Estrogen receptor (ER) and progesterone receptor (PR) status
Receptors are proteins in or on certain cells that can attach to certain substances, such as hormones, that circulate in the blood. Normal breast cells and some breast cancer cells contain receptors that attach to estrogen and progesterone. These 2 hormones often fuel the growth of breast cancer cells.
An important step in evaluating a breast cancer is to test a portion of the cancer removed during the biopsy (or surgery) to see if they have estrogen and progesterone receptors. Cancer cells may contain neither, one, or both of these receptors. Breast cancers that have estrogen receptors are often referred to as ER-positive (or ER+) cancers, while those containing progesterone receptors are called PR-positive (or PR+) cancers. If either type of receptor is present, the cancer is said to be hormone receptor-postive.
Hormone receptor–positive breast cancers tend to grow more slowly and are much more likely to respond to hormone therapy than breast cancers without these receptors.
All breast cancers, should be tested for these hormone receptors either on the the biopsy sample or when they are removed with surgery. About 2 of 3 breast cancers have at least one of these receptors. This percentage is higher in older women than in younger women.
HER2/neu status
About 1 of 5 breast cancers have too much of a growth-promoting protein called HER2/neu (often just shortened to HER2). The HER2/neu gene instructs the cells to make this protein. Tumors with increased levels of HER2/neu are referred to as HER2-positive.
Women with HER2-positive breast cancers have too many copies of the HER2/neu gene, resulting in greater than normal amounts of the HER2/neu protein. These cancers tend to grow and spread more aggressively than other breast cancers.
All newly diagnosed breast cancers should be tested for HER2/neu because HER2-positive cancers are much more likely to benefit from treatment with drugs that target the HER2/neu protein, such as trastuzumab (Herceptin®) and lapatinib (Tykerb®). See the section, "How is breast cancer treated?" for more information on these drugs.
Testing of the biopsy or surgery sample is usually done in 1 of 2 ways:
- Immunohistochemistry (IHC): In this test, special antibodies that identify the HER2/neu protein are applied to the sample, which cause cells to change color if many copies are present. This color change can be seen under a microscope. The test results are reported as 0, 1+, 2+, or 3+.
- Fluorescent in situ hybridization (FISH): This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted under a special microscope.
Many breast cancer specialists feel the FISH test is more accurate than IHC. However, it is more expensive and takes longer to get the results. Often the IHC test is used first. If the results are 1+ (or 0), the cancer is considered HER2-negative. People with HER2-negative tumors are not treated with drugs (like trastuzumab) that target HER2. If the test comes back 3+, the cancer is HER2-positive. Patients with HER2-positive tumors may be treated with drugs like trastuzumab. When the result is 2+, the HER2 status of the tumor is not clear. This usually leads to testing the tumor with FISH. Some institutions also use FISH to confirm HER2 status that is 3+ by IHC and some perform only FISH.
A newer type of test, known as chromogenic in situ hybridization (CISH), works similarly to FISH, by using small DNA probes to count the number of HER2 genes in breast cancer cells. But this test looks for color changes (not fluorescence) and doesn't require a special microscope, which could make it less expensive. Right now, it is not being used as much as IHC or FISH.
Tests of ploidy and cell proliferation rate
The ploidy of cancer cells refers to the amount of DNA they contain. If there's a normal amount of DNA in the cells, they are said to be diploid. If the amount is abnormal, then the cells are described as aneuploid. Tests of ploidy may help determine prognosis, but they rarely change treatment and are considered optional. They are not usually recommended as part of a routine breast cancer work-up.
The S-phase fraction is the percentage of cells in a sample that are replicating (copying) their DNA. DNA replication means that the cell is getting ready to divide into 2 new cells. The rate of cancer cell division can also be estimated by a Ki-67 test. If the S-phase fraction or Ki-67 labeling index is high, it means that the cancer cells are dividing more rapidly, which indicates a more aggressive cancer.
Tests of gene patterns
Researchers have found that looking at the patterns of a number of different genes at the same time (sometimes referred to as gene expression profiling) can help predict whether or not an early stage breast cancer is likely to come back after initial treatment. Two such tests, which look at different sets of genes, are now available: the Oncotype DX®and the MammaPrint®
Oncotype DX®: The Oncotype DX test may be helpful when deciding whether additional (adjuvant) treatment with chemotherapy (after surgery) might be useful in women with certain early-stage breast cancers that usually have a low chance of coming back (stage I or II estrogen receptor–positive breast cancers without lymph node involvement). Recent data has shown it may also be helpful for patients with positive lymph nodes.
The test looks at a set of 21 genes in cells from tumor samples to determine a 'recurrence score', which is a number between 0 and 100:
- Women with a recurrence score of 17 or below have a low risk of recurrence (cancer coming back after treatment) if they are treated with hormone therapy. These women would probably not benefit from chemotherapy.
- Women with a score of 18 to 30 are at intermediate risk and some might benefit from chemotherapy.
- Women with a score of 31 or more are at high risk and are likely to benefit from chemotherapy in addition to hormone therapy.
The test estimates risk, but it cannot tell for certain if any particular woman will have a recurrence. It is a tool that can be used, along with other factors, to help guide women and their doctors when deciding whether more treatment might be useful.
.
