BREAST CANCER: UNDERSTANDING TREATMENT AND OPTIONS

The treatment options available to you will depend on a number of factors, including the type of tumor, the extent of the disease at the time of diagnosis, your age, and your medical history. However, your personal feelings about the treatment, your self-image and your lifestyle will also be important considerations in your doctor’s assessment and recommendations. You and your doctor should discuss these treatment methods and how they apply to your situation. Understanding all of your options from the beginning of your diagnosis allows you to have all of the information you need to make an informed and rational decision about your care.

TWO-STEP TREATMENT

The two step treatment method involves having a biopsy one day; then, if the lump is cancerous, the treatment takes place within the next few weeks. In many cases, the biopsy can be done on an outpatient basis-often in the doctor’s office or mammography suite. Most biopsies can be performed under local anesthesia. Your surgeon will discuss the specific type of biopsy with you.

The short time between biopsy and treatment (which will not reduce the chances for success) allows time to examine the permanent section slides, to perform additional tests to determine the extend of the disease, to discuss treatment options, to gain another medical opinion, to make home and work arrangements, and to prepare emotionally for the treatment.

STAGING

Once a diagnosis of invasive cancer is made, you may go through a staging process to determine if the tumor has spread to any other organs in the body. This usually includes a chest x-ray, liver function tests, and bone scan. In certain instances your physician may request a PET scan, MRI, or CAT scan. An abnormality in these does not mean the tumor has spread, but that further testing is needed.

BREAST SURGERY

Mastectomy is the medical term for surgical removal of the breast. It refers to a number of different operations, ranging from those that remove the breast, chest muscles and underarm lymph nodes, to those that remove only the breast lump.

The different types of breast surgery are described below. Based on the size and location of the lump, your doctor will recommend the type of surgery that offers you the best chance of successful treatment.

Most medical and surgical procedures carry some risk. The risks are categorized small or serious, frequent or rare. Because there is such a wide range of potential risks and benefits from various treatments for the different stages and kinds of breast cancer, you should discuss with your doctor the particular benefits and risks of treatment methods suitable for you.

MODIFIED RADICAL MASTECTOMY OR TOTAL MASTECTOMY WITH AXILLARY NODE DISSECTION

This procedure removes the breast, the underarm lymph nodes, and the lining over the chest muscles. It is also called “total mastectomy with axillary (or underarm) dissection.”

ADVANTAGES
Keeps the chest muscle and the muscle strength of the arm. Swelling is less likely, and when it occurs, it is milder than the swelling that can occur after a radial mastectomy. Survival rates are the same as for the radial mastectomy when cancer is treated in earl stages. Breast reconstruction is easier and can be planned before surgery.

DISADVANTAGES
The breast is removed. In some cases, there may be swelling of the arm because of the removal of the lymph nodes. (8%-10% risk of lymph edema).

TOTAL OR SIMPLE MASTECTOMY

This type of surgery removes only the breast. Ideally a few of the underarm lymph nodes closest to the breast are removed to assure complete removal of the axillary tail of the breast. This is most often used to treat noninvasive breast cancers or in prophylactic mastectomies.

ADVANTAGES
Most or all of the underarm lymph nodes remain, so the risk of swelling of the arm is greatly reduced. Breast reconstruction is easier.

DISADVANTAGES
The breast is removed. If cancer has spread to the underarm lymph nodes, it may remain undiscovered.

SKIN SPARING MASTECTOMY

The mastectomy is performed through a small keyhose using the nipple/areolar complex as the only skin that is removed.

LUMPECTOMY

This procedure removes the tumor plus a wedge of normal tissue surrounding the cancer. Occasionally the skin and the lining of the chest muscle below the tumor will need to be removed to obtain clear margins. A margin of normal tissue must be removed to insure the tumor has been completely removed. (A 5 mm margin of normal tissue is optimal, but a 2 mm margin is mandatory to decrease the risk of local recurrence after radiation therapy). It is followed by approximately six weeks of radiation therapy.

ADVANTAGES
If a woman is large breasted, most of the breast is preserved. There is little possibility of loss of muscle strength or arm swelling.

