Management of Breast Cancer

Introduction
Breast cancer is the most common cancer in women, representing one-third of all new cancer diagnoses in women in the United States annually (213,000 cases). Fortunately, earlier diagnosis and a better understanding of the disease leading to more effective, targeted therapies have led to a continued improvement in prognosis and outcome.

In the next few weeks, you will be faced with the impact of this diagnosis and have to maneuver through an increasingly complex medical system for tests, consultations, surgery and other therapies. The following is a break down the steps involved in this process and familiarize you with the options in management.

Breast evaluation
If there has not been a recent mammogram at the time of breast cancer diagnosis (within six months), one should be ordered.

It is important to know whether multiple areas of the breast are involved with tumor (multifocality or multicentricity) and to screen the opposite breast for tumors undetectable by traditional imaging (mammograms or ultrasounds). Magnetic Resonance Imaging (MRI) scanning of both breasts may be recommended, especially in younger women with dense breasts or in women whose cancers were not detected by mammography.

Staging evaluation
Clinical staging of breast cancer involves an assessment of the size of the tumor and whether or not lymph glands under the arm (axilla) appear to be involved. It is difficult for doctors to accurately assess node involvement on the basis of a physical examination or non-invasive testing. For that reason, initial preoperative clinical staging is considered preliminary. Final pathologic staging occurs after surgical results are available. Surgery results may change the initial clinical stage.

The majority of patients present with early stage breast cancer. Staging of breast cancer is as follows:

It is unusual for breast cancer to have already spread at the time of the initial diagnosis. However, after the diagnosis of breast cancer has been made, it is important to determine this. X-rays and blood tests are typically ordered. Not all patients require all these tests. Your doctor’s assessment of how early or advanced the tumor is and whether or not symptoms are present will determine the need for various studies. Common tests ordered include a chest x-ray, laboratory blood studies to include an assessment of liver function, bone scan, CT scans and PET scans. If abnormalities are found on initial testing, further testing may be needed.

Breast cancer treatment is generally classified into local therapy and systemic therapy. Local therapy is what is done to the breast. Surgery and radiation therapy are examples of local therapy. Systemic therapy affects the whole body. In early, potentially curable breast cancer, systemic therapy reduces the likelihood that the tumor will come back in other parts of the body. Decisions about local and systemic therapy are separate.

Surgical treatment options
Most patients have a choice between breast-conserving therapy and mastectomy. Breast-conserving therapy consists of a lumpectomy with tumor-free surgical margins, an assessment of the axillary lymph nodes (see separate sheet on sentinel node biopsy) followed by radiation therapy. In order to be a good candidate for this form of breast cancer treatment, there must be a single tumor within the breast measuring less than 5 cm.

Multiple tumors need to be treated with mastectomy. Also, the margins of tumor excision must be tumor-free. If tumor is persistently present at the surgical margins despite re-excision(s), mastectomy is the recommended option. Women that cannot undergo radiation therapy (e.g., pregnancy, prior radiation at the same site), also need a mastectomy.

Lumpectomy with sentinel node biopsy or axillary dissection is done under general anesthesia as an outpatient. Complications are rare but include bleeding, infection, allergic reactions to sentinel node mapping agents. Arm swelling (lymphedema) may be seen in 2-3 percent of patients undergoing sentinel node biopsy and 10-15 percent of those undergoing axillary dissection. Arm stiffness and numbness can occasionally be seen. Recuperation is generally 2-3 weeks.

If the final pathology shows tumor-involvement of the surgical margins, additional operations may be necessary to take more tissue out of the breast. If the sentinel node is unexpectedly found to be involved, an axillary dissection at a later date may also be needed.

Radiation therapy is an integral part of this treatment. It reduces local recurrence rates by 50-75 percent. Lumpectomy alone is associated with a 30-50 percent chance that the tumor may come back in the treated breast (local recurrence). With the addition of radiation therapy, that rate is lowered to 10 percent. If a local recurrence happens after lumpectomy and radiation therapy, a mastectomy is needed because the tissue cannot be radiated again.

Mastectomy is the operation that removes the breast including the nipple-areolar complex. The chest wall muscles are not removed. Some lymph nodes are by necessity removed during this operation as there is an overlap region between the breast tissue and the lymphatic tissue near the underarm region. Assessment of the axillary nodes is the same as with breast-conserving therapy (see sentinel node biopsy information sheet). Some patients require mastectomy for medical reasons (see above). Others may prefer a mastectomy. Occasionally, a prophylactic mastectomy of the uninvolved breast is recommended, especially in cases where a significantly positive family history is present.