Classifying breast cancer
Research on patterns of gene expression has also suggested some newer ways to classify breast cancers. The current types of breast cancer are based largely on how tumors look under a microscope. A newer classification, based on molecular features, divides breast cancers into 4 groups. This testing, called the PAM50, is currently available but is not used as yet to make treatment decisions:
Luminal A and luminal B types: The luminal types are estrogen receptor (ER)–positive. The gene expression patterns of these cancers are similar to normal cells that line the breast ducts and glands (the inside of a duct or gland is called its lumen). Luminal A cancers are low grade, tend to grow fairly slowly, and have the best prognosis. Luminal B cancers generally grow somewhat faster than luminal A cancers and their outlook is not quite as good.
HER2 type: These cancers have extra copies of the HER2 gene and sometimes some others. They usually have a high-grade appearance under the microscope. These cancers tend to grow more quickly and have a worse prognosis, although they often can be treated successfully with targeted therapies such as trastuzumab (Herceptin) and lapatinib (Tykerb) which are usually given along with chemotherapy.
Basal type: Most of these cancers are of the so-called triple-negative type, that is, they lack estrogen or progesterone receptors and have normal amounts of HER2. The gene expression patterns of these cancers are similar to cells in the deeper basal layers of breast ducts and glands. This type is more common among women with BRCA1 gene mutations. For reasons that are not well understood, this cancer is also more common among younger and African-American women.
These are high-grade cancers that tend to grow quickly and have a poor outlook. Hormone therapy and anti-HER2 therapies like trastuzumab and lapatinib are not effective against these cancers, although chemotherapy can be helpful. A great deal of research is being done to find better ways to treat these cancers.
It is hoped that these new breast cancer classifications might someday allow doctors to better tailor breast cancer treatments, but more research is needed in this area before this will be possible.
Imaging tests that look for breast cancer spread
Once breast cancer is diagnosed, one or more of the following tests may be done. These tests aren’t often done for early breast cancer. Which tests (if any) are done depends on how likely it is the cancer has spread, based on the size of the tumor, the presence of lymph node spread, and any symptoms you are having.
Chest x-ray
This test may be done to see whether the breast cancer has spread to your lungs.
Mammogram
If they haven't been done already, more extensive mammograms may be done to get more thorough views of the breasts. This is to check for any other abnormal areas that could be cancer as well. This test is described in the section, "How is breast cancer diagnosed?"
Bone scan
A bone scan can help show if a cancer has spread (metastasized) to your bones. It can be more useful than standard x-rays because it can show all of the bones of the body at the same time and can find small areas of cancer spread not seen on plain x-rays.
For this test, a small amount of low-level radioactive material is injected into a vein (intravenously, or IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.
Areas of bone changes appear as "hot spots" on your skeleton—that is, they attract the radioactivity. These areas may suggest the presence of metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish between these conditions, your cancer care team may use other imaging tests such as simple x-rays or CT or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.
Computed tomography (CT) scan
The CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. In women with breast cancer, this test is most often used to look at the chest and/or abdomen to see if the cancer has spread to other organs such as the lungs or liver.
Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body.
The injection might cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives. Rarely, more serious reactions like trouble breathing or low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
CT scans take longer than regular x-rays, but in general are very quick. You need to lie still on a table while they are being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring while the pictures are being taken.
CT guided needle biopsy: If an abnormality is seen on a CT scan, but it is not clear if it is cancer, it may need to be biopsied. The biopsy can be done using the CT scan to precisely guide a biopsy needle into a suspected area of cancer spread. For this procedure, you remain on the CT scanning table while a radiologist advances a biopsy needle through the skin and toward the location of the mass. CT scans are repeated until the doctors are sure that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8-inch in diameter) is then removed and sent to be looked at under a microscope.
Magnetic resonance imaging (MRI) scan
This use of this test to look at the breast was discussed earlier in this section.
MRI scans are also used to look for cancer that has spread to various parts of the body, just like CT scans. MRI scans are particularly helpful in looking at the brain and spinal cord.
There are some differences between using this test to look at the breast and other areas of the body. First, you will lie face up in the machine. Second, the contrast material called gadolinium is not always needed to look at other areas of the body. Also, you might have the option of having the scan in a less confining machine known as an "open" MRI machine. The images from an open machine are not always as good, though, so this might not always be an option.
Ultrasound
The use of this test to look at the breast was discussed earlier in this section. But ultrasound can also be used to look for cancer that has spread to some other parts of the body.
Abdominal ultrasound can be used to look for tumors in your liver or other abdominal organs. When you have an abdominal ultrasound exam, you simply lie on a table and a technician moves the transducer on the skin over the part of your body being examined. Usually, the skin is first lubricated with gel.
Positron emission tomography (PET) scan
For a PET scan, glucose (a form of sugar) that contains a radioactive atom is injected into the bloodstream. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. After about an hour, a special camera is used to create a picture of areas of radioactivity in the body.
A PET scan is useful when your doctor thinks the cancer might have spread but doesn't know where. The picture is not finely detailed like a CT or MRI scan, but it provides helpful information about your whole body. Some newer machines are able to do both a PET and CT scan at the same time (PET/CT scan). This lets the radiologist compare areas of higher radioactivity on the PET with the appearance of that area on the CT.
