Breast Cancer 101

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Welcome to Breast Cancer 101 (Image-©1998 Breast Cancer 101)

FACTS

80% of women diagnosed with breast cancer have NO known risk factors. 5-10% have a family history of breast cancer. Only 10% have some risk factor.
During the 10 years of the Vietnam War, 58,000 men and women died. During that same ten-year period, 330,000 women died of breast cancer.
In 1998, over 178,700 women will be diagnosed with breast cancer (one every 3 minutes), and 43,500 will die (one every 12 minutes). Additionally, 1,600 men will develop breast cancer, and 400 will die.
Breast cancer is the most common cancer among women of all ages. It is the leading cause of death, from all causes, of women between the ages of 35 and 54.
Until we know more about preventing breast cancer, detection of breast cancer at an early stage provides a greater chance of survival and more treatment options. When the disease is confined to the breast, the 5-year survival rate is over 95%.

STAGES OF BREAST CANCER DEFINED Stages of breast cancer:

Once breast cancer has been found, more tests will be done to find out if the cancer has spread from the breast to other parts of the body. This is called staging. To plan treatment, a doctor needs to know the stage of the disease. The following stages are used for breast cancer.

Carcinoma in situ:

About 15% to 20% of breast cancers are very early cancers. They are sometimes called carcinoma in situ. There are two types of breast cancer in situ. One type is ductal carcinoma in situ (DCIS; also known as intraductal carcinoma); the other type is lobular carcinoma in situ (LCIS). LCIS is not cancer, but for the purpose of classifying the disease, it is called breast cancer in situ, carcinoma in situ, or stage 0 breast cancer. Sometimes LCIS is found when a biopsy is done for another lump or abnormality found on the mammogram. Patients with this condition have a 25% chance of developing breast cancer in either breast in the next 25 years.

Stage I

The cancer is no larger than 2 centimeters (about 1 inch) and has not spread outside the breast.
Stage II:

Any of the following may be true:

The cancer is no larger than 2 centimeters but has spread to the lymph nodes under the arm (the axillary lymph nodes).
The cancer is between 2 and 5 centimeters (from 1 to 2 inches). The cancer may or may not have spread to the lymph nodes under the arm.
The cancer is larger than 5 centimeters (larger than 2 inches) but has not spread to the lymph nodes under the arm.

Stage III:

Stage III is divided into stages IIIA and IIIB.

Stage IIIA is defined by either of the following:

The cancer is smaller than 5 centimeters and has spread to the lymph nodes under the arm, and the lymph nodes are attached to each other or to other structures.
The cancer is larger than 5 centimeters and has spread to the lymph nodes under the arm.

Stage IIIB is defined by either of the following:

The cancer has spread to tissues near the breast (skin or chest wall, including the ribs and the muscles in the chest).
The cancer has spread to lymph nodes inside the chest wall along the breast bone.

Stage IV:

The cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain. Or, tumor has spread locally to the skin and lymph nodes inside the neck, near the collarbone.

Inflmmatory breast cancer:

Inflammatory breast cancer is a special class of breast cancer that is rare. The breast looks as if it is inflamed because of its red appearance and warmth. The skin may show signs of ridges and wheals or it may have a pitted appearance. Inflammatory breast cancer tends to spread quickly.

Recurrent:

Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the breast, in the soft tissues of the chest (the chest wall), or in another part of the body.

TREATMENT OPTION OVERVIEW
How breast cancer is treated:

There are treatments for all patients with breast cancer. Four types of treatment are used:

surgery (taking out the cancer in an operation)
radiation therapy (using high-dose x-rays to kill cancer cells)
chemotherapy (using drugs to kill cancer cells)
hormone therapy (using drugs that change the way hormones work or taking out organs that make hormones, such as the ovaries)
Biological therapy (using the body's immune system to fight cancer), bone marrow transplantation, and peripheral blood stem cell transplantation are being tested in clinical trials.

Most patients with breast cancer have surgery to remove the cancer from the breast. Usually, some of the lymph nodes under the arm are also taken out and looked at under a microscope to see if there are any cancer cells.

Different types of operations used:

Surgery to conserve the breast:

Lumpectomy (sometimes called excisional biopsy or wide excision) is the removal of the lump in the breast and some of the tissue around it. It is usually followed by radiation therapy to the part of the breast that remains. Most doctors also take out some of the lymph nodes under the arm.
Partial or segmental mastectomy is the removal of the cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor. Usually some of the lymph nodes under the arm are taken out. In most cases, radiation therapy follows.

