Breast
Conserving Treatment
Lumpectomy
Axillary Node Dissection
Total or Simple Mastectomy
Modified Radical Mastectomy
Radiation Oncology
Hormone Therapy
Chemotherapy
A team of physicians who specialize in breast cancer will be involved
in your care, specifically surgical oncologists, medical oncologists and
radiation oncologists. An important concept to keep in mind as you consider
treatment options is the difference between local
and systemic treatments. Local treatments
are procedures performed on the breast and surrounding areas, such as
surgery and radiation oncology. Systemic treatments, such as chemotherapy
and hormone therapy, are used to treat breast cancer cells that may have
spread to other parts of the body. Local and systemic treatments are often
combined to ensure the best outcome possible, and your priorities are
an essential part of making the best treatment choice.
Surgery
The first step in treating the most common types of breast cancer is
surgery, and your first decision will probably include a fundamental choice
between breast conservation and removal of the breast. The surgical procedures
are: lumpectomy (also called wide excision
or partial mastectomy) with axillary lymph node
dissection, total or simple mastectomy,
and modified radical mastectomy, which includes
axillary dissection. Lumpectomy is considered a partial mastectomy and
conserves varying degrees of breast tissue. Total mastectomy removes the
entire breast. Modified radical mastectomy removes the entire breast and
some axillary lymph nodes, but the pectoralis (chest) muscle stays in
place.
Before surgery, tests such as a chest X-ray, a complete blood chemistry,
and a urinalysis must be performed to determine your body's ability to
tolerate surgery and anesthesia.
Surgical Treatment
Lumpectomy and Axillary Lymph Node Dissection, plus Radiation
If your cancer is diagnosed at an early stage, a lumpectomy
or wide excision with axillary
lymph node dissection may be offered as a treatment choice. The goal
of this surgery is to remove the entire lump and some normal tissue surrounding
the lump, but preserve the breast. Radiation
follows lumpectomy and axillary lymph node dissection and is an integral
part of breast conserving treatment. The two treatments combined, surgery
and radiation, have proven to be as effective as the modified radical
mastectomy.
Not all women, however, are candidates for breast conserving treatment;
acceptable cosmetic results may not be possible for women whose breast
cancers are multicentric (found in more than
one area of the breast) or who have a large breast cancer and relatively
small breasts. Also, it is extremely important for candidates who choose
breast conservation to accept that radiation is integral to successful
treatment. Willingness to accept radiation treatment following lumpectomy
and axillary node dissection, and an understanding that regular follow-up
is a lifetime commitment, are essential elements for making this choice.
For women who choose not to have radiation, modified radical mastectomy
is the treatment of choice.
Axillary Lymph Node Dissection
Lumpectomy versus Mastectomy
Lumpectomy is removal of the cancer with surrounding normal tissue. This normal tissue is called the “margin.” After the lumpectomy, surgeons check the pathology report to be sure that the margins, or edges, of the lumpectomy are clear of cancer cells. If the margin is not clear, a re-excision will be scheduled. Cancer cells on the margin are more likely in women with invasive lobular cancer, because of the finger-like projections, and in women who have ductal carcinoma in situ, because the surgeon cannot feel the cancer cells. Breast surgeons at Continuum Cancer Centers of New York aim for five millimeter to 10 millimeter margin widths.
Mastectomy is the removal of all the breast tissue. In the case of an
invasive cancer (not in the case of ductal carcinoma in situ), both lumpectomy
and mastectomy are accompanied by either sentinel node biopsy, or a full
axillary node dissection (see below).
Lumpectomy is almost always followed by radiation. The purpose of the
radiation is to decrease the recurrence of breast cancer in the remaining
breast tissue. A 2002 New England Journal of Medicine report* discussed
the 20-year follow-up of a trial comparing mastectomy, lumpectomy, and
lumpectomy plus radiation. The authors found that the recurrence rate
of breast cancer in the affected breast after lumpectomy and radiation
was 14 percent, whereas if no radiation was given, it was 39 percent.
When a recurrence is found, a mastectomy is usually performed. In some
cases, however, a second lumpectomy is done. Mastectomy has a very small
local recurrence rate (about 4 percent). This is because some breast tissue
may remain on the skin when the breast tissue is removed from under it.
