shown to increase cure, modified radical mastectomy, where the major chest wall muscles are kept in place, (which helps arm function) and the internal mammary lymph nodes are kept in place. Along with the breast removal surgery, a new artificial breast may be constructed by sewing a bag of gel material under the skin. Even a fake nipple can be formed.

Surgery side effects include standard operative death risk of 1- 2%, infection risk of 10%, and possible arm weakness and swelling (called "edema") with extensive surgery. The recovery period depends upon the extent of the surgery, but is weeks to months. The results of surgery depend upon the stage of the cancer, but in general, 10 year survival is about 70% for early breast cancer treated with mastectomy.

Radiation has been used as the only therapy for patients who cannot tolerate surgery. The treatment is prescribed by a Radiation Oncologist, a cancer doctor giving radiation. This involves radiation of the entire breast for even early breast cancer, as up to 1/3 of breast cancers are "multicentric," meaning that they are spread through more than one quadrant of the breast. The patient is first "simulated," which means they are placed on a hard table, the breast is exposed, and aligned with laser lights. The treatment area is then marked out, first with markers and eventually small tatoos are placed in the skin. Sometimes a CAT scan of the chest is also obtained, and data from this is put into a treatment planning computer. A "plan" is generated, which tells how much radiation is going to the breast and how much is going to normal tissues like the lung. The patient then begins receiving treatments, Monday through Friday, taking only 15 minutes per day for 5 -7 weeks. The total dose of radiation is between 45 and 75 Gray (units of radiation) depending upon the extent of the cancer. X-Ray "Verification Films" are taken each week or so, which only tell about consistency of the patients position; they do not tell anything about the cancer. It is common for the last week of treatment to be a "boost" to the actual tumor area, which spares the remainder of the breast. The patient does not get sick, become radioactive or lose their hair. They can maintain normal diet and most activities, like driving.

Side effects of Breast Radiation are divided into possible "acute" and "late" effects. Acute effects occur during the treatment period, while late effects occur months to years after treatment is complete. Common acute effects include redness and tenderness of the breast area, especially about the skin folds under the breast and the nipple. This starts occuring after about 2 weeks of treatments, and may progress to skin peeling, caused "desquamation." Special salves, like acemannan, or steroid creams may reduce the irritation. Patients are also usually mildly fatigued during the treatment period. Later effects of radiation include possible lung injury, called "radiation pneumonitis," which is usually only detectable by chest X-Ray and has no symptoms. In less than 10% of patients, symptoms of cought, shortness of breath, and fatigue are seen, which usually respond quickly to steroids. Skin reaction and lung or heart problems tend to be greater if chemotherapy is used. Very Rarely (<1%) patients may develop a severe syndrome of lung injury leading to debility or death. Other rare later effects include arm swelling and a higher risk of developing lung cancer, especially in smokers. Most commonly, the radiation is well tolerated, the skin reaction subsides after conclusion of treatment, and the breast becomes somewhat firmer and smaller than it was previously.

The results of radiation alone show a survival somewhat inferior to surgery, about 55% 10 year survival. This is overall survival for a combination of local breast cancer stages. Many of these patients have other morbid medical conditions for which they couldn't tolerate surgery, so their life expectancy is therefore shorter.

Chemotherapy has not been conventionally used alone for early breast cancer, but it is used extensively in combination with other treatments, like surgery and radiation. Popular Chemotherapy drugs includeAdriamycin ("A"), Cyclophosphamide ("C"), Methotrexate ("M") and 5-Fluorouracil (5-FU or "F"). Combinations are frequently prescribed, such as CAF or CMF, usually given for six"cycles"(monthly administrations). In early invasive breast cancer, the idea of this chemotherapy is to kill cancer cells that may have escaped from the tumor, travelled through the bloodstream, and implanted elsewhere in the body. These are called "micro-metastasis", and although they cannot be detected with any current technology (since they are so small), we know that they may be present and eventually grow into large tumors. Chemotherapy may kill these cells and so prevent the cancer from recurring. This is inferred in 2 ways- the first being the evident shrinkage of a large breast tumor when chemotherapy is given for advanced breast cancer, and the second being an actual increase in survival seen when chemotherapy is added to other therapy for certain early invasive breast cancers. These particular patients, from the large "Scottish Trialists" study in 1992 published in Lancet:

1) Any woman who is "pre-menapausal" (still having periods) with an invasive tumor larger than 1 cm.
2) Any woman post-menapausal woman (no longer having periods) who's Estrogen and Progesterone Receptor studies are negative.
3) Any patient with axillary lymph node involvement ("positive nodes").