Other types of surgery:

Total or simple mastectomy is the removal of the whole breast. Sometimes lymph nodes under the arm are also taken out.
Modified radical mastectomy is the removal of the breast, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes part of the chest wall muscles. This is the most common operation for breast cancer.
Radical mastectomy (also called the Halsted radical mastectomy) is the removal of the breast, chest muscles, and all of the lymph nodes under the arm. For many years, this was the operation most used, but it is used now only when the tumor has spread to the chest muscles.
Radiation therapy is the use of high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).
Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by mouth or it may be put into the body by inserting a needle into a vein or muscle. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells outside the breast area.
If tests show that the breast cancer cells have estrogen receptors and progesterone receptors, hormone therapy may be given. Hormone therapy is used to change the way hormones in the body help cancers grow. This may be done by using drugs that change the way hormones work or by surgery to take out organs that make hormones, such as the ovaries. Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer. Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase the chance of getting cancer of the uterus. A doctor should be seen for a pelvic examination every year. Any vaginal bleeding, other than menstrual bleeding, should be reported to a doctor as soon as possible. Even if the doctor removes all the cancer that can be seen at the time of the operation, the patient may be given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer cells that may be left. Therapy given after an operation en there are no cancer cells that can be seen is called adjuvant therapy.
Biological therapy tries to get the body to fight cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. This treatment is currently only being given in clinical trials.
Bone marrow transplantation is a newer type of treatment that is being studied in clinical trials. Sometimes breast cancer becomes resistant to treatment with radiation therapy or chemotherapy. Very high doses of chemotherapy may then be used to treat the cancer. Because the high doses of chemotherapy can destroy the bone marrow, marrow is taken from the bones before treatment. The marrow is then frozen and the patient is given high-dose chemotherapy with or without radiation therapy to treat the cancer. The marrow that was taken out is then thawed and given back to the patient through a needle inserted into a vein to replace the marrow that was destroyed. This type of transplant is called an autologous transplant. If the marrow that is given is taken from another person, the transplant is called an allogeneic transplant.
Another type of autologous transplant is called a peripheral blood stem cell transplant. The patient's blood is passed through a machine that removes the stem cells (immature cells from which all blood cells develop) and then returns the blood back to the patient. This procedure is called leukapheresis and usually takes 3 or 4 hours to complete. The stem cells are treated with drugs to kill any cancer cells and then frozen until they are transplanted back to the patient. This procedure may be done alone or with an autologous bone marrow transplant. A greater chance for recovery occurs if the doctor chooses a hospital that does more than five bone marrow transplantations per year.

Treatment by stage:

Treatment of breast cancer depends on the type and stage of the disease, and the patient's age, menopausal status, and overall health.

Standard treatment may be considered because of its effectiveness in patients in past studies, or participation in a clinical trial may be considered.

CARCINOMA IN SITU:

The treatment depends on whether the patient has ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS). Since it is difficult to distinguish between these two types, it may be helpful to have a second opinion by having the patient's biopsy preparations (slides) studied by pathologists at another hospital.

If the patient has DCIS, treatment may be one of the following:

1. Surgery to remove the whole breast (total mastectomy).
2. Breast-conserving surgery with radiation therapy.
3. Clinical trial of surgery to remove only the cancer (lumpectomy) followed by radiation therapy with or without hormone therapy.

Rarely, some of the lymph nodes under the arm may also be removed during the above surgeries.

If a patient has LCIS, the patient may have a higher risk of developing invasive cancer in both breasts: about a 25% chance over 25 years. LCIS is not breast cancer, and many women with LCIS never develop breast cancer. The treatment options for LCIS are varied and quite controversial. Treatment may be one of the following:

1. Biopsy to diagnose the LCIS followed by regular examinations and yearly mammograms to find any changes as early as
possible.
2. A large clinical trial is testing hormone therapy with the drug tamoxifen to see whether it can prevent cancer from
occurring. The Cancer Information Service can be called for more information (1-800-4-CANCER).
3. Surgery to remove both breasts (total mastectomy).

If a patient is going to have a mastectomy, breast reconstruction (making a new breast mound) may be considered. It may be done at the time of the mastectomy or at some future time. The breast may be made with the patient's own (non- breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater rather than silicone gel, may also be used. Before the decision to get an implant is made, patients can call the FDA's Center for Devices and Radiologic Health at 1-888-INFO-FDA (1-888-463- 6332) to obtain additional information. Additional questions can then be discussed with a doctor.

STAGE I BREAST CANCER:

Treatment may be one of the following:

1. Breast-conserving surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or to remove
part of the breast (partial or segmental mastectomy); both are followed by radiation therapy. Some of the lymph nodes
under the arm are also removed. This treatment provides identical long-term cure rates as those from mastectomy. A
doctor's recommendation on which procedure to have is based on tumor size and location and its appearance on
mammogram.
2. Surgery to remove the whole breast (total mastectomy) or the whole breast and the lining over the chest muscles
(modified radical mastectomy). Some of the lymph nodes under the arm are also taken out.

Adjuvant therapy (given in addition to the treatments listed above):

1. Chemotherapy.
2. Hormone therapy.
3. A clinical trial of adjuvant chemotherapy in certain patients.
4. A clinical trial of no adjuvant therapy for patients with a good chance of recovery (prognosis).
5. A clinical trial of treatment to keep the ovaries from working.

