HEALTH - BREAST CANCER (CANCERS OF THE BREAST SYMPTOMS & TREATMENT)
What is Breast Cancer?
Heightened awareness of breast cancer risk in the past decades has led to an increase in the number of women undergoing mammography for screening, leading to detection of cancers in earlier stages and a resultant improvement in survival rates. Still, breast cancer is the most common cause of death in women between the ages of 45 and 55. Although breast cancer in women is a common form of cancer, male breast cancer does occur and accounts for about 1% of all cancer deaths in men.
The breast is mainly composed of fatty tissue. Within this tissue is a network of lobes, which are made up of tiny, tube-like structures called lobules that contain milk glands. Tiny ducts connect the glands, lobules, and lobes, carrying the milk from the lobes to the nipple, located in the middle of the areola (darker area that surrounds the nipple of the breast). Blood and lymph vessels run throughout the breast; blood nourishes the cells, and the lymph system drains bodily waste products. The lymph vessels connect to lymph nodes, which are tiny, bean-shaped organs that normally help fight infection.
About 90% of all breast cancer health cases start in the ducts or lobes. Almost 75% of all breast cancers begin in the cells lining the milk ducts and are called ductal carcinomas. Cancer that begins in the lobules is called lobular carcinoma. If the disease has spread outside of the duct and into the surrounding tissue, it is called invasive or infiltrating ductal carcinoma. If the disease has spread outside of the lobule, it is called invasive or infiltrating lobular carcinoma. Disease that has not spread is called in situ, meaning “in place.” The course of in situ disease, as well as its treatment, depends on whether it is ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS).
Other, less common cancers of the breast include medullary, mucinous, tubular, metaplastic, or papillary breast cancer. Inflammatory breast cancer is a faster-growing type of cancer that accounts for about 1% to 5% of all breast cancers. It may be misdiagnosed as a breast infection because there is often swelling of the breast and redness of the breast skin. Paget’s disease is a type of in situ cancer that can begin in the ducts of the nipple. The skin often appears scaly and may be itchy.
Cancer may begin as a single, genetically abnormal cell. As this one cell divides, it eventually becomes a tumor (a mass of cells) and develops a blood supply to nourish its continued growth. At some point, cells may break off from the primary mass and move to other parts of the body in a process called metastasis.
Breast cancer spreads when breast cancer cells move to other sites in the body through the blood vessels and/or lymph vessels. A common site of spread is the regional lymph nodes. The lymph nodes can be axillary (located under the arm), cervical (located in the neck), or supraclavicular (located just above the collarbone). The most common sites of distant metastasis are the bones, lungs, and liver. Less commonly, breast cancer may spread to the brain. The cancer can also recur (come back after treatment) locally in the skin, in the same breast (if it was not removed as part of treatment), other tissues of the chest, or elsewhere in the body.
Most of the time, breast cancer is diagnosed and treated before metastasis occurs. According to the latest data from the National Cancer Institute (NCI), 61% of breast cancers are diagnosed while the cancer is still in the breast, 31% are diagnosed after the cancer has spread to nearby lymph nodes or just outside the breast, and 6% are diagnosed once the cancer has metastasized beyond the adjoining lymph nodes.
Health: Causes of Breast Cancer (Cancers)
It's not clear what causes breast cancer. Doctors know that breast cancer occurs when some breast cells begin growing abnormally. These cells divide more rapidly than healthy cells do. The accumulating cells form a tumor that may spread (metastasize) through your breast, to your lymph nodes or to other parts of your body.
Breast cancer most often begins with cells in the milk-producing ducts. Doctors call this type of breast cancer invasive ductal carcinoma. Breast cancer may also begin in the lobules (invasive lobular carcinoma) or cells within the breast.
Researchers have identified things that can increase your risk of breast cancer. But it's not clear why some people who have no risk factors develop cancer, yet other people with risk factors never do. It's likely that breast cancer is caused by a complex combination of your genetic makeup and your environment.
Inherited breast cancer
Doctors estimate that 5 to 10 percent of breast cancers are linked to
gene mutation passed through generations of a family. A number of
inherited defective genes that can increase the likelihood of breast
cancer have been identified. The most common are breast cancer gene 1
(BRCA1) and breast cancer gene 2 (BRCA2), both of which increase the
risk of both breast and ovarian cancer.
If you have a strong family health history of breast cancer or other cancers, blood tests may help identify defective BRCA or other genes that are being passed through your family. Consider asking your doctor for a referral to a genetic counselor who can review your family health history. A genetic counselor can also discuss the health benefits, risks and limitations of genetic testing with you.
