This information is intended to provide basic information about your options for treatment of breast cancer.

Background

When a diagnosis of breast cancer is made, the first step is to know the extent of your cancer. This is called staging the cancer. If you have a diagnosis of ductal carcinoma in situ (intraductal carcinoma) this is Stage 0 cancer and has an excellent prognosis. If there is evidence of invasive disease, which means a cancer that is growing outside the ducts of the breast, the staging can range from Stage I, which is an early stage breast cancer to Stage IV. It is important to know that most patients do not have Stage IV or advanced breast cancer at the time of diagnosis. If your cancer is detected based on mammogram, it is likely that you have very early stage breast cancer and most likely you have a Stage I disease.

Some of the important information that you should ask your doctor about is what is the size of your cancer on the mammogram and the ultrasound. The other important question is whether the cancer has spread to the lymph node in the armpits (the axilla). The decision about using chemotherapy is usually based on a combination of the size of the cancer and if the cancer has spread to the lymph nodes.

Breast cancer is unique in the sense that it can be dependent on estrogen for growth. Breast cancer comes in two different types that are treated differently. The first type is referred to as hormone sensitive breast cancer. This is usually diagnosed if certain proteins are present in your tumor. The first protein is called estrogen receptor (ER) and the second protein is called progesterone receptor (PR). If you have estrogen receptor or progesterone receptor present in the cancer cells that means that your cancer is sensitive to hormone. If you are on hormone replacement therapy or birth control pills, these medications should be discontinued.

The other type of breast cancer is not dependent on estrogen or progesterone and that is usually evidenced by the lack of the presence of these proteins in the cancer itself. Tumors that are not dependent on hormones for their growth are usually treated with chemotherapy. However, it is important to note that chemotherapy is also used in patients with hormone sensitive disease. Please refer to the section on chemotherapy for further discussion about when to use chemotherapy.

The systemic nature of breast cancer

One of the important concepts in the management of breast cancer is the treatment of systemic disease. It is very important to understand this concept since it is one of the major aspects of breast cancer. While the cancer cells are growing in the breast, it is possible that a few of the cancer cells are escaping from the breast and going to other parts of the body. This can happen through the blood vessels or through the lymph vessels. These cancer seeds are very small and cannot be seen by any current technology. Even the most sophisticated testing, such as CT scan or PET scan cannot detect these cells. The presence of these cells in the body is referred to as micrometastases. These micrometastases can be carried through the vessels and deposit themselves in any part of the body, including the liver, bone, lung, or any other organ of the body. The reason to use systemic chemotherapy and hormonal therapy is to target these micrometastases.

Again, discussion about chemotherapy and hormonal therapy is provided in detail in the following sections.

Once these tiny cancer cells are deposited in the body, they can grow over a period of time. It could be months or years later before a mass is identified in another part of the body. That is what is referred to as metastatic breast cancer or Stage IV disease. The goal of systemic therapy for breast cancer is to prevent the development of metastatic disease. There is extensive literature on the ability of chemotherapy and hormonal therapy to eradicate these micrometastases and prevent the occurrence of obvious metastatic disease.

Once question that every patient should ask is, “What is my risk of developing metastatic disease?” Your doctor can calculate your risk based on the size of your cancer and whether the lymph nodes are involved. For example, if the size of the cancer is less than one centimeter and the lymph nodes are not involved, the chances of developing metastatic disease is fewer than 10% in general. On the other hand, if the cancer has spread to five lymph nodes, the chance of developing metastatic disease without chemotherapy or hormonal therapy is 50% to 60%. Your doctor can calculate your specific risk of developing metastatic disease based on the specific information of your cancer.

Let’s now discuss the three treatments that are usually used to treat breast cancer. The first one is surgery. The second one is radiation therapy. And the third one is systemic therapy, which includes chemotherapy and hormonal therapy.

Local Therapy

Local therapy for breast cancer. Local therapy refers to the treatment of the breast itself. This includes surgery and radiation therapy. First we will be talking about surgery.