Side effects of the common chemotherapeutic agents:

Adriamycin can cause heart damage and the dose is limited to 500 mg/ per square meter of patient body surface area. It is common to get a "heart scan" called a "MUGA" test before giving adriamycin. It also causes greater skin redness and irritation if radiation is given.

Cyclophosphamide is derived from mustard gas and causes a lowering of blood counts. Drops in red-blood cell count cause anemia, with paleness and tiredness, drops in white-blood cell count lead to "neutropenia" which shows as infections and fevers, while a drop in platelet count leads to prolongued bleeding and easy bruising.

5-Fluorouracil (5-FU) has its side effects on rapidly dividing cells in the body such as the lining of the intestines and also the bone marrow. It can cause mouth sores and diarrhea. Rarely, 5-FU can cause skin peeling and nervous system symptoms.

Methotrexate has similar side effects to 5-FU, and can also cause decrease in liver and kidney function.

The results of chemotherapy alone shows shrinkage in over 80% of tumors when it is given in combinations like CMF and CAF. Practically speaking, however, it is difficult to completely obliterate the cancer with chemotherapy alone, and the response may be short-lived. Cancer cells can develop resistance to chemotherapy. Therefore, it is used in combination with other treatments such as surgery and radiation to increase its effectiveness, for both "local" and "distant" control of breast cancer.

Hormonal Therapy alone is also insufficient treatment. It has been long obvious that some breast cancers are very dependent on the female hormones estrogen and progesterone to grow. Women who had their ovaries either removed surgically (called "oophorectomy") or sterilized with radiation treatments often had a slowing of the progression of their breast cancer. Instead of actually removing or radiating the ovaries, drugs have been developed which counteract estrogen and progesterone. The most common "anti- estrogen" drug is tamoxifen (nolvadex), which is given as a 10 mg tablet twice per day. Since it also has some estrogen-like properties, patients with spread to bone may have an initial increase in pain, called a "flare" when first starting tamoxifen. It also commonly causes hot flashes and fatigue. Tamoxifen also appears to increase uterine cancer in women who have kept their uterus. Breast cancer may respond to tamoxifen for many years, then become resistant to it. Other anti estrogen drugs, called "progestational agents" such as megacecan then be used (40 mg four times per day). The cancer cells may become resistant even progesterones also, afterwhich male sex hormones such as halotestin may be tried. These cause hair growth and increased muscles, but may stymie the cancer for a while. All women who are ER and/or PR positive will be started on hormonal therapy, even for early invasive breast cancer. This includes most women over 50 years old, who tend to have less aggressive tumors anyway. If there is no sign of cancer spread, (monitored with bone scans), then how long to continue hormones is controversial, but at least 5 years after diagnosis is reasonable.

What is the Latest, Effective Therapy for Early Breast Cancer?

