Dr. Anthony Smith, MD, FACS Discusses Paragon Breast Care
Dr. Anthony Smith is a Fellowship Trained Surgeon specializing in breast care surgery at Paragon Surgical Specialists and Paragon Breast Care in Concord, North Carolina.
Paragon Breast Care is the first practice of its kind in Concord and the Charlotte region. Our dedicated purpose is to provide comprehensive and cohesive care for women with breast cancer and other breast disorders. From prevention and diagnosis, to treatment and recovery, our patients will find a comforting atmosphere combined with state-of-the-art care and committed medical expertise. Our facility is also a member of the National Consortium of Breast Centers.
Every woman is at risk for breast cancer. Breast cancer is the most common cancer of women and as you get older, your risk for breast cancer increases. Three-quarters of all breast cancers occur in women over age 50. Though rare, men can also develop breast cancer.
Risk is somewhat higher in women whose close female relatives-their mothers or sisters-have the disease. Also, women who never have had children or had their first child after age 30 appear to be at somewhat higher risk for breast cancer.
It is still not clear what causes breast cancer or how to prevent it. The best protection against breast cancer is to detect it at its earliest stage and to treat it promptly. Researchers are investigating the possible roles of heredity, the environment, lifestyle and diet.
The recommendation of the American Cancer Society and the nation’s leading health organizations is this three-step early detection program:
- Have regular mammograms: Screening mammograms should begin by age 40. Have one every year or two to age 49, and every year after age 50.
- See your doctor for regular breast exams: At least every three years between the ages of 20 and 40 and every year over 40.
- Practice monthly breast self-exam: Ask your doctor, nurse or mammography technician to teach you the proper method.
The most common sign is a lump or thickening that does not go away or seem to change. Most lumps in the breast are not cancerous-four out of five are from other causes. All lumps should be checked by a doctor. Other signs to be aware of if they persist are swelling, puckering or dimpling, skin irritation, pain, or tenderness of the nipple. If any of these symptoms or signs occurs in a man, they should be checked immediately.
A mammogram is an x-ray picture of the breast. Modern mammography equipment and techniques expose women to only minimal amounts of radiation. A trained radiolologic technologist positions your breast between two plastic plates that compress it, spreading it out so that the x-ray can produce as precise an image as possible. Two x-rays are taken of each breast during mammography-one from above and one from side to side. A specially trained physician-a radiologist-reads the mammogram to see if any suspicious areas exist.
Not all breast cancers or breast cancer patients are alike. Treatments for early breast cancer can include lumpectomy (limited surgery which removes the cancer but not the entire breast), followed by radiation therapy; or mastectomy (surgical removal of the breast). Additional treatment may include chemotherapy or hormone therapy. A woman with breast cancer should fully review her treatment options with her doctor before decisions are made on a treatment program.
DCIS is a form of breast cancer that is now diagnosed more frequently as a result of the widespread use of screening mammography. The vast majority of women with this condition have no symptoms but are diagnosed via a mammography. In our experience, approximately 1 out of 4 women that require a biopsy have a positive diagnosis of breast cancer.
DCIS originates near the end of the ductal system next to the lobules. Lobules make milk which flows along the duct to the nipple. Normal ducts are composed of small, even rectangular cells with a small central round nuclei. It is thought that an early stage in the development of breast cancer is hyperplasia, in which the cells become irregular and pile up upon themselves. In DCIS, the ducts are lined by cells that are even more irregular and the nuclei become more distorted. In both conditions, the cells are confined to the ducts. In invasive ductal cancer, the cells invade into the surrounding breast tissue. These invasive cells have the potential to spread to other parts of the body.
In the past, most cases of DCIS were associated with a lump and many of these lumps also contained invasive cancer. Currently, most women diagnosed with DCIS have no symptoms and are diagnosed because a screening mammogram showed a cluster of calcifications.
Calcium is a normal component of bone and often deposits in normal tissue – it has nothing to do with dietary intake of calcium. Most normal mammograms have some areas of calcification; it is only when the calcification shows certain characteristics such as clustering or irregularities in size or shape that it becomes of concern.
In cases where the calcification pattern is considered suspicious, a biopsy is recommended. In most instances, a “localization” will be preformed prior to your biopsy. This technique is used to mark the area of concern that appears on the mammogram, but cannot be felt. Using your mammogram as a guide, a radiologist places a needle at the spot in question. Another mammogram confirms that the needle is in position. Then blue dye is injected and a flexible “hook” wire is inserted and used by your surgeon as a guide to the area of concern. The biopsy specimen is x-rayed to insure that the calcifications are present in the specimen.
The margin refers to the distance between the tumor and the edge of the lumpectomy or mastectomy specimen. To save the breast and avoid mastectomy the margins must be cleared. This is not as easy as it sounds. Breast cancers often have microscopic extensions beyond the obvious tumor that are not visible to the mammographer preoperatively or to the surgeon at the time of the surgery. Immediately after the surgeon removes the tumor from the breast, the pathologist color codes the surface with ink. A few days latter the specimen is examined under the microscope. If there is wide clearance between the tumor and the color coded edges, the margins are considered clear. If the tumor is near or at the margin, the margin is considered positive. If the margins are positive and the woman still desires breast conservation, another surgery is required. Since the margins were color coded, the surgeon knows which area is in need of further removal.
The reason that the margin issue is so important is that breast cancer recurrence rates are higher if the margins are not adequately cleared. How much clearance is necessary is controversial. In our practice we like 2mm of clearance for invasive cancers and 5 mm of clearance for DCIS. With this aggressive approach we have a 5 year local recurrence rate of less than 2% which is very low as compared to national standards.
A common problem facing women who has recently been diagnosed with DCIS is that her margins are positive after the area of calcification has been completely removed. The common explanation is that much of the cancer does not contain calcifications. For this reason it is not seen on the mammogram and cannot be felt by the surgeon. It is usually not found for 2-3 days after the surgery when the pathologist examines the slides under the microscope.
If margins are clear, mastectomy can usually be avoided. Small, non-aggressive forms of DCIS may be safely treated with careful observation and follow-up. However, in larger or more aggressive forms, radiation therapy is always required to lower the rate of local recurrence. Even cases with involved margins can often be treated with breast preservation, as long as the margins can be cleared with a subsequent biopsy.
In cases where the DCIS is more extensive or when re-excision margins are again involved, mastectomy with or without reconstruction is usually the treatment of choice.
The most important point to remember is that DCIS is 100% curable! If diagnosed early, the breast can be preserved and most women can live happy and productive lives.
The Breast Care Center encourages patients and their families to become better informed about breast health, disease and treatment. Please click here to learn about our Patient Support Services.
The numbers are a classification of mammogram which tells the physician what to do with the results. This classification is called BIRADS. The following is what is meant by each number.
- Benign…nothing to worry about.
- Probably benign;<2% chance this is a cancer
- (obtain another mammogram in 6 months)
- Worrisome; consult for biopsy
- Suspicious for cancer; biopsy
Calcifications are small white spots seen on the mammogram which represent calcium deposits. Calcium is a byproduct of changing breast tissue. Most of these changes are not cancer. The radiologist can describe which ones are not worrisome and which ones need to be biopsied to see if they are associated with a cancer.
Mammograms are falsely negative 10% of the time in postmenopausal women and 25% of the time in premenopausal women. Lump + negative mammogram = lump. Yes, still have an exam to have your lump checked out.
We now have available several minimally-invasive diagnostic options. An attempt is made to select the option that is the least invasive and the best tolerated by the patient. In most instances, the diagnosis can be made in the office on the patient’s first visit.