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Health: Risk Factor of Breast Cancer (Cancers)
No one knows the exact causes of breast cancer. Doctors often cannot explain why one woman develops breast cancer and another does not. They do know that bumping, bruising, or touching the breast does not cause cancer. And breast cancer is not contagious. You cannot "catch" it from another person.
Research has shown that women with certain risk factors are more likely than others to develop breast cancer. A risk factor is something that may increase the chance of developing a disease.
Studies have found the following risk factors for breast cancer:
- Age: The chance of getting breast cancer goes up as a woman gets older. Most cases of breast cancer occur in women over 60. This disease is not common before menopause.
- Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting cancer in her other breast.
- Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer. The risk is higher if her family member got breast cancer before age 40. Having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's health risk.
- Certain breast changes: Some women have cells in the breast that look abnormal under a microscope. Having certain types of abnormal cells (atypical hyperplasia and lobular carcinoma in situ [LCIS]) increases the health risk of breast cancer.
- Gene changes: Changes in certain genes increase the risk of breast cancer. These genes include BRCA1, BRCA2, and others. Tests can sometimes show the presence of specific gene changes in families with many women who have had breast cancer. Health care providers may suggest ways to try to reduce the risk of breast cancer, or to improve the detection of this disease in women who have these changes in their genes.
- Reproductive and menstrual history:
- The older a woman is when she has her first child, the greater her chance of breast cancer.
- Women who had their first menstrual period before age 12 are at an increased risk of breast cancer.
- Women who went through menopause after age 55 are at an increased risk of breast cancer.
- Women who never had children are at an increased risk of breast cancer.
- Women who take menopausal hormone therapy with estrogen plus progestin after menopause also appear to have an increased risk of breast cancer.
- Large, well-designed studies have shown no link between abortion or miscarriage and breast cancer.
- Race: Breast cancer is diagnosed more often in white women than Latina, Asian, or African American women.
- Being female. Women are much more likely than men are to develop breast cancer.
- Radiation therapy to the chest: Women who had radiation therapy to the chest (including breasts) before age 30 are at an increased risk of breast cancer. This includes women treated with radiation for Hodgkin's lymphoma. Studies show that the younger a woman was when she received radiation treatment, the higher her risk of breast cancer later in life.
- Breast density: Breast tissue may be dense or fatty. Older women whose mammograms (breast x-rays) show more dense tissue are at increased risk of breast cancer.
- Taking DES (diethylstilbestrol): DES was given to some pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.) Women who took DES during pregnancy may have a slightly increased risk of breast cancer. The possible effects on their daughters are under study.
- Being overweight or obese after menopause: The chance of getting breast cancer after menopause is higher in women who are overweight or obese.
- Lack of physical activity: Women who are physically inactive throughout life may have an increased risk of breast cancer. Being active may help reduce risk by preventing weight gain and obesity.
- Drinking alcohol: Studies suggest that the more alcohol a woman drinks, the greater her risk of breast cancer.
- Having your first child at an older age. Women who give birth to their first child after age 35 may have an increased risk of breast cancer.
Other possible risk factors are under study. Researchers are studying the effect of diet, physical activity, and genetics on breast cancer risk. They are also studying whether certain substances in the environment can increase the risk of breast cancer.
Many risk factors can be avoided. Others, such as family health history, cannot be avoided. Women can help protect themselves by staying away from known risk factors whenever possible.
But it is also important to keep in mind that most women who have known risk factors do not get breast cancer. Also, most women with breast cancer do not have a family health history of the disease. In fact, except for growing older, most women with breast cancer have no clear risk factors.
If you think you may be at a health risk, you should discuss this concern with your doctor or health care provider. Your doctor may be able to suggest ways to reduce your health risk and can plan a schedule for checkups.
Health: Symptoms of Breast Cancer (Cancers)
Women with breast cancer may experience the following symptoms. Sometimes, women with breast cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical health condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor or health care provider. However, most women who develop breast cancer have no signs or symptoms. The symptoms to look for include:
- New lumps (many women normally have lumpy breasts) or a thickening in the breast or under the arm
- Nipple tenderness, discharge, or physical changes (such as a nipple turned inward or a persistent sore)
- Skin irritation or changes, such as puckers, dimples, scaliness, or new creases
- Warm, red, swollen breasts with a rash resembling the skin of an orange (called peau d'orange)
- Pain in the breast (usually not a symptom of breast cancer, but should be reported to a doctor)
Note: any changes in the breast should be reported to a doctor without delay. Symptoms can be caused by cancer or by a number of less serious conditions. Early diagnosis is especially important for breast cancer because the disease responds best to treatment before it has spread. The earlier breast cancer is found and treated, the better a woman's chance for complete recovery.