In general, the latest treatments use a combination of the above conventional treatments to reduce the chance that the cancer will come back. Increasing efforts have also been made to save the breast, instead of routinely removing it. The particular treatment recommended depends upon the type and extent of cancer found at biopsy. For non-invasive cancers, such as Ductal Carcinoma in Situ (DCIS) and Lobular Carcinoma in Situ (LCIS), which in the past were routinely treated with mastectomy breast conservation is now usually possible. The results of limited surgery to remove the tumor ("lumpectomy") and "adjuvant radiation treatments" are just as good, or even better than, mastectomy. For DCI, which is non-invasive Breast Cancer, the current best known therapy for localized disease (not in more than one quadrant of the breast) is lumpectomy and adjuvant radiation therapy to 50 Gray (units of radiation). The benefit of adding this radiation therapy to the whole breast was shown in alandmark study (NSABP-17) published in the New England Journal of Medicine in June 1993. In this study, patients with non-invasive Breast Cancer were divided into 2 groups-- the first had only a local removal of the tumor with a safety margin, while the second had local removal followedby radiation therapy to the affected breast. After 5 years, the cancer had come back in20% of those with surgery only, compared to just 10% for those who had both surgery and radiation . Furthermore, when the cancer came back in those with surgery only, it was 50% likely to be the worse invasive type, while in those who had both surgery andradiation treatment, only 25% had the invasive type. In non-invasive disease, there isless than a 2% chance of spread to the axillary lymph nodes, so these are not checked with an "axillary lymph node dissection" (as is routinely done for invasive breast cancer).However, the radiation given nevertheless does treat the portion of the axilla that would be the most likely part involved. Giving hormones (tamoxifen) is reasonable if the tumor as aggressive characteristics, detailed in the "Backround on Breast CA" segment. Note: Chemotherapy is not appropriate for non-invasive disease.

The results of lumpectomy + breast radiation treatment for non-invasive disease show over 98% survival at 5 years, which is exactly similar to getting total breast removal (mastectomy). Patients who should have mastectomy are those with disease spread through the breast, and those who cannot have radiation treatments (to be described). For LCIS (lobular cancinoma in situ) simple surgical removal (lumpectomy) with a safety margin is adequate therapy, unless an invasive ductal cancer is found (which is the case in 30% of patients with LCIS-- it is considered a "marker" for possible invasive disease). Surgeons used to do "blind biopsies" of the opposite breast to look for this cancer, but this is usually just done with mammographs now. LCIS is less aggressive than DCIS, so unless it is spread through the breast, simple lumpectomy is enough, with careful monitoring to ensure that an invasive cancer does not get ignored.

Latest Effective Therapy for Early Invasive Breast Cancer

While patients used to be routinely treated with modified radical mastectomy, breast conservation is now possible for the great majority of women. If the tumor is only removed with a "safety margin," then about40% of these cancers will come back in the breast. Therefore, simple "lumpectomy" is inadequate treatment . On the other hand, if the whole breast is removed, about 10% of the cancers will recurr. While modified radical mastectomy is adequate surgery, it is also drastic. Oncologists had to be convinced, however, that other approaches besides mastectomy were safe. This proof has come in the form a 7 large studies, comparing the results of mastectomy versus lumpectomy with the addition of radiation treatments to the affected breast. These studies, including the landmark NSABP-06 study, have all shown no differance in results or survival between conventional mastectomy and breast-conserving treatment . Still, only 35% of women eligible to have their breast preserved actually keep it, although this is increasing. Some women, however, with either invasive or non-invasive breast cancer aren't able to have their breast preserved and get a modified radical mastectomy instead. These are:

1) Women who do not want 6 weeks of radiation treatment, or prefer mastectomy.
2) All the tumor can't be removed at lumpectomy, that is a"negative margin" isn't obtained. However, if the first lumpectomy has cancer cells at the edge of the tumor specimen, a "re-excision" (second try) may preserve the breast.
3) The tumor is"multi-centric" -- that is spread through the breast.
4) The patient has a large tumor in a small breast (poor cosmetic result)
5) Prior radiation treatments to the chest (such as for Hodgkin's disease).
6) Collagen-Vascular diseas like Lupus or Scleroderma (skin intolerate of radiation).
7) Pregnant and unable to wait for delivery to get treatment.

Note that involvement of the axillary lymph nodes does NOT prevent breast preservation - it only means that chemotherapy is appropriate to try to increase survival.

The National Cancer Institute (NCI) has concluded that breast conservation is an appropriate method of treatment for the majority of women with early breast cancer and is even preferable since it providesequivalent survival rates to mastectomy while preserving the breast.