Although the local recurrence rates are different between lumpectomy and
mastectomy, the survival rate for women undergoing either of these procedures
is the same. The New England Journal report showed that the 20-year survival
for women undergoing mastectomy, lumpectomy, or lumpectomy with radiation
was exactly the same. This conclusion has been supported many times in
other reports, including another 20-year follow-up from Italy.**
*Bernard Fisher et al. New England Journal of Medicine 2002;347:1233-41
**Umberto Veronesi et al. New England Journal of Medicine 2002;347:1227-32
Sentinel Node Biopsy versus Axillary Node Dissection
Lymph nodes are small lima bean-shaped structures which contain white
blood cells called lymphocytes. There are lymph nodes in many locations
in the body, including the axilla (or armpit), which contains about 30
lymph nodes. In the past 10-15 years, lymph nodes were removed from the
axilla to check for spread of the breast cancer. However, a new technique
called sentinel node biopsy is now used, which checks for the spread of
cancer by removing only one or two nodes. The sentinel node is the first
or primary node to receive lymphatic drainage from the breast. The surgeon
finds this lymph node by using a radioactive compound called Technicium.
Technicium is injected into the skin of the breast, over the area of the
cancer, on either the day before or the morning of surgery. The lymphatics
of the breast carry the Technicium to the sentinel node, and the surgeon
finds the node by using a Geiger counter. In a lumpectomy, the sentinel
node is removed through a small incision in the axilla. In a mastectomy,
the sentinel node is removed through the mastectomy incision.
The sentinel node is often tested by frozen section during surgery. If
the sentinel node is clear of cancer cells, no other lymph nodes will
be removed from the axilla. If the sentinel node contains cancer cells,
a full-node dissection will be performed, since more nodes may be affected.
Approximately 10 percent of sentinel nodes found to be negative by the
pathologist on the frozen section will contain cancer cells on the final
pathology report. If this occurs, further surgery to remove additional
nodes may be required, and will be scheduled as soon as possible.
Making Choices
The choice that most women with breast cancer face is to undergo either breast conserving treatment (only the lump is removed followed by radiation) or modified radical mastectomy. Research involving thousands of women over many years has shown that for women with early stage breast cancers, there is no difference in survival between these two options. Sometimes breast cancers do recur in the lumpectomy breast, but mastectomy can be performed at that time. For most women who undergo breast conserving treatment, the outcome is the same as those who had mastectomy in the first place.
Nonetheless, making a decision between breast conserving treatment, lumpectomy with axillary lymph node dissection plus radiation, or modified radical mastectomy is a very personal one. If you choose a mastectomy, or our oncologist recommends that you have a mastectomy, then you may wish to consider reconstructive surgery. Reconstruction can be performed immediately, it can be delayed, or you may not wish to undergo reconstruction at all.
It is important to remember that no decision must be made overnight.
You need to give yourself a chance to discuss these options with family
members, with your physicians and with friends. When you have additional
questions, please contact the surgeon and other members of the interdisciplinary
healthcare team during your decision-making process.
After a Lumpectomy with Sentinel Node Biopsy
Lumpectomies with axillary node dissection are usually performed with
local anesthesia and sedation. Patients are usually sent home the same
or next day after surgery, once the effects of the anesthetic have worn
off. A followup appointment will be scheduled within 7 to 10 days after
your surgery.
After a Total Mastectomy and Sentinel Node Biopsy
If you have a Total Mastectomy and Sentinel Node Biopsy, two drainage tubes will be in place to drain fluids that may collect in the operative areas--one to drain the chest area and the other to drain where the sentinel node was removed. Should the drainage tube(s) not be removed during your hospital stay, you and a family member or friend will receive simple instructions before you are discharged on how to care for the tubes at home. After you wake up from a Sentinel Node Biopsy, you may experience some discomfort around your chest and under your arm. Your doctor will order pain medication that will control your discomfort. You'll be encouraged to get out of bed the same day as surgery, as soon as the anesthetic has worn off, and at that time you should be able to eat regular food. Expect to stay in the hospital overnight. If you are having breast reconstruction, the stay is two to four nights.
Prior to leaving the hospital, we will give you a temporary prosthesis, or breast form. It provides symmetry without putting pressure on the surgical area. Once you have healed, usually 4-6 weeks after your surgery, we will give you a prescription to purchase a permanent prosthesis or breast form.
A followup appointment will be scheduled within 7 to 10 days after your
surgery to remove the drainage tube under your arm. At this visit, the
surgeon will provide information on your pathology and future treatments.
Adjuvant Therapy
After the primary tumor has been treated, we then consider adjuvant therapy. Adjuvant means "in addition to," and these therapies are given in addition to surgery, or surgery plus radiation, to decrease the risk of the breast cancer returning. Our intent is to choose an adjuvant therapy that has the best chance to kill any breast cancer cells lingering throughout the body, or to block the hormonal receptors of either the remaining cancer cells or normal breast cells. We determine the therapy that best kills the cancer cells, while preventing as much as possible the onset of disrupting side effects. Adjuvant therapies include radiation, chemotherapy, and hormonal therapies.