DISADVANTAGES
If a woman has small or medium-sized breasts, the procedure may noticeably change the breast’s shape. There is a possibility of arm swelling if an axillary lymph node dissection is performed.

SENTINEL LYMPH NODE BIOPSY

Axillary lymph node evaluation has been the standard of care in breast cancer treatment. This procedure involves the removal of two levels of lymph nodes from the axilla (armpit) to determine if the cancer has spread locally. This is considered part of the staging of the breast cancer and is routinely done at the time of the definitive breast cancer surgery.

One of the debilitating side effects of axillary dissection has been lymphedema (arm swelling). This occurs in approximately 8-10% of patients. The arm may also become number above the elbow at the level of the triceps muscle. You must protect your arm from cuts and scrapes for the rest of your life to prevent lymphangitis (an infection in the lymphatics of the arm).

In an attempt to better diagnose lymph node metastasis and decrease complications associated with axillary dissection, a method of lymph node mapping adopted from melanoma treatment has been used to identify the sentinel (the first line of defense) lymph node. This lymph node can be evaluated for microscopic metastasis through a procedure called cytokeratin staining. It generally takes 7 days to receive the results and is far more sensitive than the naked eye of the pathologist.

We know that women previously thought to be node negative; and therefore, have local disease, have died of distant metastasis. This may be related to our previous inability to find these microscopic metastatic deposits and treat them aggressively with chemotherapy.

The absolute answers to these questions still have not been completely resolved. Sentinel lymph node identification is appropriate in both lumpectomy and mastectomy patients. Parameters may vary from surgeon to surgeon and will be based upon your individual tumor characteristics. The procedure to identify the node starts with an injection of radioactive tracer called technetium Sulphur colloid. It may be injected the day before surgery or the morning of surgery. It must remain in the breast for 3-4 hours before you are taken to the operating room.

At the time of surgery, after you are asleep, a vital blue dye may be injected around the tumor bed. These two modalities allow us to identify the sentinel lymph node in 90% of patients. When a sentinel lymph node is found at surgery, a frozen section (quick diagnosis) may be performed. Once the sentinel node is identified, your surgeon will manually check your axilla for other nodes that may have tumor in them. Lymph nodes filled completely with cancer cells may not have the ability to pick up the radioactive tracer and blue dye; therefore this is also an important part of the process.

If the frozen section reveals spread of cancer cells to the lymph node, a level I and II axillary node dissection is performed. If the frozen section is negative for spread of the cancer, then no further lymph node surgery is performed at that time. At your postoperative visit, you will discuss your final pathology, which will include the results of your margins of tumor resection and the cytokeratin staining (high tech evaluation for spread) for microscopic metastasis.

Frequently Asked Questions

If you identify a sentinel lymph node, does that mean that the cancer has spread?

NO. Finding a sentinel lymph node only means that we are able to find a node or nodes that has taken up the tracer or blue due. It only identifies the lymph node that is at the highest risk to have metastatic cancer in it.

Is the sentinel lymph node identification fool proof?

NO. We believe that it is approximately 98% accurate in finding the first line of cancer spread. That means we could potentially miss 1-2% of cancer metastasis.

Can there be more than one sentinel lymph node?

YES. You can have several nodes show up with radioactive tracer. Usually only is blue. On average 2 or 3 nodes are removed.

What happens if you can’t find a sentinel node or if more than one lights up?

It is the surgeon’s judgment that determines if a node dissection needs to be completed. When in doubt, it is still the safest course and the surgeon should remove level I and II lymph nodes.

Why wouldn’t a sentinel lymph node show up?

Some tumors do not drain via the axillary lymphatics and therefore cannot be identified. Not finding a sentinel lymph node may also help the oncologist to determine the need for chemotherapy. Lymph nodes that are replaced completely with tumor may not take up the tracer.

What happens to the radio-labeled tracer and the blue dye?

It is excreted in the urine and therefore you will see blue urine for 24-48 hours after surgery. Your skin may also have a blue discoloration on the breast and systemically.