In some situations, an open surgical biopsy is still required to establish an accurate diagnosis. Procedures used at the Center include the following:
- Fine Needle Aspiration
- Core Needle Biopsy
- Stereotactic Core Biopsy
Fine Needle Aspiration
The original, minimally-invasive procedure for diagnosing breast cancer was the use of a fine needle aspiration biopsy. This technique has been used for over 50 years and has proven to be highly valuable in situations where expert pathologists are available to interpret the aspirated specimen. We have performed over 5,000 of these aspirations at The Breast Care Center with excellent results.
The techniques of this procedure are rather simple. A very fine needle is inserted into the tumor. In some cases where the tumor is not palpable, an ultrasound is used to guide the needle to the area of concern. The needle is moved back and forth and placed on a slight suction so that cells can be removed from the tumor. These cells are placed on a slide and evaluated by the pathologist. In our experience, 80% of palpable tumors can be diagnosed using this technique. It is usually performed at the time of the patient’s first office visit. The results are often available within two hours. In cases where this procedure does not give a precise diagnosis, the next step is usually a core needle biopsy.
Core Needle Biopsy
The core needle removes a sliver of tissue from the tumor (the biopsy specimen is approximately the diameter of the lead in a pencil). Because of the large sample size, a more detailed analysis can be performed. This allows the pathologist to comment on the tumor’s cell type and to differentiate between invasive and noninvasive cancer. The procedure is approximately 98% accurate in our hands and is used quite commonly when a fine needle aspiration has failed to give a specific diagnosis, or in cases where the added information is important in pretreatment planning.
This procedure requires local anesthesia and usually takes 20 minutes to perform. Again, this procedure is done in the office and results are available within 24 hours. In cases where this procedure does not give a precise diagnosis, an open biopsy is performed.
Stereotactic Core Biopsy
In situations where a suspicious lesion is identified on the mammogram, but is not palpable or visible on the ultrasound, the stereotactic technique is used to make the diagnosis. This procedure is performed by our mammographers. The patient lies down on a table with the breast protruding through a special opening. A mini-mobile mammogram unit is placed under the table. Films are taken of various angles, which allow a computer to construct a three-dimensional image. A needle is then directed to the area of concern and a core biopsy specimen is obtained. The results are usually available within 24 hours. This procedure requires local anesthesia, is relatively painless, and takes about 45 minutes.
The mammotome is a variation of the stereotactic technique in which a larger sample of tissue is obtained with the use of a specially designed suction device. This is currently the procedure of choice at The Breast Care Center and has proven to be remarkably successful in lesions seen on the mammogram.
Lymph Node Surgery
In the treatment of invasive cancer, whether a woman has a mastectomy or lumpectomy, she and her doctor usually need to know if the cancer has spread to the lymph nodes. When the lymph nodes are affected, there is an increased likelihood that cancer cells have spread through the bloodstream to other parts of the body.
Doctors once believed that removing as many lymph nodes as possible would reduce the risk of developing spread of breast cancer and improve a woman’s chance for long-term survival. We now know that removing the lymph nodes probably does not improve the chance for long-term survival. But knowing whether lymph nodes are involved is important in selecting the best treatment to prevent cancer recurrence.
The only way to accurately determine if lymph nodes are involved is to remove and examine them under the microscope. This means removing some or all of the lymph nodes in the armpit. In the standard operation, called an axillary lymph node dissection, all the lymph nodes are removed. This is often necessary. In many cases, lymph node testing may be done with a more limited surgery that only removes a few lymph nodes with fewer side effects. This is called sentinel lymph node biopsy, and is discussed further below.
For some women with invasive cancer, removing the underarm lymph nodes can be considered optional. This includes:
- Women with tumors so small and with such a favorable outlook that lymph node spread is unlikely
- Instances where it would not affect whether adjuvant treatment is given
- Elderly women
- Women with serious medical conditions
Lymph node surgery is not usually necessary with ductal carcinoma in situ or pure lobular carcinoma in situ. A sentinel node biopsy may be done if the woman is having surgery (such as mastectomy) that would make it impossible to do the sentinel node biopsy procedure if invasive cancer were found in the tissue removed during the surgery.
The surgical technique used to remove lymph nodes from under the armpit depends on the personal circumstances of the patient.
If there are enlarged lymph nodes with apparent spread of the cancer, or the lymph nodes are otherwise found to be involved with cancer, then complete axillary lymph dissection is necessary. However, in many cases, the lymph nodes are not enlarged and are not likely to contain cancer. In such cases, the more limited sentinel lymph node biopsy procedure can be performed.
In the sentinel lymph node biopsy procedure the surgeon finds and removes the “sentinel nodes”, the first few lymph nodes into which a tumor drains. These are the lymph nodes most likely to contain cancer cells. To find these so-called “sentinel lymph nodes”, the surgeon injects a radioactive substance and/or a blue dye under the nipple or into the area around the tumor. Lymphatic vessels carry these substances into the sentinel lymph nodes and provide the doctor with a “lymph node map”. The doctor can either see the blue dye or detect the radioactivity with a Geiger counter. The surgeon then removes the marked nodes for examination by the pathologist.
If the sentinel node contains cancer, the surgeon removes more lymph nodes in the armpit (axillary dissection). This may be done at the same time or several days after the original sentinel node biopsy. If the sentinel node is cancer-free, the patient will not need more lymph node surgery and can avoid the side effects of full lymph node surgery. This limited sampling of lymph nodes is not appropriate for some women. A sentinel lymph node biopsy should be considered only if there is a team experienced with this technique.
Lymph node removal will be recommended for most women with breast cancer. Lymph nodes are lima bean shaped structures that vary in size from that of a pea to the size of a marble. A primary function of a lymph node is to filter unwanted materials from the body, and this includes cancer cells. In fact, if breast cancer cells break off from the main tumor, the first place they are likely to go to the lymph nodes under the arm (i.e. the axillary lymph nodes). One of the most important indicators of prognosis is the status of the axillary lymph nodes (i.e. no nodes involved good means prognosis; the more nodes involved, the worse the prognosis). For this reason it was standard therapy in the past to remove all of the lymph nodes under the arm at the time of the removal of the breast cancer to determine prognosis.
Side Effects of Lymph Node Surgery
Side effects of lymph node surgery can be bothersome to many women. The side effects can occur with either the full axillary lymph node dissection or sentinel lymph node biopsy. Side effects are much less common and less severe with the sentinel lymph node procedure. Side effects of lymph node procedure:
- Temporary or permanent numbness in the skin on the inside of the upper arm
- Temporary limitation of arm and shoulder movements
- Swelling of the breast and arm called lymphedema
Lymphedema is the most significant of these side effects. If it develops it may be permanent. Most women who develop lymphedema find it bothersome but not disabling. No one can predict which patients will develop this condition or when it will develop. Lymphedema can develop just after surgery, or even months or years later. Significant lymphedema occurs in about 10% of women who have axillary lymph node dissection and in up to 5% of women who have sentinel lymph node biopsy.
With care, patients can take steps to help avoid lymphedema or at least keep it under control. Talk to your doctor for more details.
To reach cancer cells that may have spread beyond the breast and nearby tissues, doctors use drugs that can be given by pills or by injection. This type of treatment is called systemic therapy. Examples of systemic treatment include chemotherapy, hormone therapy, and monoclonal antibody therapy. Hormone therapy is only helpful if the tumor is hormone receptor positive.
Even in early stages of the disease, cancer cells can break away from the breast and spread through the bloodstream. These cells usually do not cause symptoms, they do not show up on an x-ray, and they cannot be felt during a physical examination. But if they are allowed to grow, they can establish new tumors in other places in the body. Systemic treatment given to patients who have no evidence of spread of cancer, but who are at risk of developing spread of the cancer is called adjuvant therapy. The goal of adjuvant therapy is to kill undetected cancer cells that have traveled from the breast.
