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Breast Cancer; Treatment.

The treatment you and your health care professional choose will depend upon many things. Treatment often includes surgical, radiation and medical therapy.

The most common surgical treatment for invasive cancer is lumpectomy with sentinel lymph node biopsy technique. (Described below.) Dissection of axillary lymph node (a large group of lymph nodes located in various places) and modified radical mastectomy, are other common surgical treatments for invasive cancer.

Lumpectomy, also known as excisional biopsy or wide excision, is a breast-conserving surgical procedure. It has become more common in the last 10 years as a means of treating early-stage cancer. In fact, results from two major studies that appeared in the October 2002 New England Journal of Medicine confirmed earlier studies that lumpectomy followed by radiation to the breast is just as effective as mastectomy in treating breast cancer.

During lumpectomy, a surgeon removes just the tumor along with a margin of healthy tissue, leaving the remainder of the breast intact, followed by radiation. Regardless of whether you choose lumpectomy or mastectomy, an axillary lymph node dissection should be performed for invasive forms of the disease.

Simple or total mastectomy: The entire breast is removed.

Modified radical mastectomy: One of the most common breast cancer surgeries performed (the other is lumpectomy with axillary lymph node dissection). The entire breast is removed along with underarm lymph nodes (sometimes the lining over the chest muscles and, more rarely, part of the chest wall muscle is also removed).

Adjuvant Therapy

In addition to surgery, adjuvant therapy is used to kill any cancer cells that may have spread. In deciding whether adjuvant treatment is necessary, your doctor takes into account the extent (stage) and nature of your disease, general health and other prognostic factors.

The choice of the type of adjuvant therapy depends on many factors, such as whether the cancer cells contain hormone receptors (estrogen and progesterone), Her2/neu expression, the grade of tumor and the size of tumor and lymph nodes. Most women receive some form of adjuvant therapy.

Adjuvant therapy usually begins between two and 12 weeks after surgery. It includes chemotherapy and/or hormone therapy, as well as radiation therapy.

Chemotherapy involves a combination of anticancer drugs. These drugs are powerful and can have many side effects. Anticancer drugs are given by mouth or by injection into a blood vessel. Either way, the drugs enter the bloodstream and travel throughout the body.

Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most patients receive treatment in an outpatient part of the hospital or at the doctor's office. Adjuvant chemotherapy usually lasts for three to six months.

Hormone therapy deprives cancer cells of the female hormone estrogen, which some breast cancer cells need to grow. For many women, hormone therapy means treatment with the drug tamoxifen or an aromatase inhibitor, such as anastrozole (Arimidex), letrozole (Femara) or exemestane (Aromasin).

Some premenopausal patients may have surgery to remove their ovaries, which are a woman's main source of estrogen. Or they may be treated with a medication to reduce ovarian function.

Like anticancer drugs, tamoxifen and the aromatase inhibitors are taken once a day via pill and are absorbed into the bloodstream. Most women take hormone therapy for five years. In 2003, the results of a clinical trial examining whether the aromatase inhibitor letrozole prevents late recurrences of breast cancer were reported in the New England Journal of Medicine. The data showed that taking the drug after a five-year course of tamoxifen significantly reduced the incidence of recurrent breast cancer in postmenopausal women. In fact, the study was stopped prematurely to give those women who were taking a placebo the opportunity to receive the drug.

Another study, this one reported in a 2004 issue of the New England Journal of Medicine, found that taking exemestane following two to three years of tamoxifen improved cancer-free survival as compared with the standard five-year tamoxifen treatment in estrogen receptor-positive breast cancers.

A study published in the Lancet in late 2004, reported on the results of a clinical trial comparing the use of aromatase inhibitors to tamoxifen over five years. The trial, called the Arimidex, Tamoxifen, Alone or in Combination (ATAC) Trial, found that anastrozole significantly reduced breast cancer recurrences compared to tamoxifen, in both breasts as well as in other parts of the body. Women taking anastrozole also experienced fewer side effects than those taking tamoxifen, especially hot flashes, blood clots, vaginal discharge/bleeding and stroke, but were more likely to experience a bone fracture or other musculoskeletal disorder.

Tamoxifen also carries some risks, however, which prompted the FDA to issue a "black box" warning for the drug's label. The warning notes that an increased risk of stroke, pulmonary emboli and fatal uterine cancers may accompany use of the drug, and suggests patients discuss these risks with their health care professionals.

Radiation therapy is used in patients having a lumpectomy. It is also sometimes used after a mastectomy for women with large cancer tumors or with four or more positive lymph nodes, or when the margins of the surgical removal show some cancer cells. Such treatment can help destroy breast cancer cells that may have been left behind in the area where the breast was.

Choosing the Right Treatment

So how do you know which treatment to choose? Your health care professional will try to determine your prognosis--the likely outcome after treatment. One indicator most commonly used is lymph node involvement.

Cancer cells commonly spread from the breast to lymph nodes in underarm and chest areas. To determine if and how far breast cancer has spread, and which treatment option may be the best option, a number of lymph nodes are typically removed for biopsy to see if they contain cancer cells.

If cancer is found, the woman is said to be "node positive." If the lymph nodes are free of cancer, the patient is said to be "node negative." Women who have multiple positive nodes are more likely than those with negative nodes to have a systemic recurrence. Plus, the more lymph nodes that are involved, the more serious the cancer.

A procedure that is widely used is called sentinel lymph node biopsy. It is effective as a less invasive technique than conventional axillary lymph node dissection to determine if certain cancers have spread.