Radiation Oncology
As part of the interdisciplinary approach to the treatment of breast cancer, the Departments of Radiation Oncology at Continuum Cancer Centers of New York are recognized among the largest and most sophisticated in the country. Our world-renowned, highly skilled specialists and innovative technology attracts patients from around the world.
Radiation oncology is an integral part of breast conserving treatment, but is rarely used when mastectomy has been performed. Instead, it is often used after a lumpectomy to prevent a recurrence of the cancer in that breast or chest wall region. The treatment usually begins about two to three weeks after surgery and lasts approximately six weeks. Radiation is typically given five days a week (Monday-Friday), and each session lasts approximately ten minutes. Radiation is considered "local therapy," in that it does not affect the rest of your body.
A precise, individualized treatment plan will be developed for you by a radiation oncologist using a special machine called a simulator. Treatment is administered by a radiation oncology technologist, under the supervision of a radiation oncologist. Toward the end of the treatment period, the radiation is focused on the smaller area of the breast where the tumor was located, a procedure known as a “boost.”
Potential side effects include fatigue during and right after treatment, reddening of the skin (similar to a sunburn), or swelling of the breast. However, the state-of-the-art equipment used at Continuum Cancer Centers of New York means that these side effects are usually temporary and the final results are very good.
While emphasizing maintenance of our patients’ quality of life without sacrificing control or lessening survival, innovative treatments also now focus on ways to reduce radiation. For example, high-energy beams can limit doses to tissues around the tumor bed, causing less trouble with surrounding organs. Three-dimensional conformal external beam radiation therapy and intensity modulated radiation therapy (IMRT) are two such state-of-the-art procedures that ensure accurate and effective delivery of radiation:
• Three-dimensional conformal external beam radiation therapy, using advanced computer graphics and computed tomography (CT) scans, conforms a highly precise beam to the patient's tumor. With this type of computerized radiation, beams enter and exit specific points on the body from different angles. Some beams may be filtered to adjust the intensity of radiation delivered. This adjustment allows the radiation oncologist to concentrate the radiation in the region of the cancer, and minimize the dose to the surrounding normal organs. It is a daily 20-minute outpatient procedure that requires treatment five days a week for seven and a half weeks followed by routine quarterly check-ups.
• Intensity modulated radiation therapy uses a state-of-the-art computer system to optimize the radiation delivery technique. The system evaluates millions of possible beam arrangements and creates a clinically optimized treatment plan. It maximizes the radiation dose delivered to the tumor while minimizing the radiation dose delivered to the surrounding normal tissues. The ability to maximize the dose to the tumor while sparing the normal tissues allows radiation oncologists to deliver more cancer-killing radiation to the tumor while reducing potential adverse side effects of radiation treatment.
Brachytherapy (MammoSite and Seed Implants)
For breast cancer patients, another radiation technique offered at Continuum
hospitals is brachytherapy, in which radioactive seeds are implanted directly
into the tumor or tumor bed, thus minimizing radiation exposure to healthy
tissue. Treatment with brachytherapy alone is completed in five to seven
days, as compared to the six weeks of daily external beam therapy. Brachytherapy
delivery methods include the MammoSite® Radiation Therapy System (RTS),
a new, minimally invasive method that allows radiation to be delivered
from inside the space left after a lumpectomy for breast cancer. MammoSite
RTS is a single small balloon catheter that fits inside the tumor resection
cavity—the space that is left after the surgeon removes the tumor.
A tiny radioactive seed, connected to a machine called an afterloader,
is inserted into the balloon and delivers the radiation from inside the
breast. This focuses the radiation dose close to the tissue that is at
highest risk for tumor recurrence. MammoSite RTS may be an appropriate
treatment for patients who are candidates for breast conservation surgery.
The therapy is given on an outpatient basis and can be completed in five
days.
The radioactive implants are used to treat breast cancer, prostate cancer, gynecologic cancer, soft tissue sarcomas, eye tumors, head and neck cancer, certain lung cancer, as well as other malignancies. Brachytherapy is also used for recurrent cancers, as a way of re-treating an area that was previously irradiated. These implants involve seeds that remain in the body either permanently or temporarily (several days), thereby delivering the prescribed dose of radiation to the involved area.
Intraoperative Radiation Therapy
We may recommend that you undergo intraoperative radiation therapy (IORT).