Women who have invasive breast cancer should receive adjuvant therapy, except those with very small or well-differentiated tumors. In most cases, systemic treatment is given soon after surgery using the results of the surgery and pathology evaluation to determine the best choice treatment. In some cases, the systemic therapy is given to patients after a needle biopsy but before lumpectomy or mastectomy. This is called neoadjuvant treatment. Oncologists give patients neoadjuvant treatment to try to shrink the tumor enough to make surgical removal easier. This may allow women who would otherwise need mastectomy to have breast-conserving surgery.
For women whose breast cancer has spread to other organs in the body (metastases), systemic treatment is the main treatment. This treatment may be chemotherapy, hormone therapy, trastuzumab, or combined therapy.
Paragon Breast Care has a three-pronged approach to screening asymptomatic women with a goal of maximizing the chances for early detection. We have found that when our patients participate in our combined three-part early detection program under the supervision of one of our breast surgeons, the chances of detecting an early and potentially curable breast cancer improve dramatically
Our experience has convinced us that women, who are given the proper instructions on self examination, are capable of finding small and potentially curable breast cancers. We have seen many cases over the years where a mammogram missed a cancer. The only reason that we were successful in early detection was that the woman was aware of a change in her breast because she did self examination, and she brought those changes to the attention of her doctor.
We recommend a routine yearly breast examination by a health care professional starting at age 20. In most cases this examination can be performed by a primary care physician. For women who are at high risk or who have special concerns, a yearly beast examination preformed by one of our breast surgeons along with a same day mammogram can be accomplished.
A yearly screening mammogram is the one test that has been scientifically proven to reduce breast cancer mortality. We believe that every woman from 40 years of age and older should have a yearly mammogram. Women with risk factors should consider starting mammography 10 years early than the age of their youngest first degree relative with breast cancer ( i.e. if you mother had breast cancer at age 45, you should have your first mammogram by age 35). Women with breast symptoms should have a diagnostic mammogram. The diagnostic mammogram focuses on the area of concern with additional views and usually an ultrasound is also performed. We have recently implemented a new digital mammography program, and we consider this to be a major technologic break-through.
Screening for breast cancer before there are symptoms can be important. Screening can help doctors find and treat cancer early. Treatment is more likely to work well when cancer is found early.
Your doctor may suggest the following screening tests for breast cancer.
- Screening mammogram
- Clinical breast exam
- Breast self-examination
You should ask your doctor about when to start and how often to check for breast cancer.
It is recommended that women in their 40s and older should have mammograms every 1 to 2 years. A mammogram is a picture of the breast made with x-rays. Women who are younger than 40 and have risk factors for breast cancer should ask their health care provider whether to have mammograms and how often to have them.
Mammograms can often show a breast lump before it can be felt. They also can show a cluster of tiny specks of calcium. These specks are called microcalcifications. Lumps or specks can be from cancer, precancerous cells, or other conditions. Further tests are needed to find out if abnormal cells are present.
If an abnormal area shows up on your mammogram, you may need to have more x-rays. You also may need a biopsy. A biopsy is the only way to tell for sure if cancer is present.
Mammograms are the best tool doctors have to find breast cancer early. However, mammograms are not perfect:
- A mammogram may miss some cancers.
- A mammogram may show things that turn out not to be cancer.
- Some fast-growing tumors may grow large or spread to other parts of the body before a mammogram detects them.
Clinical Breast Exam
During a clinical breast exam, your health care provider checks your breasts. You may be asked to raise your arms over your head, let them hang by your side, or press your hands against your hips.
Your health care provider looks for differences in size or shape of your breast. The skin of your breast is checked for a rash, dimpling, or other abnormal signs. Your nipples may be squeezed to check for fluid.
Using the pads of the fingers to feel for lumps, your health care provider checks your entire breast, underarm, and collarbone area. A lump is generally the size of a pea before anyone can feel it. The exam is done on one side, then the other. Your health care provider checks the lymph nodes near the breast to see if they are enlarged.
You may perform monthly breast self-examinations to check for any changes in your breasts. It is important to remember that changes can occur because of aging, your menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for breasts to feel a little lumpy and uneven. Also, it is common for your breasts to be swollen and tender right before or during your menstrual period.
You should contact your health care provider if you notice any unusual changes in your breasts.
Breast self-examinations cannot replace regular screening mammograms and clinical breast exams.
When a woman is informed that she has just been diagnosed with breast cancer, she typically goes into a state of mental shock. “You’ve made a mistake”, “Why me?”, and, “Am I going to live?” are just a few of the common thoughts that spin through a woman’s mind. Since every woman is unique, the approach to guiding a woman through the process of understanding her diagnosis and her treatment options must be individualized. However, experience has taught us that there are a series of helpful steps that minimize the stress in the journey from just being diagnosed to the successful completion of treatment.
We prided ourselves on our ability to provide newly diagnosed breast cancer patients with immediate and comprehensive explanations about their breast cancer. We learn that most women are not ready to absorb these intricate details in the first days after being diagnosed. We still see the patient and her family immediately following diagnosis and attempt to answer all questions. Now, however, a major focus of the initial discussion is to ensure that the patient is emotionally prepared to go forward with the process.
An essential component of the support services offered at our center is our Breast Nurse Navigator. She is a trained professional that is a supporter of the breast cancer patient and her family in understanding and coping with the strong emotions that accompany a breast cancer diagnosis; she remains a constant caregiver and overseer of the patient’s and her family’s educational, emotional, and social needs. Our navigator is with the patient at the time of diagnosis, and follows the patient through the entire treatment process and beyond. They often spend hours with newly diagnosed patients. In most cases they can prepare the patient to go forward with confidence, but some patients need more help. In situations in which professional support is needed, it is often the volunteer who identifies the need for a referral to a social worker.
Within 48 hours of being diagnosed, most women are ready to focus on their treatment options. Before reviewing these options, it is essential that a woman has a clear understanding of her cancer diagnosis. A first question that must be answered: Is my cancer invasive or non-invasive? With non-invasive cancers the initial focus of the discussion is whether or not the breast can be saved (in most cases it can). The amount of time consumed to make a decision is less of an issue since these cancers are almost always curable.
With invasive cancers time is an issue; however, the process should not be rushed. It is essential that a woman take the time to fully understand the nature of her cancer, as well as all her treatment options. It is also essential that the treatment team have time to study the various clinical issues so that the most accurate treatment recommendations can be made. As a Paragon Breast Care patient, all newly diagnosed breast cancer patients are presented to a weekly treatment conference in which a radiologist re-reviews the mammograms, a pathologist re-reviews the slides, a surgeon presents the history and clinical findings, and oncologists (medical and radiation) are also present. Based on these findings the team formulates a treatment plan.
The important risk factors are associated with first degree relatives (mother, sister, daughter), especially if they have had early onset breast cancer (that is, breast cancer under 50 years, bilateral breast cancer, or a family history of ovarian cancer). Other patterns in family history may strongly suggest an inherited gene abnormality that is independent of normal aging and is associated with a relatively higher risk of breast cancer. The following signs suggest that there may be an inherited gene abnormality in your family:
- Having a mother, sister, or daughter with breast cancer
- Having multiple generations of family members affected by breast or ovarian cancer
- Having relatives who were diagnosed with breast cancer at a young age (under 50 years of age)
- Having relatives who had both breasts affected by cancer
We suggest that women who are under 40 years when diagnosed, or have a strong family history of breast or ovarian cancer see one of the genetic counselors.
Personal history of breast cancer
If you have had cancer in one breast you have an increased risk of developing cancer in the other breast. This risk can be reduced with drugs like tamoxifen, but the bottom line is that women who have had cancer in one breast should be followed very closely so that if a cancer develops in the other breast it can be caught early.
Most breast biopsies are benign, and do not influence future risk for breast cancer. However, if a woman had a previous biopsy that showed either atypical changes or lobular carcinoma in situ, her risk for breast cancer is increased. These women should seek the guidance of a physician knowledgeable in diseases of the breast. Many of these women would benefit from risk reduction medication such as Tamoxifen. They also require careful long-term follow-up.
