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Tailoring treatments to specific types of breast cancer: the type, stage, and subtype of cancer influence the choice of treatments.

When it comes to breast cancer treatment, one size does not fit all. There are many types of breast cancers and many kinds of treatments.

"We've made a lot of progress," says Anne Moore, MD, medical director of the Weill Cornell Breast Center, a noted researcher, and a professor of clinical medicine at Weill Cornell Medical College. "We've developed a lot of new drugs in the past few years, and the death rate from breast cancer has been going down every year."

How do doctors choose the best method of attack?

Breast cancer type and stage

Developing a treatment plan starts with determining the type of cancer--noninvasive or invasive. Non-invasive breast cancer is limited to the milk ducts; it doesn't spread to other tissues. Invasive cancer starts in the milk ducts and then spreads into the surrounding tissue.

Once the type of cancer is pinpointed, doctors look at the stage of the cancer. Non-invasive cancer is always stage zero. Invasive cancer ranges from stage one, in the early stages, to stage four, when the cancer has spread to other organs.

Subtypes of breast cancer

Breast cancer subtypes include estrogen (and/or progesterone) receptor positive, HER-2 positive, triple-negative, and inflammatory breast cancer.

Estrogen receptor positive breast cancer cells have proteins that attract the hormones estrogen and/or progesterone as they float by in the blood. The hormones promote the growth of the cancer cells. Most cancers that are estrogen receptor-positive (ER) are also progesterone receptor-positive (PR).

HER-2 positive cancer cells make too much of the growth-promoting protein HER2/neu (HER-2). HER-2 makes cancer grow and spread quickly.

Triple-negative cancer cells have no estrogen or progesterone receptors, and don't overproduce the HER-2 protein.

Inflammatory breast cancer is rare. Symptoms of this cancer, which develop suddenly, include swelling and reddening of the breast, and skin texture similar to an orange peel. This cancer is very aggressive, and symptoms must be reported to a doctor as soon as possible.

Treatment options

The type, stage, and subtype of cancer influence the choice and sequence of treatment. While therapy must be individualized to each person and her particular health needs, Dr. Moore says it often boils down to the following plans for a woman with newly diagnosed breast cancer:

Non-invasive breast cancer: Treatment is primarily surgery, either a mastectomy (the removal of the breast) or a lumpectomy (the removal of part of the breast). "If there's a lumpectomy, we'll usually do radiation therapy afterward to kill any remaining cells that may have been missed," says Dr. Moore.

ER- and/or PR-positive cancer: "Depending on the stage of the cancer, the first treatment is surgery, and then radiation if there was a lumpectomy, and possibly chemotherapy," says Dr. Moore. After those treatments, she recommends a course of drugs. Postmenopausal women are given an aromatase inhibitor, such as anastrozole (Arimidex) or letrozole (Femara), which blocks the enzyme aromatase, needed to make estrogen. Premenopausal women are given tamoxifen (Nolvadex), a medicine that interferes with estrogen receptors. "These drugs are very specific treatments known as targeted therapies, and they've made a big difference in reducing the recurrence of the disease," says Dr. Moore.

HER-2 positive cancer: "We usually recommend surgery first, but if the cancer is advanced, we'll recommend chemotherapy with trastuzumab (Herceptin) first," says Dr. Moore. Trastuzumab is a targeted therapy that attaches to HER-2 proteins and can slow or stop cancer cell growth. It works best when given in addition to chemotherapy.

Inflammatory breast cancer: "Chemotherapy always comes before surgery for inflammatory breast cancer. Surgery in this case is a mastectomy and usually includes lymph nodes," says Dr. Moore.

Triple negative: Treatment includes either a lumpectomy or a mastectomy, depending on the stage of the cancer, and chemotherapy before or after surgery. Aromatase inhibitors, tamoxifen, and trastuzumab are not used.

"The point is, there are several types of breast cancer, but now we have targeted treatments for many of them. Still, there's more work to be done to understand the nature of each cancer; we're working on that," says Dr. Moore.


* Early detection is critical; get a mammogram when your doctor recommends it.

* The American Cancer Society no longer recommends a breast self-exam as a screening tool.

* You may choose to do breast self-exams; if you do, report any changes you notice to your doctor.
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Title Annotation:ONCOLOGY
Publication:Women's Health Advisor
Date:Oct 1, 2015
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