Surgery

For the treatment of breast cancer, there are two types of surgery that can be performed. The first one is removing the lump only. This is referred to as a lumpectomy. The second type of surgery is removing the whole breast, which is referred to as a mastectomy. Removing the lump alone is very safe and is the preferred method of treatment of breast cancer. Having said that, it is important to make sure that you are a good candidate for removing the lump only. If you decide to have a lumpectomy, it is very important to understand that most of the time radiation therapy is usually needed to make sure that any cancer cells that are left in the breast are killed by the radiation treatment. Several research studies show that doing lumpectomy alone without radiation therapy puts you at risk of having the cancer come back in the breast itself and requiring another surgery in the future.

To make this point very clear, if you choose to have lumpectomy, you are also choosing to have radiation therapy most of the time. There are always exceptions to the rules and you need to check with your doctors about your specific situation.

One question that is often asked is, “Am I more likely to survive breast cancer if you have a mastectomy rather than a lumpectomy?” The answer to this question is a categorical, “No.” Several research studies showed that the chance of being cured from breast cancer is the same whether you have a lumpectomy and radiation or you have a mastectomy. Let’s think about this for a minute. What really determines if you are going to be cured from your breast cancer is whether the micrometastases, which are sitting outside the breast, are going to be eradicated by using systemic therapy. The treatment for the breast itself is not going to eradicate these micrometastases.

In other words, these micrometastases, again the tiny cancer cell that has been carried out by the blood vessels and are sitting in other parts of your body, are going to be present or not present, regardless of whether you have a lumpectomy or mastectomy. By the time your cancer has been discovered, these micro metastases are already deposited outside the breast. Therefore, having a lumpectomy is not going to increase your risk of having micrometastases. It is very important to be very clear on this point and if this discussion does not clarify this point, please ask your doctor to clarify it.

To summarize, having a lumpectomy is a very safe and very good way to treat your breast cancer. Usually radiation therapy is prescribed after your lumpectomy.

It is important to mention that radiation is not usually needed after mastectomy except in very special situations. One question that is usually asked is, whether everybody should have a lumpectomy. Most women can have a lumpectomy, however there are a few situations where a mastectomy is preferred over lumpectomy.

One situation is that if there is evidence of breast cancer in more than one part of the breast, meaning if there is a cancer in one part of the breast and if there is another area of cancer in the opposite part of the breast, typically in these situations, it is not advisable to have lumpectomy and a mastectomy is indicated. The other reason to have a mastectomy is if you are not willing to have radiation treatment. Some patients should not have radiation treatment and that includes patients with autoimmune conditions such as rheumatoid arthritis or systemic lupus erythematosus.

Sentinel Lymph Node Biopsy

One part of local therapy that is very important is to take some of the lymph nodes from the armpit (axilla) to see if the cancer has spread. In the past, the procedure was called axillary lymph node dissection and this procedure used to lead to a significant amount of lymphedema. The new way of evaluating the lymph node is referred to as a sentinel lymph node biopsy. Usually the cancer drains to one or two lymph nodes and now we are able to identify which are the lymph nodes that need to be removed by surgery. Those lymph nodes are referred as the sentinel lymph nodes.

The way to identify these lymph nodes usually involves injecting a small amount of radioactive material around the cancer cells and then tracing this material into the lymph nodes. Your surgeon is usually able to identify which lymph nodes are considered the sentinel lymph nodes based on the presence of radioactivity in these lymph nodes. This procedure usually allows for the removal of only a few lymph nodes, typically under five, and most of the time only one or two lymph nodes are removed. If these lymph nodes are cancer free, it is very unlikely that you have cancer in the other lymph nodes. The major advantage for this procedure is the decrease incidence of significant lymphedema in the future. Lymphedema, again, is a swelling in the arm, which used to be a common complication of removing the lymph nodes randomly, or what is referred to as axillary lymph node dissection.

In summary, most women can be treated with a lumpectomy and sentinel lymph node evaluation. This procedure is usually performed as an outpatient and does not require overnight hospitalization. A few women, who are not candidates for lumpectomy or are not willing to have radiation, should have a mastectomy.