So far, most studies show PET scans aren't very helpful in early breast cancer, but they may be used for very large tumors, inflammatory breast cancer, or for breast cancers that are known to have spread.
BREAST CANCER STAGING
one of the most important factors in determining prognosis and treatment options
- describes the extent
- invasive or non-invasive,
- the size of the tumor,
- how many lymph nodes are involved,
- spread to other parts of the body.
Staging is
- the process of finding out
- how widespread a cancer is
- . Depending on
- physical exam
- biopsy,
- imaging tests - Not all are done
- chest x-ray,
- mammograms
- bone scans,
- computed tomography (CT) scans,
- magnetic resonance imaging (MRI),
- and/or positron emission tomography (PET) scans.
- Blood tests
The American Joint Committee on Cancer (AJCC) TNM system
A staging system is a standardized way for the cancer care team to summarize information about how far a cancer has spread. The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM system.
The stage of a breast cancer can be based either on the results of physical exam, biopsy, and imaging tests (called theclinical stage), or on the results of these tests plus the results of surgery (called the pathologic stage). The staging described here is the pathologic stage, which includes the findings after surgery, when the pathologist has looked at the breast mass and nearby lymph nodes. Pathologic staging is likely to be more accurate than clinical staging, as it allows the doctor to get a firsthand impression of the extent of the cancer.
The TNM staging system classifies cancers based on their T, N, and M stages:
- The letter T followed by a number from 0 to 4 describes the tumor's size and spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.
- The letter N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are affected.
- The letter M followed by a 0 or 1 indicates whether the cancer has spread to distant organs -- for example, the lungs or bones.
Primary tumor (T) categories:
TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass)
T1 (includes T1a, T1b, and T1c): Tumor is 2 cm (3/4 of an inch) or less across.
T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across.
T3: Tumor is more than 5 cm across.
T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.
Nearby lymph nodes (N; based on looking at them under a microscope):
Lymph node staging for breast cancer has changed as technology has evolved. Earlier methods were useful in finding large deposits of cancer cells in the lymph nodes, but could miss microscopic areas of cancer spread. Newer methods have made it possible to find smaller and smaller deposits of cancer cells. Experts haven't been sure what to do with the new information. Do tiny deposits of cancer cells affect outlook the same way that larger deposits do? How much cancer in the lymph node is needed to see a change in outlook or treatment?
These questions are still being studied, but for now, a deposit of cancer cells must contain at least 200 cells or be at least 0.2 mm across (less than 1/100 of an inch) for it to change the N stage. An area of cancer spread that is smaller than 0.2 mm (or less than 200 cells) doesn't change the stage, but is recorded with abbreviations that reflect the way the cancer spread was detected. The abbreviation "i+" means that a small number of cancer cells (called isolated tumor cells) were seen in routine stains or when a special type of staining technique, called immunohistochemistry, was used.
The abbreviation "mol+" is used if the cancer could only be found using a technique called RT-PCR. RT-PCR is a molecular test that can find very small numbers of cells that cannot be seen even using special stains. However, this test is not often used for finding breast cancer cells in lymph nodes because the results do not influence treatment decisions.
If the area of cancer spread is at least 0.2 mm (or 200 cells), but still not larger than 2 mm, it is called amicrometastasis (one mm is about the size of the width of a grain of rice). Micrometastases are counted only if there aren't any larger areas of cancer spread. Areas of cancer spread larger than 2 mm are known to affect outlook and do change the N stage. These larger areas are sometimes called macrometastases, but may just be called metastases.
NX: Nearby lymph nodes cannot be assessed (for example, if they were removed previously).
N0: Cancer has not spread to nearby lymph nodes.
- N0(i+): Tiny amounts of cancer are found in underarm lymph nodes by using either routine or special stains. The area of cancer spread contains less than 200 cells and is smaller than 0.2 mm.
- N0(mol+): Cancer cells cannot be seen in underarm lymph nodes (even using special stains), but traces of cancer cells were detected using RT-PCR.
N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts of cancer are found in internal mammary lymph nodes (those near the breast bone) on sentinel lymph node biopsy.
- N1mi: Micrometastases (tiny areas of cancer spread) in 1 to 3 lymph nodes under the arm. The areas of cancer spread in the lymph nodes are 2 mm or less across (but at least 200 cancer cells or 0.2mm across).
- N1a: Cancer has spread to 1 to 3 lymph nodes under the arm with at least one area of cancer spread greater than 2 mm across.
- N1b: Cancer has spread to internal mammary lymph nodes, but this spread could only be found on sentinel lymph node biopsy (it did not cause the lymph nodes to become enlarged).
- N1c: Both N1a and N1b apply.
N2: Cancer has spread to 4 to 9 lymph nodes under the arm, or cancer has enlarged the internal mammary lymph nodes (either N2a or N2b, but not both).
- N2a: Cancer has spread to 4 to 9 lymph nodes under the arm, with at least one area of cancer spread larger than 2 mm.
- N2b: Cancer has spread to one or more internal mammary lymph nodes, causing them to become enlarged.
N3: Any of the following:
N3a: either
- Cancer has spread to 10 or more axillary lymph nodes, with at least one area of cancer spread greater than 2mm, OR
- Cancer has spread to the lymph nodes under the clavicle (collar bone), with at least one area of cancer spread greater than 2mm.