Chemotherapy with CAF or CMF for 6 cycles, or "AC" for 4 cycles, is standard if the axillary lymph nodes were involved, and for pre-menopausal women. After menapause, no consistent survival benefit has been shown for chemotherapy, but hormonal therapy with tamoxifen reduces deaths as described below. In an overview of many studies from the Concensus Commitee at the NCI, a 25% reduction in cancer deaths during the first five years for patients getting CMF was noted. Overall, a 1/3 decrease in breast cancer deaths at 10 years is estimated for those women in whom chemotherapy is effective. Dr. Bonnadonna in Italy has been a leading proponent of giving chemotherapy to "ER/PR negative, axillary lymph node positive, pre-menapausal" women. His research has shown an average increase of 3.5 years in disease-free survival for these women given CMF chemotherapy compared to not getting it. He has also concluded that CMF is as good as the more toxic CAF in women with less than 4 involved lymph nodes in their axillas. Chemotherapy longer than 6 months doesn't help. Hormonal Therapy with Tamoxifen has been shown to reduce the death rate in women over 50 years old and those with who are ER positive. The landmark NSABP-14 study showed reduction in breast cancer coming back from 1.2% per year to 0.5% per year in Early Breast Cancer patients who were ER postive and who's axillas were not involved. It is sometimes even effective in ER negative women, and is often used. Best length of treatment is uncertain - it ranges from 6 months to over 5 years.

Conclusion from the NCI is that all cases of breast cancer except non-invasive and very small cancers (<1 cm) should get adjuvant (additional) therapy - in premenapausal women with chemotherapy and tamoxifen, and in post-menapausal women with tamoxifen alone.

How about if the Cancer Comes Back?

If the cancer recurrs in the breast after breast conservation therapy (about a 10% chance) then Mastectomy is advocated, and has a 5 year survival of up to 85%. Dr. Kurtz in St. Louis and others will now do another local excision surgery (lumpectomy) if the new tumor is small, located within the breast, and occurs at least 5 years after the first treatment was given. If the cancer comes back before 5 years, there is a decreased survival rate, but if it comes back after 5 years, survival doesn't appear to be any worse! Obviously, it makes a difference whether the "failure" is "local" or "distant" - but even those found to have distant metastasis to bone (the most common site) often live many years with appropriate therapy. For local failure only, the latest studies show the breast may still be saved, after a small recurrance. No further chemotherapy is given for small, non-invasive recurrent breast cancer, and no further radiation is given either - just surgery alone is enough. Careful monitoring with breast exam and yearly mammograms is crucial in the patient who had had breast cancer, of either both breasts (if breast conservation therapy was performed) or the remaining breast if a mastectomy was done.

Conclusion

The patient with newly diagnosed breast cancer should not rely upon any single therapy, such as a pill or ray, but instead should use a "combination approach" to maximize the chance for success. Specifically, besides the conventional medical therapies mentioned above, consider the use of a non-toxic, not over-expensive alternative therapy you can believe in. CancerAnswers offers an Alternative Therapies Transcript on Breast Cancer available through our Web Site. Also, a program of spiritual renewal, "mind over cancer', nutritional therapy and exercise is appropriate. Keep the most positive attitude possible-- research has shown this to be an important factor in cancer survival. Using a true "multi-modality"approach will give the confidence that you have done everything possible for a happy outcome, and will anyway improve quality of life. If the patient is willing to subject themselves to medical research, Clinical Trials are offered at Major University Academic Centers. The National Cancer Institute keeps of list of Open Clinical Trials on their Website; many Institutions have their own "in-house" research. However, Clinical Trials often have specific enrollment criteria, and one cannot then select which treatment (which "arm" of the study) they will get. NSABP trials are well designed and will not shirk a patient from basic established therapy; they are now to "fine-tune" the treatments. The recent advances in early breast cancer therapy make it most likely that the today's new patient will be cured, and also save her breast.

This is the full transcript, offered freely in the spirit of internet sharing, of CancerAnswers' report on early breast cancer treatment. Much more, including latest additional treatments for Early Breast Cancer can be found on our order page. Thank you for using CancerAnswers as your information resource.