Prolonged exposure to estrogen
Prolonged exposure to the combination of estrogen combined with progesterone increases the risk of developing breast cancer. The risk associated with prolonged use of estrogen alone has yet to be defined, but probably will prove to be less than that for combined therapy. Short term replacement therapy for the treatment of menopausal symptoms seems safe. Women who can get by without replacement therapy should do so, but don’t forget to have your bone density checked. Women who choose to take replacement therapy for control of symptoms should try to get by on the lowest dose of estrogen for the shortest period of time.
Other risk factors:
- Never having had a full-term pregnancy
- Late menopause or early menstruation
- First full-term pregnancy after age 30 years
- More than two alcoholic drinks per week
The most important adjunct to mammography is the ultrasound evaluation of the breast. This is a painless procedure that uses sound waves to visualize structures within the breast. One of the key advantages of the ultrasound is to differentiate between cystic and solid lesions. Cystic lesions are typically benign and can be easily treated whereas solid lesions have an increased risk for breast cancer. The ultrasound is of particular value in evaluating women 30 years of age and younger. These patients have very dense breasts and often are difficult to evaluate on a mammogram. Thus, in a symptomatic younger patient, we start with an ultrasound and reserve the mammogram for special indications.
Ductography (for nipple discharge)
Patients with spontaneous drainage, particularly of clear or bloody material, from one duct of one breast, are at increased risk for breast cancer. We are most concerned for those patients who note a spontaneous occurrence of clear or bloody fluid. These patients require further workup. If on examination there are no specific masses and the mammogram does not reveal a specific cause for the discharge, the next step is a ductogram. In this procedure a small tube is gently placed into the draining duct and an x-ray of the duct system is obtained. In cases where an abnormality can be identified, a biopsy is performed. At the Breast Care Center we do the surgical procedure on the same day as the ductogram. In our experience, approximately 10% of patients with spontaneous nipple discharge will harbor a small cancer and most of these cancers have proved to be highly curable. Approximately 90% of our patients have benign changes, most commonly called a small papilloma. These patients have had excellent results with removal of the duct.
Magnetic resonance imaging (MRI)
The MRI procedure produces images based on how the water content of cells responds to high frequency radio waves. Currently, the MRI is not used for screening. At our Center, it is used on selected patients with known breast cancer to evaluate the extent of the lesion to determine if a cancer patient is a candidate for breast-conserving surgery (see Treatment Procedures). The MRI is also commonly used at our Center to evaluate patients with breast implants, and is approximately 95% accurate in determining the presence of ruptured silicone implants. Newer technical breakthroughs in MRI research suggest that future machines will become even more valuable in the early detection of breast cancer, differentiating between suspected benign and malignant lesions.
Although standard mammography is an extremely valuable tool, it has its limitations. Approximately 15% of all breast cancers are not detected by screening mammography. One of the most exciting new techniques is digital mammography in which an x-ray image is transferred to a digital computer display. This allows the image to be manipulated for brightness, contrast, and size and allows areas of concern to be evaluated in greater detail without bringing the patient back for additional views. Current studies suggest that the digital mammogram is starting to approach the degree of resolution of the standard mammogram. We expect that in the very near future the digital mammogram will surpass the standard mammogram in terms of ability to detect very subtle changes. At this moment digital mammogram has great theoretical advantages in terms of eliminating the mammographic film, improving the ability to transfer data, and adding to the convenience of the patient.
PET/CT can reassure previously treated women they are breast cancer free, and can better predict if their disease is likely to recur than other types of diagnostic imaging according top researchers. The area generating most enthusiasm for PET imaging in breast cancer relates to monitoring therapy. Researchers and clinicians uniformly express optimism about the imaging modality’s potential role in therapeutic decision-making. There are no optimal noninvasive alternatives to PET for detecting recurrent breast cancer in the chest wall, for early treatment monitoring of either neoadjuvant chemotherapy, or for monitoring treatment of distant metastases. PET also has been demonstrated consistently to be more accurate than alternative imaging tests for staging distant disease in breast cancer. Other radiologic studies, such as mammography, sonography, CT, and MRI, provide detailed anatomic information about the size and location of masses, but not the unique metabolic information available with PET. This metabolic information generally affords PET several advantages over the anatomic modalities, including: earlier detection of malignancy; differentiation of scar or benign lesion from active malignancy; detection of metastatic disease in normal-size lymph nodes; and assessment of early tumor treatment response.
Two fundamental steps are taken in the management of patients with breast cancer. The first step is to make the diagnosis. The diagnosis is established by taking a small amount of tissue from the tumor and examining it under the microscope. The second step is the definitive surgical treatment which involves the removal of the tumor and one or more axillary (under-arm) lymph nodes. Each time tissue is removed, a pathology report is provided. These reports provide the foundation upon which clinical decisions are made. It is important for a woman to keep copies of all pathology reports, and to understand the basic message in each report.
Invasive vs. Non-Invasive
The first question to be answered is….. ‘What is my diagnosis?’ In other words, is my lump or the spot on my mammogram benign (i.e. not cancer), or malignant (i.e. cancer). Assuming that the diagnosis is malignant, the next question to answer is….”is the cancer invasive or non-invasive?”
Non-invasive cancers are basically curable. Invasive cancers have the potential to spread beyond the breast and require more complex therapy. This information will be clearly defined in your initial pathology report(s). The following are brief definitions of invasive and non-invasive cancers:
Non-invasive Breast Cancer
DCIS (Ductal carcinoma in situ): In DCIS the cancer cells are confined to the ducts and have not invaded the surrounding tissue. For this reason these tumors are considered curable with wide removal of the tumor and surrounding tissue. In many cases radiation will also be required. In situation in which mastectomy is performed, no radiation is required, and immediate reconstruction is usually recommended.
LCIS (Lobular carcinoma in situ): This tumor starts in milk producing structures of the breast called lobules. This tumor does not invade. In fact it is not a true cancer, and should be thought of only as a risk factor for the future development of breast cancer. The majority of patients with LCIS do not need surgery, and are managed with careful observation. In some cases tamoxifen is recommended for risk reduction. In rare circumstances bilateral mastectomy with immediate reconstruction is performed.
Invasive Breast Cancer
Invasive ductal or infiltrating ductal carcinoma: This is a cancer that starts in the milk ducts and invades the surrounding tissue. It is the most common form of breast cancer.
Invasive lobular carcinoma or infiltrating lobular carcinoma: This tumor arises from the milk producing lobules and invades the surrounding tissue. Lobular cancers are often difficult to visualize on the mammogram, and are usually more difficult to detect on physical examination. The treatment for invasive lobular cancer is essentially the same as that for infiltrating ductal carcinoma.
Once the diagnosis has been made, the next major question is…..”What is my prognosis?” The key to understanding your prognosis is your final pathology report, which is provided after the completion of your definitive surgical procedure. The final report includes a long list of tumor characteristics that include the size and type of the tumor, the status of the lymph nodes, and other markers as described below:
- Type of tumor: Invasive or non-invasive (see initial discussion)
- Size of tumor: The report will note the size of the invasive tumor in centimeters (1 inch equals 2.54 centimeters or 25.4 millimeters). The size of an invasive cancer is a key element in determining prognosis.
- Lymph nodes: The report will state the number of lymph nodes removed and the number of lymph nodes, if any, that contain cancer cells. This is a very important factor and together with size, determines the stage of the cancer (see below for staging).
- Margins: The margin refers to the distance between the tumor and the edge of the surgical specimen.
- Hormone receptors: Hormone receptors are like on/off switches on the surface of the cancer cell that respond to hormones in the blood stream. The hormone receptors that influence breast cancer prognosis are estrogen and progesterone receptors. If a tumor is positive for estrogen or progesterone it is more likely to respond to estrogen blocking drugs such as tamoxifen. In general, hormone negative tumors tend to be more aggressive, and are more likely to be treated with chemotherapy.