N3b: either:
- Cancer is found in at least one axillary lymph node (with at least one area of cancer spread greater than 2 mm) and has enlarged the internal mammary lymph nodes, OR
- Cancer involves 4 or more axillary lymph nodes (with at least one area of cancer spread greater than 2 mm), and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
- N3c: Cancer has spread to the lymph nodes above the clavicle with at least one area of cancer spread greater than 2mm.
Metastasis (M):
MX: Presence of distant spread (metastasis) cannot be assessed.
M0: No distant spread is found on x-rays (or other imaging procedures) or by physical exam.
- cM0(i +): Small numbers of cancer cells are found in blood or bone marrow (found only by special tests), or tiny areas of cancer spread (no larger than 0.2 mm) are found in lymph nodes away from the breast.
M1: Spread to distant organs is present. (The most common sites are bone, lung, brain, and liver.)
Breast cancer stage grouping
Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping. Cancers with similar stages tend to have a similar outlook and thus are often treated in a similar way. Stage is expressed in Roman numerals from stage I (the least advanced stage) to stage IV (the most advanced stage). Non-invasive cancer is listed as stage 0.
Stage 0: Tis, N0, M0:This is ductal carcinoma in situ (DCIS), the earliest form of breast cancer. In DCIS, cancer cells are still within a duct and have not invaded deeper into the surrounding fatty breast tissue. Lobular carcinoma in situ (LCIS) is sometimes also classified as stage 0 breast cancer, but most oncologists believe it is not a true breast cancer. Paget disease of the nipple (without an underlying tumor mass) is also stage 0. In all cases the cancer has not spread to lymph nodes or distant sites.
Stage IA: T1, N0, M0:The tumor is 2 cm (about 3/4 of an inch) or less across (T1) and has not spread to lymph nodes (N0) or distant sites (M0).
Stage IB: T0 or T1, N1mi, M0: The tumor is 2 cm or less across (or is not found) (T0 or T1) with micrometastases in 1 to 3 axillary lymph nodes (the cancer in the lymph nodes is greater than 0.2mm across and/or more than 200 cells but is not larger than 2 mm)(N1mi). The cancer has not spread to distant sites (M0).
Stage IIA: One of the following applies:
T0 or T1, N1 (but not N1mi), M0: The tumor is 2 cm or less across (or is not found) (T1 or T0) and either:
- It has spread to 1 to 3 axillary lymph nodes, with the cancer in the lymph nodes larger than 2 mm across (N1a), OR
- Tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N1b), OR
- It has spread to 1 to 3 lymph nodes under the arm and to internal mammary lymph nodes (found on sentinel lymph node biopsy) (N1c).
OR
T2, N0, M0: The tumor is larger than 2 cm across and less than 5 cm (T2) but hasn't spread to the lymph nodes (N0).
The cancer hasn't spread to distant sites (M0).
Stage IIB:One of the following applies:
T2, N1, M0: The tumor is larger than 2 cm and less than 5 cm across (T2). It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N1). The cancer hasn't spread to distant sites (M0).
OR
T3, N0, M0: The tumor is larger than 5 cm across but does not grow into the chest wall or skin and has not spread to lymph nodes (T3, N0). The cancer hasn't spread to distant sites (M0).
Stage IIIA: One of the following applies:
T0 to T2, N2, M0: The tumor is not more than 5 cm across (or cannot be found) (T0 to T2). It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal mammary lymph nodes (N2). The cancer hasn't spread to distant sites (M0).
OR
T3, N1 or N2, M0: The tumor is larger than 5 cm across but does not grow into the chest wall or skin (T3). It has spread to 1 to 9 axillary nodes, or to internal mammary nodes (N1 or N2). The cancer hasn't spread to distant sites (M0).
Stage IIIB: T4, N0 to N2, M0: The tumor has grown into the chest wall or skin (T4), and one of the following applies:
- It has not spread to the lymph nodes (N0).
- It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N1).
- It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal mammary lymph nodes (N2).
The cancer hasn't spread to distant sites (M0).
Inflammatory breast cancer is classified as T4 and is at least stage IIIB. If it has spread to many nearby lymph nodes (N3) it could be stage IIIC, and if it has spread to distant lymph nodes or organs (M1) it would be stage IV.
Stage IIIC: any T, N3, M0: The tumor is any size (or can't be found), and one of the following applies:
- Cancer has spread to 10 or more axillary lymph nodes (N3).
- Cancer has spread to the lymph nodes under the clavicle (collar bone) (N3).
- Cancer has spread to the lymph nodes above the clavicle (N3).
- Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes (N3).
- Cancer has spread to 4 or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N3).
The cancer hasn't spread to distant sites (M0).
Stage IV: any T, any N, M1: The cancer can be any size (any T) and may or may not have spread to nearby lymph nodes (any N). It has spread to distant organs or to lymph nodes far from the breast (M1). The most common sites of spread are the bone, liver, brain, or lung,
Treatment based on
- type of breast cancer,
- its stage,
- sensitivity to hormones,
- overall health
- preferences
Type of treatment
- .almost all undergo surgery
- Some receive additional treatment,
- chemotherapy,
- hormone therapy
- radiation.
