October: Breast Cancer Awareness Month

Every year there are 230,000 newly diagnosed cases of breast cancer.  While men can also develop breast cancer, they only represent one percent of the total cases (approximately 2,300 cases per year).    The vast majority of patients diagnosed with breast cancer are expected to live, but death from breast cancer is the second most common cause of death from cancer in women.

There is no one specific way to detect breast cancer. It can present itself during self examinations; with nipple discharge or itching;  routine mammogram; ultrasound images; MRI images of the breast, or the newest x-ray technique called Tomosynthesis of the breast (also called 3D imaging of the breast).   All are methods that help us identify something in the breast that can be biopsied.  

Not everything is cancer, but it is best to evaluate it and be certain.  Depending on your age, family history of cancer, the appearance and location of the mass (something you may feel different in the breast or it was found with a mammogram), your doctor will make a recommendation.  It is okay to get another opinion from a different doctor or treatment center, if you are uncomfortable or even just for peace of mind.

RISK FACTORS

So why is age, menstrual cycle status, family history, and location of the mass important? Breast cancer peaks from age 40-60 in women, with very low risk for cancer in the younger age groups of 20-40 years of age.  This age group most likely has fibroadenomas, a lesion that can look like breast cancer, but it is benign (does not spread).  And low rates are again noted from 70-80 years of age.  This group is very interesting because we are now debating less therapy for very early stage cancers.  The cancers in this age group seem to grow very slowly and respond to hormone therapy (the many drugs that block Estrogen).  However, we still state your lifetime risk is 1:8 for developing breast cancer.  

Menstrual cycle status is important because it can suggest the aggressiveness of your cancer. We usually divide between menstrual ovulation, peri-menstrual ovulation and post-menstrual ovulation.  Women who are still menstruating tend to have more aggressive cancers and they can be negative for markers.  Markers are cell surface receptors that can help identify the cell type and can be used for treatment purposes (see tumor markers below). 

Family history is very important in trying to document a genetic link for your cancer.  So take the time to recall your family members who had cancer, where the cancer started on their body, the type of cancer and their age when the cancer was diagnosed.  Discuss this with your late teen or adult kids, so that they are aware.  It is beneficial for the patient diagnosed with cancer and children who are doing screening for cancer.  

THINGS YOU CAN DO

Knowing the location of the mass is important.  If you are doing breast self- exams, you can track any changes.  If you are not, I strongly encourage you to start doing breast exams. Schedule a time, daily, that is convenient for you; remembering the location and roughly the size helps.  Does it change with your menstrual cycles? Does coffee, some teas or chocolate affect the size (anything that contains caffeine)? Is it tender?  Is there a nipple discharge? Is the skin dimpled or red?  Do you feel a lump under your armpit; when did you first notice it?  All are helpful to your physician. 

SURGERY/PATHOLOGY

Your physician may recommend you see a surgeon.  Based on review of your exam, history and images the surgeon may recommend a breast biopsy and/or sentinel lymph node biopsy. Lymph nodes are part of your immune system and help you identify and fight off infections; we have hundreds throughout the body.  A lymph node biopsy is the surgical removal of the node for examination.  

The breast biopsy can be done in radiology as a fine needle aspirate (also called FNA) or in the operating room as a lumpectomy (total removal of the mass you feel or that was identified on mammogram).  The lymph nodes of the axilla (the armpit) tell us about spread of the cancer and can be removed as a group at the time of definitive surgery, or a sentinel lymph node can be removed.  It is called sentinel because it is guarding the area where your mass was identified. The specimen will be examined by another physician called a Pathologist.  This usually takes three to four days, and a final pathology report is given.  This report includes the type of cancer, the size, the genetic test results and the margin status (is all the cancer out).  This helps the surgeon decide if more definitive surgery is needed, or extra x-ray studies are needed (staging a cancer—did the cancer spread?) or if different treatment modalities are needed.  If the cancer is small with only one site of disease, your surgeon may recommend a lumpectomy with radiation to the breast to follow.  If the cancer is large or multifocal, your surgeon may recommend mastectomy with the option of plastic surgery for reconstruction and possible radiation therapy to follow. 

CHEMOTHERAPY/ TUMOR MARKERS

Chemotherapy is administered by a physician called a Medical Oncologist.  It can be used to reduce the cancer size before definitive surgery.   Chemotherapy can be used after surgery to prevent spread of the cancer.  All cancers will be evaluated based on size, spread and tumor markers.  The tumor markers can be especially helpful to the Medical Oncologist.  The main tumor markers are ER (estrogen receptor), PR (progesterone receptor) and Her-2-neu (Human Epidermal Growth Factor Receptor 2).    These markers are best explained by thinking of how you receive TV signal in your house; old fashioned antenna, cable box or satellite dish.  The receptors sit on the cancer cell surface and accept certain hormones or proteins which can help it grow or spread (like estrogen or progesterone, which the Medical Oncologist can use against your cancer).  

Her-2-Neu is a newer marker that occurs in 15-30% of all breast cancer.  Over expression of this marker can tell the Medical Oncologist your cancer is more aggressive and susceptible to the newest form of chemotherapy called immunotherapy.  The Medical Oncologist cay use agents like Herceptin (Trastuzumab) to fight your cancer.  A cancer that is triple negative is negative for all receptors and suggests your cancer is very aggressive.  An ER/PR positive cancer in a post-menopausal woman suggests a less aggressive cancer and may need less aggressive therapy. To help Medical Oncologists decide with the borderline cases a genetic panel called Oncotype DX has been developed.  Oncotype DX is a 21 gene marker assay that helps to establish a risk rating for recurrence of your cancer.   This will help stratify women into low, intermediate, or high risk of recurrence groups.  Other genetic markers include BRCA1 (Breast Cancer Gene 1) and BRCA2 (Breast Cancer Gene 2) mutations.  The BRCA mutation represents only about 3% of all the breast cancer cases, but carries additional risks that you can discuss further with your physician. 

RADIATION THERAPY

Radiation can sometimes be used for additional local control of breast cancer.  Depending on the tumor size, multiplicity of tumors (multiple sites), and nodal status, radiation may be beneficial.  Radiation used in most cases is gamma beams and it is artificially produced in a linear accelerator and shaped to treat your specific body type.  CT treatment planning with body molding (called breast/body cast) is critical to reduce dose/damage to critical structures like the heart, normal lung and esophagus.  Typically, treatments are given once a day, Monday through Friday, for six and a half weeks.  Newer shorter courses of therapy have been recently explored that can shorten your treatment course to one week with brachytherapy (twice daily treatment with a sealed source radiation catheter inserted into the breast—ideal for small tumors only, no positive nodes), or over three to four weeks using an accelerated external radiation treatment course, called hypo-fractionation    (usually performed for small to moderate size tumors and no positive lymph nodes).  It is best to discuss this with your treating doctor to fully understand the risks, benefits, and possible side effects of your treatment choice.

As you can tell, breast cancer is a complicated disease with evolving treatment strategies and dynamics.  A multi-discipline approach to your cancer begins with your treatment team of doctors, your understanding some of the dynamics and terms used.  My discussion did not include prevention or post-treatment therapies.  Your team of experts will suggest a plan of action specific for you.  Don't be afraid to ask questions if you do not understand.  Although difficult decisions have to be made, at the end of the day, this is your battle, and your life.  Use your God-given wisdom to seek out support and advice.  Pick your battle mates wisely.