Sentinel nodes are a small cluster of lymph nodes to which cancer first spreads from the primary tumor. In a sentinel node biopsy, a surgeon removes only one or a few of the sentinel nodes instead of the larger number of nodes typically removed for biopsy. The surgeon identifies the sentinel nodes to remove by injecting a radioactive tracer substance or dye near the tumor. Then, using a scanner, he or she searches for the nodes containing the dye/tracer and removes them to check for cancer cells.

A study reported in a 2003 issue of the New England Journal of Medicine found that sentinel node biopsies of women with small breast cancers caused fewer side effects (such as swelling, pain and numbness) than conventional biopsy procedures and was a safe and accurate way to evaluate lymph nodes in women with small breast cancers.

Tumor size. In general, patients with small tumors have a better prognosis than do patients with large tumors.

Histologic grade. This term refers to how much the tumor cells resemble normal cells when viewed under the microscope. The grading scale usually ranges from 1 to 3. Grade 1 tumors are composed of cells that closely resemble normal ones. Grade 3 tumors contain very abnormal-looking and rapidly growing cancer cells.

Hormone receptors. Cells in the breast contain receptors for the female hormones estrogen and progesterone. These receptors allow the breast tissue to grow or change in response to changing hormone levels. Research finds that about two-thirds of all breast cancers contain significant levels of estrogen receptors. These tumors are said to be estrogen receptor positive (ER+). About two-thirds of ER+ tumors also test positive for receptors to progesterone (PR+). Tumors that are hormone receptor positive are more likely to respond to hormone therapy. These tumors also tend to grow less aggressively, resulting in a better prognosis for patients with ER+ tumors.

Proliferative capacity of a tumor. This characteristic refers to the rate at which cancer cells in a tumor divide to form more cells. Cancer cells that have a high proliferative capacity divide more often and can be more aggressive (fast growing) than those in tumors with a low proliferative capacity.

Oncogene expression and amplification. An oncogene is a gene that causes or promotes unrestrained growth of a cell. The activation of an oncogene can convert a normal cell into a tumor cell. Research finds that women whose tumor cells contain certain oncogenes may be more likely to have a recurrence. Tests for oncogenes are available at most medical facilities. One such test looks for the presence of the protein HER2.

About 25 to 30 percent of women with breast cancer have an excess of a protein called HER2, which makes tumors grow quickly. Two genetically engineered drugs, trastuzumab (Herceptin) and lapatinib (Tykerb), bind to HER2 to help fight cancer cells. Trastuzumab is an intravenous treatment that is used alone or in combination with chemotherapy drugs. Most recently, in 2005 two studies published in the New England Journal of Medicine found that taking Herceptin for one year after surgery reduces the risk of breast cancer recurrence by half. This was an unprecedented improvement in treating this disease and will impact the way all oncologists practice.

Tykerb, approved in March 2007, is used in combination with capectabine (Xeloda), another cancer drug, in patients with advanced HER2 positive tumors. The combination of Tykerb and Xeloda is to be used in women who have received prior therapy with other cancer drugs, including Herceptin. Tykerb, a new molecular entity (NME), is a kinase inhibitor that works by depriving tumor cells of signals that they need to grow.

Pregnancy and Breast Cancer

As many as four percent of breast cancers occur during pregnancy or within the first year after giving birth. Changes in the breast during pregnancy and lactation may make detection difficult. Pregnancy also limits the treatment options for breast cancer.

Surgery remains an option, however, with special care taken during anesthesia, but radiation must be delayed until after the pregnancy because of its dangerous effects on the developing fetus.

However, chemotherapy can be given in the second or third trimester. Or, for women who want to save their breasts, chemotherapy can be given before surgery and radiation delayed until after delivery.

Post-Mastectomy and Reconstruction

After a mastectomy, some women may choose to wear a prosthesis (an artificial breast form). Others may decide to have breast reconstruction.

There are several methods to rebuild the breast after mastectomy. The method must be tailored to the individual patient's needs. The simplest operation is to place an implant behind the remaining muscle and create a mound that resembles a normal breast. In some cases, breast reconstruction may be performed immediately following a mastectomy.

If you had a great deal of tissue removed, more skin can be created with a tissue expander. This is a balloon-type device that is placed beneath the muscle and skin. Over several weeks this is made larger by almost painless injections of saline in the health care provider's office. After several months, the expander is replaced by a permanent implant.

Another approach is flap surgery. It uses tissue from your back, thigh or abdomen to rebuild the breast. This tissue is moved into its new position, leaving a defect at the donor site. It is more major surgery. If you had radiation, which can cause significant scarring, a flap may be the best option.

The scar from breast reconstruction depends on the method used. With the flap, for example, you will have a scar at the site where the flap is removed (the donor site) and another around the flap on the breast.

You can read more on breast reconstruction on

Whichever method is used, additional surgery is needed if you want to have the nipple and areola rebuilt.

Regardless of whether you have a mastectomy alone or the added reconstructive surgery, there is a period of time after the surgeries when you can expect a certain amount of pain and limited movement. Recovery times vary depending on your surgery and overall health. Various programs are available to help you regain function; ask your health care professional for a referral to one of those programs.


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Keywords: breast cancer, lumpectomy, axillary lymph node dissection, mastectomy, adjuvant therapy, chemotherapy, hormone therapy, radiation, sentinel node biopsy, oncogene, during pregnancy, breast reconstruction
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Publication:NWHRC Health Center - Breast Cancer
Date:Apr 21, 2008
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