- many options
- may feel overwhelmed
- complex decisions
Surgery
Operations used to treat breast cancer include:
- Removing the breast cancer (lumpectomy).
- breast-sparing surgery or wide local excision,
- removes the tumor and a small margin of surrounding normal tissue.
- reserved for smaller tumors that are wide margin of normal tissue
- Removing the entire breast (mastectomy).
- remove all of your breast tissue.
- simple,
- meaning removes all of the breast tissue — the lobules, ducts, fatty tissue and some skin, including the nipple and areola.
- radical,
- meaning the underlying muscle of the chest wall is removed along with breast tissue and surrounding lymph nodes in the armpit.
- less commonly done
- skin-sparing mastectomy
- , which leaves the skin overlying the breast intact which help in reconstruction
- Removing one lymph node (sentinel node biopsy)
- cancer that spreads to the lymph nodes
- which lymph node near your breast tumor receives the lymph drainage from your cancer.
- This lymph node is removed
- using a procedure called sentinel node biopsy
- tested for breast cancer cells
- . If no cancer is found
- then chance of finding cancer in remaining lymph nodes is small
- so no other nodes need to be removed.
- Need regular follow up and operation if node involve latter on
- If cancer found
- Removal of all lymphnodes in axilla
- Removing all lymph nodes (axillary lymph node dissection)
- If cancer is found in the sentinel node,
- may remove more nodes from axilla
However, there is good evidence that if tumors less than 5 centimeters in size, and when cancer has spread to a few lymph nodes which are not palpable .
-
- then, chemotherapy and radiation treatment after the lumpectomy have proved to be equally effective.
- removal of additional affected lymph nodes does not improve survival in cases of early breast cancer following a lumpectomy, chemotherapy and whole-breast irradiation
- This avoids the serious side effects, such as chronic swelling of the arm
- If larger tumors or a lymph node is large enough to be felt then axillary clearance .is require.
Radiation therapy
- external beam radiation
- commonly used after lumpectomy for early-stage cancer
- . can also be done by placing radioactive material inside your body -brachytherapy.
- Side effects of radiation therapy
- fatigue
- a red, sunburn-like rash
- tissue may also appear swollen
- Rarely, more-serious problems may occur,
- arm swelling
- broken ribs,
- damage to the lungs or nerves.
Chemotherapy
- uses drugs to destroy cancer cells
- . adjuvant systemic chemotherapy. - after surgery
- For those who have high chance of returning or spreading to another part
- neoadjuvant chemotherapy
- given before surgery in larger tumors.
- . The goal is to decrease a tumor to a size that makes it easier to operate
- . also increase the chance of a cure.
- also used in women whose cancer has already spread to other parts of the body.
- side effects
- depend on the drugs you receive.
- Common side effects
- hair loss,
- nausea,
- vomiting,
- fatigue
- increased risk of infection.
-
Hormone therapy /hormone-blocking therapy
- often used to
- For cancers that are sensitive to hormones.
- estrogen receptor positive (ER positive)
- progesterone receptor positive (PR positive)
- used after surgery or other treatments
- to decrease the chance of returning.
- If already spread, hormone therapy may shrink and control it.
-
List of hormone therapy
- Medications that block hormones from attaching to cancer cells.
- Tamoxifen
- is the most commonly used
- It is selective estrogen receptor modulator (SERM)
- act by blocking estrogen from attaching to the estrogen receptor
- slowing the growth and killing tumor cells.
- can be used pre- and postmenopausal
- . side effects
- fatigue,
- hot flashes
- , night sweats
- vaginal dryness.
- Importent risk
- cataracts,
- blood clots,
- stroke
- uterine cancer.
- Medications that stop the body from making estrogen after menopause.
- aromatase inhibitors
- blocks the action of an enzyme that converts androgens in in to estrogen.
- effective only in postmenopausal women
- include
- anastrozole (Arimidex),
- letrozole (Femara)
- exemestane (Aromasin).
- Side effects
- joint and muscle pain,
- osteoporosis
- ., fulvestrant (Faslodex),
- directly blocks estrogen,
- given by injection once a month.
- used in postmenopausal
- when other hormone-blocking therapy is not effective
- or who can't take tamoxifen.
- Side effects
- fatigue,
- nausea
- hot flashes.
Surgery or medications to stop hormone production in the ovaries
- For premenopausal women,
- surgery to remove the ovaries
- or medications to stop the ovaries from making estrogen
- known as prophylactic oophorectomy
-
Targeted drugs
Attack specific abnormalities within cancer cells. Targeted drugs can be very expensive and aren't always covered by health insurance.
- Trastuzumab (Herceptin).
- For breast cancers which make excessive amounts of a protein called human growth factor receptor 2 (HER2).
- Trastuzumab targets this protein which helps breast cancer cells grow and survive.
- Side effects
- heart damage,
- headaches
- skin rashes.
- Lapatinib (Tykerb).
- targets the HER2 protein
- approved for use in advanced metastatic breast cancer.
- reserved for those who have already tried trastuzumab and still cancer has progressed.
- side effects
- nausea,
- vomiting,
- fatigue,
- mouth sores
- diarrhea,
- skin rashes,
- painful hands and feet.
- Bevacizumab (Avastin).