Mastectomy

Let’s talk briefly about mastectomy. Mastectomy involves removing the entire breast. The sentinel lymph node procedure can be performed during the mastectomy as well. Before you decide on having a mastectomy, you should consider the psychologic impact on your quality of life and your sexual life and the impact of mastectomy on your body image. Make sure that you are going to able to deal with the biological and psychological effect of mastectomy. Having an intact body image is very important to some women and is less important to others. You need to discuss your individualities with your doctor.

One thing that you should ask your doctor about is how to make sure there is no cancer in more than one area of the breast. Typically this is detected on your mammogram and ultrasound. One new way that is more sensitive is having an MRI of the breast performed. An MRI of the breast is a new technology that is very sensitive. Not every woman with breast cancer should have an MRI. If you decide to have an MRI or if your doctor recommends an MRI, it is very important to understand that it is likely that you are going to have additional testing done based on the results of the MRI. Most of the time, another ultrasound is performed and occasionally other biopsies are performed based on the findings from the MRI. The major disadvantage for the MRI is that it is too sensitive and it can detect too many things that are not related to your cancer and most of the time is benign. Having said that, in my experience, an MRI of the breast is very important, especially if your mammogram is difficult to read. This is referred to as dense mammogram. You might want to ask your doctor if your mammogram is dense. That means that it could be fat. If you have a fatty mammogram an MRI is probably not necessary.

Radiation Treatment

Your team of doctors involves the radiation oncologist who is in charge of delivering radiation treatment. The reason to receive radiation therapy is to kill any cancer cells that are left behind in the breast after the lumpectomy. Research studies shows that patients who receive lumpectomy without radiation are at much higher risk of having the cancer come back in the next few years in the same breast. Therefore, if you choose to have a lumpectomy, it is important to have radiation treatment. Radiation is usually prescribed on a daily basis, Monday through Friday, for about five weeks. The first one or two sessions might take about an hour, but later on it is only about ten minutes per day. Radiation is a very simple treatment and usually has minimal side effects. Some of the side effects of radiation include fatigue and redness of the skin. Your radiation doctor will discuss the side effects of radiation in detail. Rare side effects of radiation include inflammation in the lung or the heart. Most of the time, however, this does not happen, and radiation is usually very safe. Most of the radiation centers in the Denver area are state of the art centers. The state of the art technology does minimize the side effects of radiation.

In terms of timing of radiation, it is usually given after you have completed your chemotherapy. If you do not need chemotherapy, radiation is usually started about four to eight weeks after your surgery.

Now, the question is what about radiation after a mastectomy? Radiation after a mastectomy is usually indicated if the size of the tumor is over 5 cm or if there is evidence of spread to the lymph nodes. Your surgeon, medical oncologist, and radiation oncologist make a recommendation about whether you need radiation therapy. Please check with your medical team regarding the need for radiation after mastectomy. This completes the discussion about local therapy.

To summarize, local therapy involves surgery and radiation treatment. Surgery can be in the form of lumpectomy or mastectomy. Radiation is needed after lumpectomy and is usually not needed after a mastectomy. If you decide to have a mastectomy, check with your surgeon regarding reconstruction surgery and meeting with a plastic surgeon. Make sure that your radiation center has state of the art equipment. Always investigate the availability of research studies for radiation since the field of radiation is changing very fast and there are newer technologies and newer ways of doing radiation at the present time.

Systemic Therapy

Your medical oncologist usually provides the decision and discussion about systemic therapy. I am a medical oncologist and one of the major reasons you are seeing me is to discuss your need for systemic therapy. Let’s take this one step at a time.

The decision about receiving systemic therapy is based on what is your risk of having micrometastases. Again, micrometastases refer to those tiny cells that are sitting outside the breast at the time of diagnosis of your breast cancer. If your risk is over ten percent, it is recommended that you have systemic therapy. The word systemic refers to treatment that treats all of your systems or all of your organs. Typically, this is therapy that goes through the blood stream and wherever there is a cancer cell, systemic therapy does affect these micrometastases.

Systemic therapy comes in two parts. The first part is chemotherapy and the second part is hormonal therapy.