Mastectomy can be done with or without an immediate reconstruction. If mastectomy is done for local recurrence following radiation therapy, the reconstructive options are more limited.

Generally, with the option of mastectomy, radiation therapy is not needed. However, there are circumstances where post-mastectomy radiation is recommended. These include tumors that are large (greater than 5 cm.) or locally advanced, involvement of more than four axillary nodes, or direct extension of the tumor to the chest wall. The need for post-mastectomy radiation will affect the reconstructive options.

Mastectomy with or without reconstruction is done under general anesthesia as an inpatient. The length of stay in the hospital is 1-2 days for a mastectomy alone or with a simple reconstruction. More complicated reconstructions result in a 5-7 day hospital stay. Recuperation is from 4-8 weeks.

Complications following mastectomy are unusual. Significant bleeding is uncommon, even with complicated reconstructions. Transfusions are rarely needed. Infection or tissue loss can occur but are uncommonly seen. The risk of lymphedema is related to the extent of axillary surgery. With a sentinel node alone, the risk of arm swelling is 2-3%. With an axillary dissection, the risk is 10-15 percent. Arm stiffness can occur but responds well to exercises (see sheet) and physical therapy. Other rarer complications can occur, as with any surgical procedure.

Radiation therapy
Radiation therapy as part of breast-conserving therapy traditionally involves treatment of the whole breast, a process that takes six weeks. A boost to the primary site may be given at the end. Radiation starts 2-4 weeks following surgery. However, if chemotherapy is needed, that comes first after surgery and radiation would follow 2-4 weeks after completion of chemotherapy.

In selected cases, partial breast radiotherapy can be given. These are usually early, favorable tumors that have a low risk of being multifocal and a low risk of recurrence. Partial breast radiotherapy can be delivered by placement of a MammositeÒ balloon. This device is placed into the lumpectomy site in the operating room or the surgeon’s office. The device has two exiting ports, one for inflation and deflation of the balloon, and one that attaches to the radiation unit. Radiation is delivered through the catheter in two sessions daily six hours apart for one week. Once radiation is completed, the catheter and balloon are removed. This type of radiotherapy would be given shortly after the lumpectomy, before chemotherapy, as opposed to external beam whole breast radiation which is generally given after chemotherapy.

Adjuvant systemic therapy
Systemic therapy involves chemotherapy and/or hormonal therapy. Decisions about the need for adjuvant systemic therapy depend on the likelihood of recurrence of the tumor. This is assessed by the size of the tumor, involvement of the axillary nodes, presence or absence of hormone receptors or her2neu, and other factors. In hormonally-responsive tumors, when the benefit of chemotherapy is not clear-cut, tumors may be sent out for further testing to look at the gene profile of the individual tumor. This test is called Oncotype DX . It looks at a 21-gene panel and assesses the likelihood of tumor recurrence on the basis of those genes. Tumors that are at low risk for recurrence can be treated with hormonal agents alone. Those that are at intermediate or high risk should get chemotherapy followed by hormonal agents.

Chemotherapy for breast cancer usually involves a combination of drugs, generally given intravenously every 2-3 weeks for 4-8 cycles. If the tumor is positive for her2neu, a targeted drug called Herceptin will be recommended and that is given for one year.

Most breast tumors have receptors for estrogen and progesterone. When these receptors are present, medications that block either the receptor itself (e.g. Tamoxifen) or the production of estrogen (aromatase-inhibitors, e.g. Arimidex) are recommended. Aromatase-inhibitors are only effective in post-menopausal women. The use of these drugs not only reduces the chance of recurrence of the original tumor, but also reduces the likelihood of developing another breast cancer in either breast. These drugs are given orally for five years.

Breast cancer treatment team
You will need to be seen by various specialists in the treatment of breast cancer. These include the breast surgeon, medical oncologist, radiation oncologist, and plastic surgeon (if mastectomy is being done). Genetic counseling may be recommended in cases where a significant family history of breast and ovarian cancer is present. Supportive care services are provided by the Joan Karnell Cancer Center.

You may wish to get more than one opinion about your treatment options. This is commonly done in cases of breast cancer. Breast cancer is rarely an emergency. You have time to research your disease and get all the information necessary to make informed choices. You may decide to have individual members of your breast cancer treatment team at different institutions. It is important to feel comfortable with your providers, as you will need to be followed lifelong.

A Message from the Integrated Breast Center Team
This is a difficult time for patients newly diagnosed with breast cancer. Keep in mind, however, that great strides have been made and continue to be made in the struggle against this disease. The majority of patients with breast cancer have an excellent prognosis. Every year, new drugs and therapies become available that will further improve outcome. There is every reason to be optimistic.

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