- designed to stop the signals cancer cells use to attract new blood vessels.
- Without new blood vessels cancer cells die.
- side effects
- fatigue,
- high blood pressure,
- mouth sores,
- headaches,
- slow wound healing,
- blood clots,
- heart damage,
- kidney damage,
- high blood pressure
- congestive heart failure.
- Use is controversial .
Clinical trials
- used to test new and promising agents
- represent the cutting edge of cancer treatment,
-
- but they're by definition unproven treatments
- may or may not be superior to currently available treatment
follow-up care
All cancer survivors should have follow-up care.
- It is regular medical checkups
- review of a patient’s medical history
- a physical exam.
- may include
- imaging
- endoscopy
- blood work,
- other lab tests.
Importance
- early detection of local, regional or distant recurrence
- screening for a new primary breast cancer (in the ipsilateral or contralateral breast)
- helps to identify changes in health.
- help in the prevention or early detection of other diseases
- address ongoing problems
- detection and management of psychosocial distress,anxiety or depression
- detection and management of treatment-related side effects
- reviewing and updating family history information
- observation of outcomes of therapy
- reviewing treatment, including new treatments that may be appropriate
-
At every visit, patients should tell their doctor about:
-
- Symptoms
- that may be a sign that cancer has returned
- pain
- physical problems ,
- fatigue;
- difficulty with bladder, bowel, or sexual function;
- difficulty concentrating; memory changes;
- trouble sleeping;
- change in weight
- All treatment
- medicines, vitamins, or herbs
- emotional problems
- anxiety
- depression
- Any changes in their family medical history,
- new cancers
cancer recurrences may or may not be detected during follow-up visits. Recurrences may be suspected by patients between scheduled
follow-up care schedules
- frequency and nature is individualized
- based on the
- type of cancer,
- treatment received,
- overall health,
- treatment-related problems.
- General plan of follow-up
- Physical examinations should be performed
- every 3 to 6 months for the first 3 years,
- every 6 to 12 months for years 4 and 5,
- annually thereafter
- For breast-conserving surgery,
- a post-treatment mammogram 1 year after the initial mammogram
- 6 months after completion of radiation therapy.
- Thereafter, unless otherwise indicated,
- a yearly mammogram
- Following tests are not recommended for routine follow-up in an asymptomatic patient with no specific findings on clinical examination.
- complete blood counts,
- chemistry panels,
- bone scans,
- chest radiographs,
- liver ultrasounds,
- pelvic ultrasounds,
- CAT scans,
- PET scans,
- MRI
- tumor markers
- Those who have been treated for early breast cancer are
- at increased risk of
- local,
- regional
- or distant recurrence
- or development of a new primary breast cancer in the ipsilateral or contralateral breast
- may need tests to check for recurrence or to screen
- it is not clear that follow-up tests improve survival or quality of life.
- may not need to perform any tests if the person appears to be in health
- talk with the doctor about any questions or concerns about the follow-up plan.
- patients should consider who will provide the follow-up care and who will provide other medical care.
- select a doctor with whom you feel comfortable.
What after treatment ends?
request
a comprehensive care summary
and follow-up plan
ask following questions
Type treatments and drugs given
Frequency of a routine visit
Who will see me for my follow-up cancer care
Chances of cancer recurrence
chance of another cancer
follow-up tests,needed
How often
symptoms to watch
what i do if If I develop any of these symptoms,
whom should I call?
common long-term effects of the treatment
How I can maintain my health and well-being
trouble getting health insurance or keeping a job
support groups
it is helpful to write these questions and take notes or tape record for latter review
dealing with emotions after treatment
common to experience
stress,
depression,
anxiety
helpful to talk a with
family and friends,
health professionals,
other patients,
counselors
therapists.
Being part of a support group
Relaxation techniques,
Yoga
guided imagery
slow rhythmic breathing, c
participating in volunteer activities
Medical record to keep
- comprehensive care summary
- follow-up plan
- Date of cancer diagnosis
- Diagnosis
- Report of diagnostic test
- Details of all cancer treatment,
- type and dates of all surgeries;
- names and doses of all drugs;
- sites and total amounts of radiation therapy
- Contact information of important team members
- Side effects and complications during and after treatment
- Supportive care received
- nutritional supplements
- pain or nausea medication,
- emotional support, and)
-
services which may be useful during follow-up care
-
- assistance with transportation
- pain management,
- nutrition counseling,
- financial aid
- physical therapy,
- fertility/sexual counseling,
- genetic counseling,
- support groups,
- couples counseling,
- home care services,
- occupational or vocational therapy.
CANCER
Our body is made up of trillions of living cells. Cancer begins when cells start to grow out of control.
Instead of dying, cancer cells continue to grow and form new, abnormal cells. It can also grow into other tissues, Due to damage to DNA Cells become cancer cells. DNA directs all its actions. when DNA gets damaged either cell repairs the damage or l dies. The damaged DNA is not repaired In cancer cells. Instead, of dying this cell goes on making new cells that the body does not need. They all have the same damaged DNA .
Generally DNA damage is caused by mistakes in reproduction or environment factors. People can inherit damaged DNA.
Cancer cells can go to other parts of the body, where they grow and form new tumors. -metastasis.