- Differentiation or grade: In this analysis tumor cells are compared to normal breast cells. In Grade 1 (low grade or well differentiated) the cells are only slightly different from normal cells. These tumors tend to grow slowly. In Grade 3, the cells are markedly different from normal cells, and they tend to be faster growing tumors. Grade 2 tumors tend to be somewhere in between.
- Lymphatic invasion: The breast has a network of lymph channels that can drain tissue around the breast tumor. They connect with the lymph nodes under the arm. If cancer cells are found in these lymph channels, it suggests that the tumor may be more aggressive.
- Cancer genes: A new test that is now commonly performed on the tumor to evaluate the status of the HER2/neu receptors. HER2/neu is a gene that controls how cells grow, divide, and repair themselves. These genes direct the production of proteins called HER2 receptors. If the cell makes too many copies of these receptors it tends to grow faster. There is a new treatment called Herceptin that can effectively treat cancers that have this mutation.
- Bloom-Richardson score (SBR): This is the most commonly used cancer grading system. The score ranges from 3 (low grade: best prognosis) to 9 (highest grade); scores of 6 and 7 are considered intermediated grade. The score is based on the microscopic examination of the tumor cells. Three characteristics of the cells are evaluated, and each is grade on a scale of 1-3. The characteristics that are evaluated by the pathologists are: 1) cell division: the more mitosis, the higher the score, 2) cell structure: the less the formation of normal glandular structures, the higher the score, and 3) nuclear grade: the more irregular the nucleus the higher the score.
Stages of Breast Cancer
- Stage O: This stage applies to non-invasive breast cancer.
- Stage I: In stage I the invasive breast cancer is 2 centimeters or less in diameter, and the lymph nodes are negative.
- Stage II A: lymph nodes positive and tumor less than 2 cm., or lymph nodes negative and tumor between 2 and 5 cm.
- Stage II B: tumor between 2 and 5 cm and lymph nodes positive, or tumor more than 5 cm. and lymph nodes negative.
- Stage III A: fixed or matted lymph nodes in axilla with any size tumor, or tumor more than 5 cm with positive, but non-matted lymph nodes in axilla.
- Stage III B: tumor with extension to skin, chest wall, or inflammatory breast cancer
- Stage III C: more than 10 positive axillary lymph nodes, infraclavicular lymph nodes, or combinations of positive axillary and internal mammary lymph nodes.
- Stage IV: The tumor has spread to other parts of the body such as the bone, lung, liver, etc.
- Recurrent cancer: In recurrent cancer, the disease has come back despite treatment. The cancer can grow in the breast or chest wall (local recurrence), or in distant organs, bones, or lymph nodes (distant metastases).
Introduction to Breast Cancer
Breast cancer is the most common cause of cancer in women and the second most common cause of cancer death in women in the U.S. While the majority of new breast cancers are diagnosed as a result of an abnormality seen on a mammogram, a lump or change in consistency of the breast tissue can also be a warning sign of the disease. Heightened awareness of breast cancer risk in the past decades has led to an increase in the number of women undergoing mammography for screening, leading to detection of cancers in earlier stages and a improvement in survival rates. Still, breast cancer is the most common cause of death in women between the ages of 45 and 55. Although breast cancer in women is a common form of cancer, male breast cancer does occur and accounts for about 1% of all cancer deaths in men.
Research has yielded much information about the causes of breast cancers, and it is now believed that genetic and/or hormonal factors are the primary risk factors for breast cancer. Staging systems have been developed to allow doctors to characterize the extent to which a particular cancer has spread and to make decisions concerning treatment options. Breast cancer treatment depends upon many factors, including the type of cancer and the extent to which it has spread. Treatment options for breast cancer may involve surgery (removal of the cancer alone or, in some cases, mastectomy), radiation therapy, hormonal therapy, and/or chemotherapy.
With advances in screening, diagnosis, and treatment, the death rate for breast cancer has declined by about 20% over the past decade, and research is ongoing to develop even more effective screening and treatment programs.
How is the breast designed?
The breasts sit on the chest muscles that cover the ribs. Each breast is made of 15 to 20 lobes. Lobes contain many smaller lobules. Lobules contain groups of tiny glands that can produce milk. Milk flows from the lobules through thin tubes called ducts to the nipple. The nipple is in the center of a dark area of skin called the areola. Fat fills the spaces between the lobules and ducts.
The breasts also contain lymph vessels. These vessels lead to small, round organs called lymph nodes. Groups of lymph nodes are near the breast in the axilla (underarm), above the collarbone, in the chest behind the breastbone, and in many other parts of the body. The lymph nodes trap bacteria, cancer cells, or other harmful substances.
What is breast cancer?
Breast cancer is an abnormal growth of cells that normally line the ducts and the lobules. Breast cancer is classified by whether the cancer started in the ducts or lobules, whether the cells have “invaded” (grown or spread) through the duct or lobule, and the way the cancer cells look under a microscope.
When the cancer is confined in the ducts or lobules of the breast, the cancer is referred to as in-situ or non-invasive. The most common type begins in the lining of the milk ducts and is referred to as “ductal carcinoma in situ”, those that begin in the lobules where breast milk is produced is known as “lobular carcinoma in situ”, and those that have spread beyond the walls of the ducts or lobules (referred to as “infiltrating” or “invasive”). The cells in infiltrating or invasive cancers can enter the blood stream or lymphatic system. Once this happens; the cancer can spread (metastasize) to other parts of the body. The most common area of metastasis is in the lymph nodes under the arm, called axillary lymph nodes. Mestastatis can also be found in other lymph nodes in the body, or more commonly, in the bones, lungs, or liver.
It is not unusual for a single breast tumor to have combinations of these types, and to have a mixture of invasive and non-invasive cancer.
Types of Breast Cancers
Carcinoma In Situ
Carcinoma is another word for cancer and carcinoma in situ (CIS) means that the cancer is a very early cancer and it is still confined to the ducts or lobules where it started. It has not spread into surrounding fatty tissues in the breast or to other organs in the body.
There are 2 types of breast carcinoma in situ:
- Ductal carcinoma in situ (DCIS): This is the most common type of noninvasive breast cancer. In DCIS, cancer cells inside the ducts do not spread through the walls of the ducts into the fatty tissue of the breast. DCIS is treated with surgery and sometimes radiation, which are usually curative. If not treated, DCIS may grow and become an invasive cancer.
- Lobular carcinoma in situ (LCIS): Also called lobular neoplasia; not considered to be a true cancer. It begins in the milk-producing glands of the breast lobules, but has not grown through the lobule walls. Breast cancer specialists think that LCIS is thought to be only a risk factor for the future development of breast cancer but women with this condition do run a higher risk of developing an invasive cancer in either breast.
Invasive Breast Cancers
Invasive cancer describes those cancers that have started to grow and have spread beyond the ducts or lobules. These cancers are divided into different types of invasive breast cancer depending on how the cancer cells look under the microscope. They are also grouped according to how closely they look like normal cells. This is called the grade which helps predict whether the woman has a good or less favorable outlook. Outlook is referred to as prognosis.
Mixed tumors describe those that contain a variety of cell types, such as invasive ductal combined with invasive lobular breast cancer. With this type, the tumor is usually treated as if it were an invasive ductal cancer.
This special type of infiltrating ductal cancer has a fairly well-defined boundary between tumor tissue and normal breast tissue. It also has a number of special features, including the presence of immune system cells at the edges of the tumor. It accounts for about 5% of all breast cancer. It can be difficult to distinguish medullary breast cancer from the more common invasive ductal breast cancer. Most cancer specialists think that medullary cancer is very rare, and that cancers that are called medullary cancer should be treated as invasive ductal breast cancer.