IORT requires the special skills of both a radiation oncologist and a
surgeon. This procedure utilizes an advanced computer planning system
to deliver a single high dose of radiation during surgery to an area from
which a tumor has just been removed. We perform this technique in a special,
shielded operating room that enables our surgeons and radiation oncologists
to significantly intensify treatment. This therapy is used for appropriate
patients with head and neck cancers, as well as colorectal cancers, other
GI tumors, breast cancers, thoracic malignancies, and other specialized
situations. We are one of a few institutions in the country that offer
this form of therapy, and have led the development of IORT procedures.
Click here
for information on Continuum Cancer Centers of New York’s Radiation
Oncology services.
Chemotherapy
Even when surgery and radiation is completed, we know that it is possible for microscopic breast cancer cells to spread beyond the breast and lymph nodes to other parts of the body. The presence of these microscopic breast cancer cells is called micrometastasis, because the quantity of cells is too small to be detected by any current medical procedure. Staging considers the size of the tumor and the presence or absence of positive axillary lymph nodes. In addition, we take into account your age and general health as well as your menopausal status. We also consider the characteristics of the tumor: nuclear grade; hormone receptor status; S-phase fraction; presence of known mutations to breast cancer genes; and other factors that may signify an aggressive tumor, such as HER-2/neu amplifications.
Based on these characteristics, systemic (whole body) adjuvant therapy may be recommended. Our medical oncologists determine what type of systemic therapy that would provide the greatest benefits with the least toxicity. In general, this systemic therapy is chemotherapy and/or hormone therapy.
Chemotherapy is the use of drugs to provide systemic treatment that destroys cancer cells throughout the body. In the treatment of breast cancer, it is administered in varying doses through the veins or by mouth. It is usually administered after surgery, and the doses, or courses, may be given over an average period of six months. If your treatment includes radiation oncology, chemotherapy may be recommended before, after, or at the same time. Whether and when you undergo chemotherapy will depend on the stage of your cancer, and, to some degree, on your age and other factors. In some cases, it is used to shrink a cancerous tumor before surgery, so that the tumor can be removed more easily. The physician who determines what type of chemotherapy you should have, and the dosage, is called a medical oncologist.
After your surgery, you and your oncologists will decide whether you should receive chemotherapy or hormonal therapy (tamoxifen) for the treatment of your breast cancer. This decision will be based on the size of the cancer and whether it has spread to the lymph nodes under your arm.
Given in cycles, chemotherapy generally does not require a hospital stay. Different chemotherapy drugs have been shown to be effective in specific types of breast cancer. Research has shown that combinations of certain drugs are more effective than individual drugs. We continue to ask women with breast cancer to participate in clinical trials that offer new drugs or new combinations of existing drugs.
Medical oncologists may administer chemotherapy prior to surgery (neoadjuvant
therapy) to shrink a large tumor. Chemotherapy drugs are so powerful that
they affect cells throughout the body. Normal cells that grow quickly,
such as those lining the gastrointestinal tract or hair follicles, may
be damaged or killed along with cancer cells. Side effects can include
fatigue, nausea, and vomiting, lowered white blood cell count and a corresponding
increased risk of infection, mouth sores, hair loss, and premature menopause.
For an in-depth, on-line guide to receiving chemotherapy, click
here
For additional information, we recommend the following links:
· PDQ-The
National Cancer Institute’s Comprehensive Cancer Database
Hormone Therapy
Hormonal therapy is used to treat breast cancer that tested positive for either estrogen or progesterone receptors. Much has been learned about the role of hormones, particularly estrogen and progesterone, in the development, diagnosis, and treatment of breast cancer. Hormones are normal chemicals that your body produces to stimulate various physiological processes in the body. Breast cancer cell growth may be stimulated by hormones such as estrogen and progesterone. Tests that show whether your cancer cells are hormone-receptor-positive or hormone-receptor-negative may be helpful in determining the type of treatment that is most appropriate for you. In general, women who have gone through menopause are more likely to have cells that are hormone-receptor positive; for them, hormone therapy is often recommended. Premenopausal women are more likely to have hormone-receptor negative cancer cells.
Hormone therapy is a systemic treatment for breast cancer that keeps the cells from growing and multiplying. It accomplishes this by blocking the ability of cancer cells to bind with estrogen or progesterone, which certain cancer cells need to grow. As mentioned previously, hormone therapy is usually recommended when the cancerous tissue has tested hormone-receptor-positive.