Chemotherapy

Chemotherapy is usually drugs that are given in your veins. You might need a special catheter placed if you have poor veins or they are not easy to find.

The chemotherapy drugs that are usually used for the treatment of breast cancer are Adriamycin, Taxol or Taxotere, and Cytoxan. The value of chemotherapy in the treatment of your breast cancer is established beyond all doubt. Several studies have showed women are more like to be cured if they receive chemotherapy. It is important to note that if you have Stage 0 breast cancer, that is ductal carcinoma in situ, you do not need chemotherapy. Chemotherapy is only used for invasive disease. Ask your physician why he is recommending chemotherapy. A physician who deals with breast cancer on a regular basis is able to use certain calculators to calculate your risk of having the cancer come back if you do not choose chemotherapy. And, they are able to provide you with the exact benefit that you should receive from chemotherapy. There are several tools available online for your doctors to calculate your risk of relapse without chemotherapy versus your risk of relapse with chemotherapy. This information should provide you with the knowledge of how much benefit your will be getting from chemotherapy.

Typically, this is one of the most difficult decisions for a woman with breast cancer. A Let me give you few general guidelines regarding the need for chemotherapy. A woman under the age of 50 is typically given systemic chemotherapy unless she has very early stage breast cancer, meaning cancer that is less than one centimeter and it is estrogen receptor positive. If there is a cancer in the lymph nodes, chemotherapy is usually indicated since the risk of having micro metastases is quite high. There is no right or wrong answer about whether you should or should not receive chemotherapy. You should evaluate how much benefit you are going to get from the chemotherapy and weigh that against the potential side effects of chemotherapy when making you decision.

One of the major advances in breast cancer treatment is our understanding of the value of chemotherapy. Again, more women are cured from their breast cancer because of chemotherapy.

Some of the side effects of chemotherapy include hair loss, nausea, vomiting, and, rarely, damage to the heart. This last side effect is very rare. You should have a heart test prior to receiving chemotherapy referred to as an echocardiogram or a MUGA scan prior to receiving chemotherapy.

It is important to note that there are rare longterm side effects of chemotherapy including acute leukemia. This usually occurs after five years of receiving chemotherapy and the risk is quite low and is probably under one to two percent. If your benefit from chemotherapy is three to four percent, it is probably worthwhile, since the benefits of chemotherapy outweigh the risk of leukemia.

One important side effect of chemotherapy is lowering the ability of the immune system to fight infection. If you develop any fever over 100 or have sever chills, you should notify your doctor immediately. This is considered a medical emergency. You should not take any Tylenol or any other medication to bring down your fever before contacting your doctor. It is very also important not to take any Tylenol or any other medication to bring down your fever if you have a temperature between 99 and 100. You should allow the fever to declare itself. If you treat the fever with any medication and bring it down, you might have an infection that goes undetected, which can be life threatening.

The administration of chemotherapy and the side effect are usually very safe as long as the guidelines are followed. Again, the need to call your doctor with any fever over 100 is very, very important.

Before receiving chemotherapy, there is usually an hour or so session of teaching about the chemotherapy. In our office, this usually involves watching videotape and having a discussion with one of our chemotherapy nurses. I usually see my patients prior to starting chemotherapy and before each treatment.

Some other questions that are frequently asked about chemotherapy are, “How often is it used?” Typically it is given between three to six months, which depend on the specific characteristics of your breast cancer, and the risk of having micro metastases. Usually chemotherapy is given every three weeks and the total number of treatments is four to eight. Sometimes chemotherapy is given every two weeks, especially if you have cancer in your lymph nodes and you do not have any other medical problems. You should check with your doctor about the specific program that is being recommended. It is also very important to participate in clinical research studies that are done nationwide and even internationally. There are always new drugs that become available and some of them do have added benefit. Participating in research studies is very important for you personally and also for advancing the knowledge about breast cancer. You want to make sure that you have access to the state of the art research studies.