Metaplastic tumors are a very rare type of invasive ductal cancer. These tumors include cells that are normally not found in the breast, such as cells that look like skin cells (squamous cells) or cells that make bone. These tumors are treated similarly to invasive ductal cancer.
Inflammatory Breast Cancer (IBC)
Inflammatory breast cancer is a special type of breast cancer in which the cancer cells have spread to the lymph channels in the skin of the breast. Inflammatory breast cancer accounts for about 1% to 3 % of all breast cancers. The skin of the affected breast is red, swollen, may feel warm, and has the appearance of an orange peel. The affected breast may become larger, firmer, tender, or itchy. IBC is often mistaken for infection in its early stages.
Inflammatory breast cancer has a higher chance of spreading and a worse outlook than typical invasive ductal or lobular cancer. Inflammatory breast cancer is always staged as stage IIIB unless it has already spread to other organs at the time of diagnosis which would then make it a stage IV (see discussion of stages).
This rare type of invasive ductal breast cancer, also called mucinous carcinoma, is formed by mucus-producing cancer cells. Colloid carcinoma has a better outlook and a lower chance of metastasis than invasive lobular or invasive ductal cancers of the same size.
Tubular carcinoma is a special type of invasive ductal breast carcinoma. About 2% of all breast cancers are tubular carcinomas. Women with this type of breast cancer have a better outlook because the cancer is less likely to spread outside the breast than invasive lobular or invasive ductal cancers of the same size. The majority of tubular cancers are hormone receptor positive and HER-2 negative.
Breast pain is the most common breast symptom causing women to consult primary care physicians and surgeons. Breast pain may occur in one or both breasts or in the underarm (axilla) region of the body. Though breast pain is rarely associated with breast cancer, women who experience any breast abnormalities, including breast pain, should consult their physicians.
There are two main types of breast pain, cyclical and non-cyclical. Cyclical breast pain is associated with the menstrual cycle and is most severe before the menses. The breast pain is usually bilateral (both breasts) and poorly localized. The pain is generally described as a heaviness or soreness that often radiates to the axilla and arm. The pain has a variable duration and is often relieved after the menses. Pain usually resolves spontaneously.
Non-cyclical breast pain is far less common than cyclical breast pain and is not related to a woman’s menstrual cycle. Non-cyclical breast pain is usually unilateral (one breast) and is described as a sharp, burning pain that is in one specific area of the breast. Non-cyclical breast pain can occur occasionally secondary to the presence of a fibroadenoma (benign growth) or cyst. If breast pain is accompanied by lumpiness, cysts (accumulated pockets of fluid), or areas of thickness, the condition is usually called fibrocystic change.
Other factors that may contribute to breast pain in some women include oral contraceptive pills, hormone replacement therapy, weight gain, bras that do not fit properly, and tumors (most painful tumors do not indicate breast cancer).
Breast pain should be treated when it is severe enough to interfere with a woman’s lifestyle and occurs for more than a few days each month. Most women with moderate breast pain are not treated with medications or surgical procedures.
The following suggestions have been shown to reduce breast pain in some women:
- Wear a good supportive bra to reduce breast movement.
- Avoid caffeine intake (coffee, tea, and soft drinks, chocolate).
- Over-the-counter Vitamin E supplementation (400 IU daily).
- Over-the-counter anti-inflammatory (Ibuprofen or Advil – 800mg three times a day with food).
- Heat to the affected breast.
Try the above recommendations for 2 weeks. If no relief, can reintroduce caffeine and try the herb, Evening Primrose Oil, in liquid or tablet form (2 grams orally/day).
This type of cancer, also called intraductal carcinoma, is made up of abnormal cells in the lining of the milk passage, or duct, of the breast. In the initial stages, the malignant tumor is non-invasive, and the abnormal cells have not spread beyond the duct and have not invaded the surrounding breast tissue. Because it is noninvasive, DCIS is sometimes called Stage 0 breast cancer. DCIS does, however, have the potential to progress and become invasive.
Fibroadenoma is a common benign tumor found in young women. Like breast lumps caused by other types of breast disease, fibroadenoma can cause anxiety for women. Any breast lump should be checked by medical professionals to rule out breast cancer. An understanding of breast disease symptoms and breast cancer screening methods helps women detect the early signs of breast disease.
Not All Breast Disease is Breast Cancer
Breast cancer is what comes to mind when most people think of breast disease. In fact, a number of other types of breast disease exist, including some, such as breast mastitis and fibrocystic breast disease that can produce non-cancerous breast lumps. The appearance of any form of breast lump is a frightening event, as the first thought of most women is that they have found a breast cancer tumor.
Fibrocystic Breast Disease
Fibrocystic breast condition (sometimes referred to as fibrocystic breast disease, fibrocystic change, cystic disease, chronic cystic mastitis, or mammary dysplasia) is not a disease, but rather, it describes a variety of changes in the glandular and stromal tissue of the breast. Symptoms of fibrocystic breasts include cysts (accumulated pockets of fluid), fibrosis (formation of scar-like connective tissue), lumpiness, and areas of thickening, tenderness, or breast pain. Though sometimes painful, fibrocystic breast condition is not cancer. However, fibrocystic breasts can sometimes make breast cancer more difficult to detect with mammography. Therefore, ultrasound may be necessary in some cases if a breast abnormality is detected in a woman with fibrocystic breasts.
Fibrocystic breast changes are the most common cause of non-cancerous breast lumps in women between 30 and 50 years old. More than 50% of women have fibrocystic breast symptoms at some point in their lives.
Women who suffer from fibrocystic changes typically have cyclic breast pain, or tenderness that coincides with their menstrual cycle. The cause of the condition is related to the way breast tissue responds to monthly changes in the body’s levels of the hormones estrogen and progesterone. During each menstrual cycle, breast tissue sometimes swells because hormonal stimulation causes the breast milk glands and ducts to enlarge, and in turn, causes the breasts to retain water. During menstruation, breasts may feel swollen, painful, tender, or lumpy. Breast swelling usually ends when menstruation is over.
Fibrocystic changes are typically discovered in both breasts in the upper outer quadrant and the underside of the breast where a ridge may sometimes be felt. Depending on the individual situation, several measures may be recommended to relieve the symptoms of fibrocystic breasts.
For breast pain from fibrocystic breast disorder:
- Wear a good supportive bra.
- Avoid caffeine intake (coffee, tea, and soft drinks, chocolate).
- Over-the-counter Vitamin E supplementation (400 IU daily), Vitamin B6, Niacin, or other vitamins.
- Over-the-counter anti-inflammatory (Ibuprofen or Advil – 800mg three times a day with food).
- Heat to the affected breast.
- Maintaining a low fat diet rich in fruits, vegetables, and grains.
- Reducing salt intake.
- Evening Primrose Oil, in liquid or tablet form (2 grams orally/day)
The cancer starts in a milk passage, or duct, of the breast, but then the cancer cells break through the wall of the duct and spread into the surrounding tissue of the breast. Cancer cells can then spread into lymphatic channels or blood vessels of the breast and to other parts of the body (known as “metastasize”). IDC is considered to be the most common type of invasive breast cancers; about 80% of all breast cancers are invasive ductal carcinoma.
This type of cancer starts in the milk passage, or duct, of the breast, then the cancerous cells break through the wall of the duct and spread into the surrounding breast tissue. The cancer cells can then spread into lymphatic channels or blood vessels of the breast and to other parts of the body (known as “to metastasize”). IDC is considered to be the most common type of invasive breast cancers, making up about 80% of all breast cancers.
Not all breast disease is confined to women. Adolescent boys often develop excessive breast growth due to hormone fluctuations. The condition, which is usually temporary, is called gynecomastia. Men can also develop other breast disease, including breast cancer, although incidence rates are much lower among males.