AXILLARY NODE DISSECTION

Axillary node dissection refers to the staging procedure performed in conjunction with lumpectomy for breast conservation or mastectomy. The procedure involves an axillary incision below the hairline when performed with a lumpectomy and is performed through the mastectomy incision with removal of the breast.

Removal of level I and Ii lymph nodes includes the tissue between the axillary portion of the breast and the area above the axillary vein underlying the pectoral major muscle are preserved to decrease the incidence of arm edema. It may also remove a small nerve in the process resulting in numbness to the posterior aspect of the arm. Determining whether the lymph nodes are involved with the tumor will stage the cancer to determine if chemotherapy will be needed.

A WORD ABOUT BREAST RECONSTRUCTION

As you consider mastectomy as a treatment option, you should be aware of breast reconstruction, a way to recreate the breast’s shape after a natural breast has been removed.

Today, almost any woman who has had a mastectomy can have her breast reconstructed. Successful reconstruction is no longer hampered by radiation-damaged, thin skin, tight skin, or the absence of chest wall muscles. The options for immediate reconstruction after mastectomy will be discussed with your surgeon and again when you consult with a plastic and reconstructive surgeon.

Reconstruction is not for everyone and may not be right for you. After mastectomy, many women prefer to wear artificial breast forms or prostheses inside their surgical bras. Both a general surgeon and a plastic surgeon may help you decide whether to have breast reconstruction.

You should discuss breast reconstruction before your surgery because the position of the incision may affect the reconstruction procedure. A procedure called a skin-sparing mastectomy has been able to greatly enhance the final reconstruction results and should also be discussed with your surgeon prior to the operation.

Having breast reconstruction at the time of your cancer surgery can lead to better cosmetic results, decreased risks from additional anesthesia and added psychological benefits to you. All of these benefits can result from immediate reconstruction, without compromising the curative aspects of your cancer operation.

RADIATION THERAPY

Radiation therapy as a primary treatment is a promising technique for women who have early stage breast cancer. This procedure allows a woman to keep her breast and involves lumpectomy followed by radiation (x-ray) treatment. Once a biopsy has been done and breast cancer has been diagnosed, radiation treatment usually involves the following steps.

• Surgery to evaluate underarm lymph nodes to see if the cancer has spread beyond the breast, i.e. sentinel lymph node biopsy or axillary lymph node dissection.


• External radiation therapy to the breast and the surrounding area (involving approximately five weeks of treatment).


• “Boost” radiation therapy to the biopsy site which is usually marked with surgical clips to mark the tumor bed (one additional week of radiation therapy).

For external radiation therapy, a machine beams x-rays to the breast and possibly the underarm lymph nodes. The usual schedule for radiation therapy is 5 days a week for about 5-7 weeks. In some instances, a “boost” or concentrated dose of radiation may be given to the area where the cancer was located. This can be done with an electron beam. Less frequently used is a boost done internally with an implant of radioactive materials.

ADVANTAGES
The breast is not removed. Lumpectomy with radiation therapy as a primary treatment for breast cancer appears to be as effective as mastectomy for treating early stage breast cancer. Usually there is not much deformity of the surrounding tissues. This skin usually regains a normal appearance.

DISADVANTAGES
A full course of treatment requires short daily visits to the hospital as an outpatient for approximately 5 weeks. Treatment may produce a skin reaction like sunburn, and may cause tiredness. Itching or peeling of the skin may also occur. Radiation therapy can sometimes cause a temporary decrease in white blood cell count, which may increase the risk of infection. You maintain your breast and, therefore, have a variable risk of local recurrence which would necessitate mastectomy should cancer return. Post-mastectomy reconstruction options are limited after radiation therapy to the breast.

WHAT IS PARTIAL BREAST IRRADIATION?

In the past there have been several modes of radiation therapy delivery to treat breast cancer. Most involve treatment of the entire breast as well as a boost to the tumor bed to decrease the risk of local recurrence. Small catheters were inserted into the breast to deliver the boost to the tumor bed.

These catheters had several problems with cosmesis and patient tolerance. At the present time, we are revisiting the use of partial breast irradiation for the treatment of Stage I breast carcinomas.

