Early Breast Cancer Treatment Information

EARLY BREAST CANCER TREATMENT INFORMATION

Background Information-- 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 remains unknown. 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" :

1) 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.

2) 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.

3 ) 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.

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

5) "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.

6) 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 contrast solution 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.

*** It is crucial to note that many patients live many productive years with their cancer!

Fortunately for the woman with early breast cancer, the treatment options available today give excellent survival while usually keeping the breast.

It is critical to get the proper treatment up front, this gives the best chance of a happy outcome. We have made tremendous strides in the treatment of early breast cancer, and the knowledgable patient can enjoy the fruit of this research and the peace-of-mind of knowing they have done everything possible to fight the cancer successfully.

CancerAnswers's material explains, in plain English, the historic and latest effective treatment for Early Breast Cancer. We describe surgery, radiation and chemotherapy as well as hormonal treatment. We tell you everything you need to know to help make the right choices today.

This is just an excerpt of CancerAnswers's report on early breast cancer treatment. Much more, including latest can be sent to you by mail when you order the complete Early Breast Cancer Treatment transcript at a nominal cost. Thank you for using CancerAnswers as your information resource.