Nipple discharge, fluid coming from the nipple(s), is the third most common breast complaint for which women seek medical attention, after lumps and breast pain. The majority of nipple discharges are associated with non-cancerous changes in the breast such as hormonal imbalances or papillomas (non-cancerous, polyp-like tumor that grows inside the breast duct). However, because a small percentage of nipple discharges can indicate breast/nipple cancer, any persistent discharge from the nipple(s) should be evaluated by a physician.
Milky discharge (cloudy, whitish or almost clear in color, thin, non-sticky) is the most common type of discharge. Most milky discharge is caused by lactation or increased stimulation. Most bloody or watery (serous) nipple discharge is due to a benign papilloma, infection, or possibly cancer. Discharges that are yellow, green, blue, or black in color are often associated with benign cysts. Bilateral nipple discharge (discharge occurring from both breasts) is usually benign and does not typically require investigation. Discharge caused by a malignant condition is almost always on one side only (unilateral).
Nipple discharge is of concern if it is:
- Bloody or watery (serous).
- Appears spontaneously without squeezing the nipple or breast.
- On one side only (unilateral)
Paget’s disease of the nipple, also called Paget’s disease of the breast, is an uncommon type of cancer that forms in or around the nipple. More than 95 percent of people with Paget’s disease of the nipple also have underlying breast cancer; however, Paget’s disease of the nipple accounts for less than 5 percent of all breast cancers.
Most patients diagnosed with Paget’s disease of the nipple are over age 50, but rare cases have been diagnosed in patients in their 20s. The disease is rare among both women and men.
Intraductal papilloma is a small, benign (non-cancerous) tumor that grows within a milk duct of the breast. Intraductal papilloma occurs most frequently in women between the ages 35-55. The causes and risk factors are unknown. Symptoms can include:
- Breast pain
- Nipple discharge, sometimes bloody, from one breast only
- Staining may be noticed inside the bra and/or clothing
- Breast lump
- Breast enlargement
Intraductal papilloma is the most common cause of spontaneous nipple discharge from a single duct. A small lump beneath the nipple may be felt by the examiner, but it is not always palpable (able to be felt with the fingers). A mammogram often does not show papillomas. Ultrasound may be helpful.
A breast biopsy is necessary to make a definitive diagnosis and rule out cancer.
Chemotherapy uses medicines that are toxic to cancer cells and that often kill the cancer cells. Usually these cancer-fighting drugs are given intravenously (injected into a vein) or as a pill by mouth. Either way, the drugs travel through the bloodstream to the entire body. Doctors who prescribe these drugs (medical oncologists) sometimes use only a single drug and other times use a combination of drugs.
When chemotherapy is given after surgery for early stage breast cancer, it is called adjuvant chemotherapy. Sometimes chemotherapy is given before surgery. This is called neoadjuvant chemotherapy. In most cases, adjuvant or neoadjuvant chemotherapy is most effective when combinations of drugs are used together. Chemotherapy may also be given to treat breast cancer that has spread to places other than the breast or lymph nodes. Both single drugs and combinations of drugs are often used in the treatment of breast cancer that has spread.
Below is a list of some common combinations of adjuvant chemotherapy drugs, divided into combinations for women with HER-2 positive tumors and HER-2 negative tumors.
Chemotherapy Drugs Commonly Used to Treat Breast Cancer
(generic brand in parenthesis)
- Adriamycin (Doxorubicin)
- Cytoxan (Cyclophosphamide)
- Ellence (Epirubicin)
- Navelbine (Vinorelbine)
- Taxol (Paclitaxel)
- Taxotere (Docetaxel)
- Xeloda (Capecitabine)
- Gemzar (Gemcitabine)
Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period. The chemotherapy is given of the first day of each cycle, and then the body is given time to recover from the effects of chemotherapy. The chemotherapy drugs are then repeated to start the next cycle. The time between giving the chemotherapy drugs varies according to the specific chemotherapy drug or combination of drugs. Adjuvant chemotherapy usually lasts for a total time of 3 to 6 months depending on the drugs used.
The side effects of chemotherapy depend on the type of drugs used, the amount taken, and the length of treatment. Some women have many side effects while other women have few side effects.
A six to eight week course of irradiation therapy will be recommended for women undergoing lumpectomy (radiation therapy may be safely avoided in selected women with small, non-invasive cancers). The purpose of radiation is to eliminate any remaining cancer cells in the breast following lumpectomy, and it is very effective in lowering the rate of cancer recurrence in the breast.
Most women undergoing mastectomy usually do not require post-operative irradiation but in some cases; may.
Radiation therapy uses a beam of high-energy rays (or particles) to destroy cancer cells left behind in the breast, chest wall, or lymph nodes after surgery. Radiation may also be needed after mastectomy in cases with either a larger breast tumor, or when cancer is found in the lymph nodes.
This type of treatment can be given in several ways.
- External beam radiation delivers radiation from a machine outside the body. This is the typical radiation therapy given after lumpectomy and is given to the entire breast with an extra dose (“boost”) to the site of the tumor. It is usually given 5 days a week for a course of 6 to 7 weeks.
- Brachytherapy, also called internal radiation or interstitial radiation, describes the placement of radioactive materials in or near where the tumor was removed. They may be placed in the lumpectomy site to “boost” the radiation dose in addition to external beam radiation therapy.
Recently there has been interest in limiting radiation therapy only to the site of the lumpectomy, referred to as partial breast irradiation. This is based on the observation that when breast cancer recurs in the breast, the most common place is in the site of the original tumor. Brachytherapy is one technique of partial breast irradiation. External beam radiation therapy also can be used to deliver partial breast irradiation.
The extent of radiation depends on whether or not a lumpectomy or mastectomy was done and whether or not lymph nodes are involved. If a lumpectomy was done, the entire breast receives radiation with an extra boost of radiation to the area in the breast where the cancer was removed to prevent it from coming back in that area.
If the surgery was mastectomy, radiation is given to the entire area of the skin and muscle where the mastectomy was done if the tumor was over 5 cm in size, or if the tumor is close to the edge of the removed mastectomy tissue.
In patients who have had lumpectomy or mastectomy, further radiation may be recommended if the cancer has spread to the lymph nodes. Radiation may be given to the area just above the collarbone and along the breastbone, depending on the number and location of involved lymph nodes.
Side effects most likely to occur from radiation include swelling and heaviness in the breast, sunburn-like skin changes in the treated area, and fatigue. Changes to the breast tissue and skin usually go away in 6 to 12 months. In some women, the breast becomes smaller and firmer after radiation therapy. There may also be some aching in the breast.
One of the most important decisions a newly diagnosed patient with breast cancer must make is to choose between breast preservation (i.e. lumpectomy and radiation) and mastectomy. Although breast preservation is generally considered the procedure of choice for women with early stage breast cancers, for various reason many women are either not candidates for breast preservation, or choose mastectomy for personal peace of mind.
If a woman is considering mastectomy, it is important that she be given the option of immediate breast reconstruction. One problem facing such women is that it is difficult to coordinate the reconstructive surgery with the mastectomy on a timely basis. Some of the more common options include:
Our most common reconstruction option is the placement of a tissue expander under the muscle at the time of the mastectomy. After the wounds have healed, the expander is slowly filled with saline over a period of several weeks. Once the skin is adequately stretched, the expander is exchanged for permanent implant. Nipple reconstruction can be performed within a few months following the placement of the permanent prosthesis.
Tissue transfer techniques
Not all women are candidates for tissue expanders and some women prefer the advantages of all natural tissue. For these women, the option of tissue transfer is a logical alternative. The two standard options for tissue transfer are:
- Transverse rectus abdominus muscle flap (TRAM): In this procedure tissue from the lower abdomen is transferred to the chest and a breast mound is reconstructed that matches the opposite breast. This procedure is often done at the time of the initial mastectomy. The patient leaves the hospital with remarkable breast symmetry (also, with a tummy tuck).