This treatment involves the use of HDR (High Dose Radiation) to treat the tumor bed in women whose cancers have a low risk of local recurrence. Brachy therapy treatment lasts one week as opposed to six weeks for conventional external beam radiation.

A balloon catheter is inserted either through an open procedure in the operating room or with US guidance in an outpatient stetting. Once the position is confirmed by CT scan images the treatment is given twice a day for a week. The Radiation Oncologist in their office can easily remove the catheter.

Am I a candidate for this procedure?

Clearly you must discus your particular case with your care management team to determine if you are eligible or this form of radiation.

Inclusion criteria:

• Age > 50
• Tumor size < 2 cm
• Lymph node status negative
• Breast size (varies with tumor size)
• Infiltrating lobular cancers are excluded
• Extensive DCIS are excluded

How do I find a Surgeon and Radiation Oncologist in my area that performs this procedure? Go to www.mammosite.com for more information.

ADJUVANT THERAPY

Recent studies have shown that women with early stage breast cancer may benefit from adjuvant (additional) therapy following primary treatment (mastectomy or lumpectomy with radiation therapy). These studies indicate that many breast cancer patients whose underarm lymph nodes show no signs of cancer (known as node negative) may benefit from chemotherapy or hormonal therapy after primary treatment.

The use of chemotherapy in node negative patients will be determined by your age at diagnosis, stage of the cancer, tumor markers, tumor biology, and future risk of systemic recurrence. (These findings do not apply to women with pre-invasive or in situ breast cancer).

Until now, women whose underarm lymph nodes were free of cancer usually received no additional therapy because they have a relatively good chance of surviving the disease after primary treatment. However, scientists know that cancer may return in about 30% of these women. Adjuvant therapy can potentially prevent or delay the return of cancer.

THE BREAST CANCER TREATMENT TEAM

During your treatment you are likely to meet several health professionals who will perform the various tests and treatments your doctor recommends. By talking with the professionals who care for you, you will come to understand more about cancer and its treatment.

These are some of the specialists you may meet and hear about:

Anesthesiologist
A doctor who administers drugs or gases to put you to sleep before surgery.

Clinical nurse specialist
A nurse with special knowledge in a particular area, such as postoperative care or radiation therapy.

Medical Oncologist
The doctor who administers anti-cancer drugs or chemotherapy.

Pathologist
Doctor who examines tissue removed by biopsy to see if it is cancerous.

Personal physician
Your doctor, who will be responsible for coordinating your treatment and working with you to ensure that treatment is satisfactory. Your personal physician may be a surgeon, radiation oncologist, medical oncologist, or family physician. Physical Therapist-A specialist who helps in rehabilitation after surgery by using exercise, heat, light, and massage.

Plastic surgeon
Doctor who specializes in reconstructive and cosmetic surgery. Plastic surgeons perform breast reconstruction.

Radiation Oncologist
Doctor who supervises radiation therapy.

Radiation therapy technologist
A specially trained technician who helps the radiation oncologist give external radiation treatments.

Surgeon
A doctor who performs surgery-such as a biopsy and mastectomy and axillary node dissections.

TAKE THE TIME TO MAKE AN INFORMED DECISION

Remember that you have time to consider options. Except in rare cases, breast cancer patients do not need to be rushed to the hospital for treatment as soon as the disease is diagnosed. Most women have time to learn more about the available options, make arrangements at medical facilities where treatments will be given, and organize home and work lives prior to treatment. A long delay, however, is not advisable because it may interfere with the success of your treatment.

GLOSSARY

ANESTHESIA
loss of feeling resulting from the administration of drugs or gasses.

BENIGN
not cancerous.

BIOPSY
removal of a sample of tissue to see if cancer cells are present.

CHEMOTHERAPY
treatment with drugs to destroy cancer cells. Most often used to supplement surgery or radiation therapy.

LYMPH NODES
part of the lymph system that removes wastes from body tissue and carries the fluids that help the body fight infection. Lymph nodes in the underarm are those most likely to be invaded by cancer cells and, therefore, are removed during breast cancer surgery.

MALIGNANT
cancerous.

MASTECTOMY
surgical removal of the breast.

PECTORAL MUSCLES
muscles that overlay the chest wall and help support the breast.