Hormonal Therapy

Hormonal therapy refers to several drugs that are available for you to take by mouth. The one that is most commonly prescribed is tamoxifen. Several newer drugs are now available, including Femara, Arimidex, and Aromasin. The last three drugs belong to a category called aromatase inhibitors. You are a candidate for hormonal therapy if your disease has estrogen receptors or progesterone receptors. Hormonal therapy is not used if you do not have estrogen or progesterone receptors in the cancer cells. Hormonal therapy is usually very well tolerated, however like any other medication, there are side effects associated with any of these drugs. The most serious side effect of tamoxifen is increased risk of blood clot, including stroke, blood clot in the legs or the lungs and increased risk of uterine cancer. If you had a hysterectomy, then you should not worry about having endometrial/uterine cancer. If you have any history of a blood clot or stroke, you should not be taking tamoxifen.

The aromatase inhibitors mentioned above (Femara, Arimidex, and Aromasin), do not increase the risk of uterine cancer or blood clots, however they do increase the risk of osteoporosis and hip fracture. They also might increase your cholesterol level. Whether you should go on tamoxifen or one of the newer drugs is a very individualized decision and that is usually discussed in detail with your medical oncologist. If you decide to use one of the newer drugs, it is important to have a bone density to make sure you do not have early osteoporosis (this is referred to as osteopenia), or osteoporosis. It is also important that you take calcium 1500 mg and vitamin D 800 units per day if you decide to go on the newer drugs. The duration of hormonal therapy is usually four or five years, however this might change in the future. Check with your doctors for how long you should take your hormonal therapy. Hormonal therapy is not used if you do not have estrogen or progesterone receptors present in the cancer cells.

It is important also to note that hormonal therapy has some additional beneficial effects. Tamoxifen is very good for your bones and can be used for treatment of osteoporosis. It is also good for your cholesterol. The newer drugs do not provide the protection for the bones and cholesterol as provided by the tamoxifen.

However, they do not have the side effects of tamoxifen including blood clots and uterine cancer.

All the hormonal agents also have the major benefit of decreasing the risk of having another breast cancer. Once you have breast cancer, you are at higher risk of having another breast cancer that could be in the same breast or the other breast. This is an independent cancer and it is important to monitor for this carefully. All the drugs mentioned above have the advantage of lowering your risk of having another breast cancer by approximately 50%. The risk of having another breast cancer on the other side is usually 0.5 to 1% per year and tamoxifen cuts this number by half. In other words, over the next ten years, you have approximately a 5% risk of having another breast cancer if you do not take hormonal therapy and if you do take hormonal therapy, that risk is cut down to about 2.5%. Ask your doctor about more specifications and more discussions about this point.

Sequence of Therapy

Typically the sequence of therapy is surgery, followed by chemotherapy if needed, followed by radiation and then followed by hormonal therapy. If you do not need chemotherapy, then you can have surgery followed by radiation and then hormonal therapy. However, there are certain situations where we do recommend starting chemotherapy before the surgery. This is usually if your tumor is large or if the tumor is very close to the muscle of your chest wall. Your doctor will discuss these special situations with you during your meeting. One of the major advantages for giving chemotherapy before surgery is to decrease the size of the cancer. This might allow you to have a lumpectomy if you are interested in this procedure. If you have a tumor over 5 cm or if you are interested in a lumpectomy, you should have chemotherapy prior to surgery.

At this point, we have discussed the issue of local therapy, which includes surgery and radiation therapy and we have also discussed systemic therapy, which includes chemotherapy and hormonal therapy. There is another important aspect of the treatment of breast cancer that you should ask your doctor about. My web site SamiDiabMD.com has a lot of information about nutritional values and how to eat during chemotherapy.

I am a firm believer in mind/body medicine and oftentimes I might recommend acupuncture, hypnosis and guided imagery while you are getting chemotherapy and other treatments for your breast cancer. Please ask me about these things and their values. I am able to make recommendations regarding highly qualified providers for these services.

Oftentimes I am asked about whether you should be taking any herbs during chemotherapy. In your package you should have some information about herbal therapy. I am currently pursuing special treatment for herbal medicine and other forms of mind/body medicine under the guidance of Dr. Andrew Weil from the University of Arizona. Please ask for specifics about this particular type of intervention.

I hope you find this information useful.

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