It is always named for the place where it started. If breast cancer that has spread to the liver then it is called breast cancer with liver metastasis , not liver cancer. .
Each cancer can behave in it’s own way. For example,ovarian cancer and breast cancer are very different diseases with different growth rate and response to treatment. So each cancer need different type of treatment.
All tumors are cancerous. Some are benign. They can grow very large and press on healthy organs and tissues which can cause problems . But they cannot grow into other tissues. so they are are almost never life threatening.
TREATMENT OF BREAST CANCER
Surgery
Surgery is mainstay of diagnosis and treatment
For Diagnosis
- FNAC/ FNAB
- Trucut Biopsy
- Incision Biopsy
- Excision Biopsy
For treatment
- Mastectomy
- Breast conserving surgery
- Sentinel lymph node biopsy
- Breast reconstruction
- immediate
- Delay
.
Breast-conserving surgery( partial (or segmental) mastectomy)
It removes a part of the affected breast, how much is depends on the size and location of the disease and other factors. Metallic clips may be placed inside the breast during surgery to mark the area for the radiation treatments.
Lumpectomy
- removes lump with surrounding margin of normal tissue.
- If adjuvant chemotherapy is to be given as well,
- radiation is done after chemotherapy is completed.
-
Quadrantectomy
- one-quarter of the breast is removed.
- Radiation therapy is usually given after surgery.
- Radiotherapy is delayed if chemotherapy is to be given
positive margins.:
cancer cells are found at any of the edges of the of tissue removed,
negative or clear margins.
No cancer cells are found at the edges of the tissue.
If margins are positive then re excision( re operation) is required. If it is not possible to get clear margin then mastectomy may be required
Close Margin
If distance between the edge of the tumor and edge of the tissue removed is too small then it is called close margin and more surgery may be needed
stage I or II breast cancer,
- breast-conserving surgery (BCS) plus radiation therapy is as effective as mastectomy.
- Still breast-conserving surgery is not an option for all
If all of following criterias are true then breast conservative therapy without radiation may be evaluated
- They are age 70 years or older.
- They have a tumor that measures 2 cm or less across that has been completely removed (with clear margins).
- The tumor is hormone receptor-positive, and the women are getting hormone therapy (such as tamoxifen or an aromatase inhibitor).
- No lymph nodes contained cancer.
Possible side effects:
- pain,
- temporary swelling,
- tenderness,
- and hard scar tissue .
- bleeding
- and infection
- change in the shape of the breast
- Reconstructive surgery may be consider or reduction mammoplasty of opposite breast
- It's very important to talk with your doctor before surgery for expected result and available options
Mastectomy
- surgery to remove the entire breast
Simple mastectomy( total mastectomy):
- removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast.
- when both breasts are removed (a double mastectomy), as preventive surgery in women at very high risk for breast cancer. Most women,
Skin-sparing mastectomy:
- If considering immediate reconstruction, a skin-sparing mastectomy can be done.-, most of the skin over the breast except the nipple and areola)is left intact. The amount of breast tissue removed is the same as with a simple mastectomy.
- not be suitable for
- larger tumors or
- those that are close to the surface of the skin
- . Implants or tissue from other parts of the body are used to reconstruct the breast. Not commonly done but many patients like this approach..
- nipple-sparing mastectomy
- It is a variation of the skin-sparing mastectomy . It is option for a small early stage cancer near the outer part of the breast. In this operation the breast tissue is removed, but the skin and nipple are left for better reconstruction.To reduce the risk of local recurrence frozan section -(biopsy during operation) is done and post operative rediotherapy is also consider.
- problems
- Nipple become deformed.
- Little or no feeling left in nipple.
- in large breast it may look out of place.
- Good cosmetic result but increase rate of local recurrence
Modified radical mastectomy:
- simple mastectomy plus removal of axillary lymph nodes.
Radical mastectomy:
- The entire breast, axillary lymph nodes, and the chest wallpectoral() muscles under the breast.
- Less common now
possible side effects of mastectomy
- include wound infection,
- hematoma
- , seroma
Choosing between breast-conserving surgery and mastectomy
In early-stage cancers choice is between breast-conserving surgery and mastectomy.
Breast-conserving surgery (BCS)
- main advantage
- Most of her breast is preserved
- A disadvantage
- Need for radiation therapy—most often for 5 to 6 weeks—after surgery
-
choice will depend on many factors
- Feeling about losing your breast
- Thinking to remove all cancer for ever and select mastectomy
- Fear of recurrence
- Feeling about radiation therapy
- Duration of radiation therapy and distance from home/ office
- Plan of reconstructive surgery
-
Contraindication for breast conserving surgery
-
- First unsuccessful treatment
- Already had radiation therapy to the affected breast
- Unsuccessful re-excision after BCS
- More than one area of disease which can not be removed satisfactory with adequate amount of breast still there.
- Contraindication to radiotherapy
- scleroderma or lupus, which increase side effects of radiation therapy
- Pregnancy
- Neoadjuvant chemotherapy may fail
- large tumors (greater than 5 cm )
- inflammatory breast cancer
- Tumor large relative to breast size
- very high risk for a second cancer
-
- young women
- a knownBRCA mutation are atr.