The most common hormone therapy for breast cancer is called tamoxifen. Therapy usually lasts five years, and it is most often recommended for women who have already been through menopause. Tamoxifen has been shown to reduce the recurrence of breast cancer and may actually prevent breast cancer from developing in the opposite, healthy breast.
Because tamoxifen therapy blocks the effects of estrogen, its potential side effects are similar to those of menopause, a natural process in which hormone production changes. Tamoxifen therapy may cause hot flashes, nausea, vaginal spotting, and other less common symptoms, but these side effects may be mild and may wear off as therapy continues. In younger women who still menstruate, periods may cease during hormone therapy. Except in women who are very close to menopause, they may return after therapy is concluded. Many younger women are still able to become pregnant after hormone therapy, but pregnancy during the therapy is not advisable.
There is a small increased risk of developing uterine (endometrial) cancer in patients taking tamoxifen. This risk, however, is far outweighed by the potential benefits of tamoxifen. While you are taking tamoxifen, you should have routine gynecologic examinations. These precautions should minimize the risks.
We also may recommend newer drugs, particularly the aromatase inhibitors, such as Anastrazole (Arimidex®), Letrozole (Femara®) and Exemestine (Aromasin®), as alternative treatments to tamoxifen. Hormonal treatments can be used either alone as single agents or in the adjuvant setting after chemotherapy.
Herceptin
We now know that approximately 25 percent of patients with breast cancer have tumors which have an increase of a particular cell surface protein called HER2/neu. Scientists have developed Trastuzumab, more popularly called Herceptin, which is a humanized monoclonal antibody that binds to the HER2/neu receptor and stops cell growth.
In patients previously treated with chemotherapy and whose tumors have
an increase of the HER2/neu receptor, administration of Herceptin as a
single agent resulted in a response rate of 21 percent. In a prospective
trial, patients with metastatic disease were randomized to receive either
chemotherapy alone (doxorubicin and cyclophosphamide or paclitaxel) or
the same chemotherapy and Herceptin. Patients treated with chemotherapy
plus Herceptin had an overall survival advantage. When combined with doxorubicin,
Herceptin is associated with significant cardiac toxicity. Consequently,
patients with metastatic breast cancer with substantial overexpression
of HER2/neu are candidates for treatment with the combination of Herceptin
and paclitaxel or for clinical studies of Herceptin combined with taxanes
and other chemotherapeutic agents.
Advanced Breast Cancer
Continuum Cancer Centers of New York uses an interdisciplinary approach to advanced breast cancer. When cancer begins, it is a single, genetically abnormal cell. The cell divides and becomes two cells, which divide into four cells, then eight cells, and so on. Eventually, the single cell becomes a mass of cells and develops a blood supply to nourish its continued growth. At some point, cells break off from the primary mass and move through the blood supply or nearby lymph system to other parts of the body, a complicated process called metastasis.
For some women, we diagnose breast cancers and treat before metastasis occurs. For other women, we plan treatment knowing that the breast cancer has metastasized. Generally, as the tumor grows, the chance of metastasis increases. Based on research, oncologists estimate that fewer than 10 percent of women diagnosed with breast cancers smaller than one centimeter in diameter will have metastases at the time of diagnosis. That number rises to 80 percent if the cancer is diagnosed when it is larger than five centimeters in diameter.
We know that breast cancer most often spreads through the blood or lymphatic systems to areas that are nourished by those systems. Breast cancer may spread to bones, liver, lung, and brain, but also to the opposite breast, adrenal glands, spleen, and ovaries. Generally, a recurrence of the disease is detected when symptoms are apparent. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research has shown that they do not improve the response to treatments used for advanced disease, nor do they prolong life.
Once metastatic disease is detected, in our interdisciplinary approach we may recommend that a woman undergo surgery to remove the metastases, or have chemotherapy or radiation to control it. Signs and symptoms of a recurrence may include:
- a lump under the arm or around the surgical area;
- bone pain or fractures, which may signal bone metastases;
- headaches or seizures, which may signal brain metastases;
- chronic coughing or wheezing, which may signal lung metastases.
Other symptoms may be related to the location of metastases and may include changes in vision, an alteration in energy levels, a feeling of "unwellness," or extreme fatigue.
Our overall goal in caring for women with more advanced disease is to
is to achieve a remission or slow the growth of the tumor, which we know
can improve symptoms, quality of life, and overall survival. Since metastatic
breast cancer is not considered curable, the patient and our physicians
must find a balance between treating the disease and achieving a good
quality of life. It should be noted that some women live years after a
recurrence of breast cancer and may undergo treatment many more times
before dying from the disease. For some women, we approach breast cancer
as a chronic disease.