- Latissimus dorsi flap: This flap comes from the back and is usually used in situations where extra skin is needed to close the mastectomy incision. It is often used when the breast has been previously radiated or when patients are not candidates for the TRAM flap.
Tram flap (tranverse rectus abdominal muscle flap)
The Tram flap has several advantages. In this procedure skin and fatty tissue for the lower abdomen are transferred under the skin to the mastectomy incision. A new breast is fashioned with the tissue. The tissue transferred to the chest has its own blood supply and feels much like normal breast tissue. Thus, immediately after the breast has been removed a new breast can be reconstructed (nipple reconstruction typically takes place a few months latter at which time the shape of the newly reconstructed breast is often revised. Not only does this reconstructed breast look and feel like a normal breast, but the woman also gets a tummy tuck in addition.
Latissimus dorsi flap
The latissimus dorsi flap is a remarkably well tolerated by the patient and is associated with very few complications. It is our flap of choice for older patients and for patients with medical problems. In this procedure skin, fatty tissue, and muscle is taken for the back and transferred under the skin to the mastectomy cavity following the removal of the breast (it can also be done as a delayed procedure following mastectomy). In many cases an implant is placed under the latissimus flap in order to create a breast that is symmetrical with the other breast. The following are examples of latissimus flap reconstruction:
- Placement of a tissue expander under the muscle at the time of mastectomy is the least traumatic and most popular of our reconstruction options. The tissue expander is nothing more than an empty sack made of silicone that is placed under the muscle after the breast has been removed. Most patients go home on the first or second day after surgery, and in general the post-operative pain is easily controlled with oral medication.
- The surgical wounds are usually given a few months to heal before the process of expansion is started. Over a period of several weeks saline is injected into the implant (simple in office procedure done with a local anesthetic) until it enlarges to a size that is slightly larger than the original breast. Following the completion of the expansion process the expander is exchanged for a permanent implant which is filled with either saline or silicone. This procedure is done as an out-patient, usually under local anesthesia.
- After another few weeks of healing, a woman may choose to have nipple reconstruction. This again is done as an outpatient, and is a well tolerated procedure. After the reconstructed nipple heals, it is tattooed so that the color matches the other side.
- In some cases there is the need to modify the opposite breast to produce a more cosmetic result. In cases where the opposite breast is small, an implant can be added. If the opposite breast is large, it can be reduced.
Reconstruction following lumpectomy and radiation
Most patients that are have lumpectomy and radiation for the treatment of their breast cancer have a good to excellent cosmetic result. However, in some cases the breast is distorted following completion of radiation therapy and reconstruction is an option for selected patients. Our standard approach to reconstructing the irradiated breast is to place an implant under the breast. Other approaches to reconstruction include the transfer a latissimus flap to fill in the surgical defect or mastectomy with tram flap reconstruction.
Choosing Between Breast-Conserving Surgery and Mastectomy
The advantage of breast-conserving surgery (lumpectomy) is that it preserves the appearance of the breast. A disadvantage is the need for several weeks of radiation therapy after surgery. Some women who have a mastectomy will still need radiation therapy. Women who choose lumpectomy and radiation can expect the same chance of survival as those who choose mastectomy.
Although most women prefer lumpectomy and radiation therapy, your choice will depend on a number of factors, such as:
- How you feel about losing your breast
- Whether or not you want to devote the additional time and travel for radiation therapy
- Whether or not you would want to have more surgery to reconstruct your breast after having a mastectomy
- Your preference for a mastectomy as a way to “take it all out as quickly as possible”
In determining the preference for lumpectomy or mastectomy, be sure to get all the facts. Though you may have a gut feeling for mastectomy to “take it all out as quickly as possible”, the fact is that in most cases doing so does not provide any better chance of long term control or a better outcome of treatment. Large research studies with thousands of women participating, and over 20 years of information show that when lumpectomy can be done, mastectomy does not provide any better chance of survival from breast cancer than lumpectomy plus radiation. It is because of these facts that most women do not have their breast removed.
For most women, breast conservation will be the treatment of choice since it is less traumatic, and the survival results are identical to survival rates with mastectomy. However, not all women are candidates for breast conservation, and some women prefer mastectomy. We believe women should be given the facts and encouraged to make their own choices.
Breast conservation therapy is not an option for all women with breast cancer.
Those who may not have breast-conserving therapy include:
- Prior radiation therapy of the affected breast or chest
- Suspicious or malignant appearing abnormalities that are widespread throughout the breast
- Women whose lumpectomy, including any possible repeat lumpectomy when needed, cannot completely remove their cancer with a satisfactory cosmetic result
- Women with active connective tissue disease involving the skin (especially scleroderma or lupus) that makes body tissues especially sensitive to the side effects of radiation
- Pregnant women who would require radiation while still pregnant
- Women whose tumors are larger than 5 centimeters (2 inches) and can not be shrunk by treatment before surgery
If cancer cells are present at the outside edge of the removed breast tissue (the margin), more surgery is usually needed to remove any remaining cancer. Most often this additional surgery is a repeat lumpectomy, but sometimes it requires removal of the entire breast (mastectomy).
Women considering breast conservation must have a clear understanding of the issue of “margins”. The goal in breast conservation is to remove the tumor with a surrounding rim of normal tissue. Obtaining a clear margin can be a challenge. Although the surgeon attempts to take out the entire tumor at the time of the initial surgery, in some cases the tumor cells, which are not visible during the surgery, are found to extend to the edge (margin) of the lumpectomy specimen, and a second operation is required. Fortunately, the vast majority of women who initially choose breast conservation will ultimately achieve a good to excellent cosmetic result. Long-term survival is equal to that with mastectomy.
Mastectomy is the removal of the entire breast, including the nipple, Mastectomy is needed for some cases, and some women choose mastectomy rather than lumpectomy. Different words are used to describe mastectomy depending on the extent of the surgery in the armpit and the muscles under the breast. In a simple or total mastectomy, the entire breast is removed, but no lymph nodes from under the arm or muscle tissue beneath the breast is removed unless a sentinel node excision is performed (see Sentinel Node Excision). In a modified radical mastectomy, all the muscle under the breast is also removed.
If a woman has a mastectomy, she may want to consider having the breast rebuilt; this is called breast reconstruction. This requires additional surgery to create the appearance of a breast after mastectomy. The breast can be reconstructed at the same time the mastectomy is done (immediate reconstruction) or at a later date (delayed reconstruction).
How does a woman decide with her doctor on the type of reconstruction, and when should she have the procedure? The answer depends on the woman’s personal preferences, the size and shape of her breasts, the size and shape of her body, her level of physical exercise, details of her medical situation (such as how much skin is removed), and if she needs chemotherapy and/or radiation.
Women considering mastectomy should be given the option of immediate reconstruction. Some women, however, are not good candidates for immediate reconstruction. For these women there is still the option of delayed reconstruction, and this option should be taken into consideration at the time the initial mastectomy is performed.
If you are thinking about breast reconstruction, please discuss this with your doctor when you are planning your treatment so that a referral can be made to a plastic surgeon.
Brian T. Moore, MD, FACS
Louisiana State University – MD
University of Tennessee – General Surgery
University of Tennessee – General Surgery
Anthony G. Smith, MD, FACS
University of Notre Dame – BBA
Wright State University – MD
The Mercy Hospital of Pittsburgh
Lisa H. Stancil, CNA II
Stanly Community College
National Consortium of Breast Centers
Brenda Steepleton, FNP-C
Winston-Salem State University – BSN
Winston-Salem State University – MSN/FNP
American Academy of Nurse Practitioners (2012)
Wound Care Certified (NAWCO)
American Academy of Nurse Practitioners
North Carolina Nurses Association