Axillary nodes dissection
Very import for staging and treatment planning after operation
In axillary lymph node dissection (ALND) lymph nodes are removed from the the area under the arm (axilla) and checked for cancer spread
- usually done at the same time as the mastectomy or BCS,
- but it can be done in a second operation.
- Sentinel lymph node biopsy (SLNB): has low rates of side effects,
- removing many lymph nodes increases the chance of lymphedema
- To lower the risk of lymphedema a sentinel lymph node biopsy (SLNB) is done.
- finds and removes the first lymph node(s) to which a tumor is likely to drain. - is the one most likely to contain cancer cells if they have started to spread.
- Radioactive substance and/or a blue dye injected in or around tumor . Lymphatic vessels will carry these substances into the sentinel node(s) which is identified by special device for radioactive substance or blue dye found in breast
- That nodes send for evaluation
- If cancer then Axillary clearance
- If negative - wait and watch
- If needed ALND latter on
- Lymphedema develops in up to 30% of women who have a full ALND. It also occurs in up to 3% of women who have a sentinel lymph node biopsy
- more common if radiation is given after surgery
- Short or long term movement problems may develop
- More common ALND then SLNB
- rope-like structure that begins under the arm
- More common with ALND then SLNB
- often goes away without treatment,
- Post operative physiotherapy is helpful shoulder and arm problems
Reconstructive surgery
. These procedures are done to restore the breast's appearance after surgery.
To get all options best to discussion before operation and find out most suitable option.
Type
- an autologous tissue reconstruction
- Implants
Immediate or delay
What to expect with surgery
.
Before surgery:
Diagnosis will take few days
For staging imaging and surgery is needed
Discuss with surgeon
Type of surgery
Reconstruction or not
- and if yes when immediate or delay
- and type of reconstruction
- Expected outcome
sign a consent form, giving the doctor permission to perform the surgery.
read the form carefully
- to be certain that you understand what you are signing.
- might be asked to give consent for researchers to use tissue or blood that is not needed for diagnostic purposes
- it may be very helpful to other in the future.
- if a transfusion might be needed
- donate blood before some operations, such as a mastectomy combined with autologous tissue reconstruction
- if a transfusion is needed, you will receive your own blood
- If needed donor blood can be given
- Review your medical records
- any medicines you are taking.
- is to be sure that you are not taking anything that might interfere with Operation
- Example aspirin, arthritis medicine, or a blood-thinning drug
- stop taking the drug about a week or 2 before surgery
- . tell your doctor about everything you take, including vitamins and herbal supplements.
- when to stop taking orally
- Preoperative evaluation by physician and anaesthetist.
- intravenous line put in -usually in a vein in your arm for intravenous medication and anesthesia during and after operation
- Monitors
- BP ,ECG, SpO2
- General anesthesia is used for most breast surgery.
- length of the operation
- depends on the type of surgery
After surgery:
-
- taken to the recovery room,
-
- stay until awake and stable
- r condition and vital signs
- pulse, blood pressure, and breathing are stable.
- stay in the hospital depends on
- the type of surgery
- overall state of health
- other medical problems,
- surgical problems
- dressing over the surgery site
- one or more drains - plastic tubes
-
- coming out from the breast or underarm area
- to remove blood and lymph fluid that collects during the healing process.
- Learn how to care for the drains,
- emptying and measuring the fluid
- identifying problems
- Depending on amount drainage drains stay in place for 1 or 2 weeks occasionally more.
- Mostly as soon as possible- on same day
- liquid orally mostly on same day
- Duration of recovery
- Depend on type of surgery
- regular activities within 2 weeks after a BCS with ALND,
- recovery time is often shorter for BCS plus a SLNB
- can take up to 4 weeks after a mastectomy
- longer if reconstruction was done
- can take months to return to full activity after some procedures.
- times can vary from person to person,
- talk to your doctor about what you can expect.
-
- Many surprised by how little pain they have
- might feel stiff or sore for some time
- skin of your chest or underarm area may feel tight
- pain, numbness, or tingling in the chest and arm
-
- may continue for a long time
Before going home Understand following
- monitoring and care
- drainage
- surgical wound and dressing
- signs of infection
- Bathing and showering
- When to
- call the doctor or nurse
- begin using the arm and how to do arm exercises to prevent stiffness
- resume wearing a bra
- begin using a prosthesis and what type to use (after mastectomy)
- What to
- eat and not to eat
- expect regarding sensations or numbness in the breast and arm
- expect regarding feelings about body image
-
- medicines,
- pain medicines
- possibly antibiotics
- other
- Any restrictions of activity
- When to see your doctor for a follow-up appointment
- Mostly after one or two weeks
- results of your pathology report
- need for further treatment.
Chronic pain after operation- post-mastectomy pain syndrome (PMPS) / neuropathic pain
-
- Mostly symptoms are not severe
- linked to damage done to the nerves in the armpit and chest during surgery
- problems with nerve pain in the chest wall, armpit, and/or arm after surgery that doesn’t go away over time.
- 20% and 30% of women develop symptoms of PMPS
- . The symptoms of PMPS are
-
- pain and tingling in the chest wall, armpit, and/or arm.
- Pain may also be felt in the shoulder or surgical scar
- . Other common complaints include numbness, shooting or pricking pain, or unbearable itching. Most women with PMPS say their.
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Cancer Vijay