If a patient is going to have a mastectomy, breast reconstruction (making a new breast mound) may be considered. It may be done at the time of the mastectomy or at some future time. The breast may be made with the patient's own (non- breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater rather than silicone gel, may also be used. Before the decision to get an implant is made, patients can call the FDA (1-800-532-4440) to obtain additional information. Additional questions can then be discussed with a doctor.

STAGE II BREAST CANCER:

Treatment may be one of the following:

1. Breast-conserving surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or to remove
part of the breast (partial or segmental mastectomy); both are followed by radiation therapy. Some of the lymph nodes
under the arm are also removed. This treatment provides identical long-term cure rates as those from mastectomy. A
doctor's recommendation on which procedure to have is based on tumor size and location and its appearance on
mammogram.
2. Surgery to remove the whole breast (total mastectomy) or the whole breast and the lining over the chest muscles
(modified radical mastectomy). Some of the lymph nodes under the arm are also taken out.

Adjuvant therapy (given in addition to the treatments listed above):

1. Chemotherapy with or without hormonal therapy.
2. Hormone therapy.
3. A clinical trial of chemotherapy before surgery (neoadjuvant therapy).
4. A clinical trial of high-dose chemotherapy with bone marrow transplantation for patients with cancer in more than three
lymph nodes.

If a patient is going to have a mastectomy, breast reconstruction (making a new breast mound) may be considered. It may be done at the time of the mastectomy or at some future time. The breast may be made with the patient's own (non- breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater rather than silicone gel, may also be used. Before the decision to get an implant is made, patients can call the FDA (1-800-532-4440) to obtain additional information. Additional questions can then be discussed with a doctor.

STAGE III BREAST CANCER:

Stage III breast cancer is further divided into stage IIIA (can be operated on) and IIIB (biopsy is usually the only surgery performed).

Stage IIIA cancer:

Treatment may be one of the following surgeries:

1. Surgery to remove the whole breast, the lining over the chest muscles, and many of the lymph nodes (modified radical
mastectomy) or the whole breast, the chest muscles, and all of the lymph nodes (radical mastectomy).
2. Radiation therapy given after surgery.
3. Chemotherapy with or without hormone therapy given with surgery and radiation therapy.
4. A clinical trial testing new chemotherapy with or without hormonal drugs; they are also testing chemotherapy before
surgery (neoadjuvant therapy).
5. A clinical trial of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.

Stage IIIB cancer:

The patient will probably have a biopsy then be given one or more of the following:

1. Surgery (radical or modified radical mastectomy) and/or radiation therapy to the breast and the lymph nodes.
2. Chemotherapy with or without hormones to shrink the tumor, followed by surgery and/or radiation therapy.
3. Hormonal therapy followed by additional therapy.
4. A clinical trial testing new chemotherapy drugs and biological therapy, new drug combinations, and new ways of giving
chemotherapy.
5. A clinical trial of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.

STAGE IV BREAST CANCER:

The patient will probably have a biopsy and then be given one or more of the following:

1. Radiation therapy or, in some cases, a mastectomy to reduce the symptoms.
2. Hormonal therapy with or without surgery to remove the ovaries.
3. Combination chemotherapy.
4. A clinical trial testing new chemotherapy and hormonal drugs and new combinations of drugs and biological therapy.
5. A clinical trial of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.

INFLAMMATORY BREAST CANCER:

Treatment will probably be a combination of chemotherapy, hormonal therapy, and radiation therapy, which may be combined with
surgery to remove the breast. The treatment is usually similar to that for stage IIIB or IV breast cancer.

RECURRENT BREAST CANCER:

Breast cancer that comes back (recurs) can often be treated, but usually cannot be cured when it recurs in another part of the body. Some patients with recurrence in the breast can be cured, however. The choice of treatment depends on hormone receptor levels, the kind of treatment the patient had before, the length of time from first treatment to when the cancer came back, where the cancer recurred, whether the patient still has menstrual periods, and other factors.

Treatment may be one of the following:

1. Hormonal therapy with or without surgery to remove the ovaries.
2. Surgery and/or radiation therapy (for the small group of patients whose cancer has come back only in one place).
3. Other types of hormone therapy.
4. Combination chemotherapy.
5. Retreatment with previously used therapies.
6. A clinical trial of newly developed chemotherapy or biologic therapy.

TO LEARN MORE..... CALL 1-800-4-CANCER

For more information on breast implants, please write to the FDA at this address:

Breast Implants
Food and Drug Administration
HFE-88
Rockville, MD 20857

The FDA also has a hotline number to answer questions about silicone gel-filled breast implants. To learn more, call
1-800-532-4440, Monday through Friday, 9 a.m. to 7 p.m. Eastern standard time.