Health: Diagnosis of Breast Cancer (Cancers)
The diagnosis may be established by a careful physical examination, mammography, ultrasonography, and biopsy.
- The doctor will examine the breasts using visual inspection and palpation. Visual inspection looks for changes in breast contour, new dimpling, nipple inversion, discharge, moles, puckering or persistent sores. Palpation is using the pads of the fingers to press down and feel the tissue around the breasts for any unusual lumps. Benign (non-cancerous) lumps may feel different from cancerous ones, but most times it is very difficult to determine whether a lump is cancerous without further testing.
- Mammography is an x-ray of the breast that reveals suspicious areas that are denser than normal breast tissue or have abnormal deposits of calcium. Mammography is an important screening test which can show a breast cancer long before it is big enough to be felt in the breast. Women over age 40 should undergo a mammogram every year in order to detect breast cancers when they are small and can be treated easily. Since mammograms have been used routinely in the United States, the death rate from breast cancer has fallen dramatically as cancers are found earlier, when they are more likely to be curable.
- Ultrasonography uses high frequency sound waves that enter the breast and bounce back. The pattern of their echoes produce a picture called a sonogram that detects whether the breast lump is solid (possibly cancerous) or filled with fluid (non-cancerous). An ultrasound is usually recommended to evaluate a palpable breast lump or an abnormality seen on a mammogram.
- Many times when an abnormality is felt in the breast or seen on a mammogram, the doctor will recommend a biopsy. In a biopsy, tissue is removed from the breast and examined by a pathologist, who can tell if cancerous cells are present. There are three ways to do breast biopsies: fine needle aspiration, large core breast biopsy and surgical biopsy. Fine needle aspiration (FNA) uses a fine needle, inserted into the breast tissue, to withdraw cells from the suspicious area. Large core breast biopsy uses a large core needle in a spring-loaded device that removes "cores" or plugs of tissue from the suspicious area. Surgical biopsy is the surgical removal of part or all of the lump or suspicious area.
If breast cancer is diagnosed, the doctor will then determine the stage (phase or progression) of the cancer. The following staging system is used:
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Health: Conventional Treatment for Breast Cancer (Cancers)
The biology and behavior of a breast cancer affects the treatment. Some tumors are small but grow fast, while others are large and grow slower. When planning the treatment for breast cancer, the doctor will consider many factors, including:
- The stage and grade of the tumor
- The tumor’s hormone receptor status (ER, PR) and HER2 status
- The patient’s age and general health
- The patient’s menopausal status
- The presence of known mutations to breast cancer genes
Even though the doctor will specifically tailor the treatment for breast cancer for each patient, there are some general steps for treating breast cancer.
There are two methods of treatment - local and systemic.
Local treatment are used to remove or destroy the cancer cells in a specific area. Surgery and Radiation therapy are examples of local treatments.
Systemic treatment are used to destroy or control cancer cells all over the body. Chemotherapy and hormonal therapy examples of systemic treatments.
The right treatment method, however, depends on the size and location of the breast tumor; the results of the pathologist’ s review of the tumor specimen, the woman's age, menopausal status, and general health; and the stage of the disease.
Local treatment:
Surgery
Generally, the smaller the tumor, the more surgical options a patient has. The types of surgery include the following:
- A lumpectomy is the removal of the tumor and a small, clear
(cancer-free) margin of tissue around the tumor. For DCIS and an
invasive cancer, follow-up radiation therapy to the remaining breast
tissue is recommended. A lumpectomy may also be called a partial
mastectomy or a segmental mastectomy.
- A total mastectomy is the removal of the entire breast, but not the
underarm lymph nodes. This surgery is also called a simple mastectomy.
- A modified radical mastectomy is the removal of the breast and underarm lymph nodes.
- Axillary lymph node dissection involves the surgeon removing lymph
nodes from under the arm and having them examined by a pathologist for
cancer cells. The actual number of nodes removed may vary.
- Sentinel lymph node biopsy is a procedure in which the surgeon
finds and removes the sentinel (first) lymph node (generally one to
three nodes) that receives drainage from the breast. The pathologist
then examines it for cancer cells. To identify the sentinel lymph node,
the surgeon injects a dye and/or a radioactive tracer into the area
around the nipple. The dye or tracer will travel to the lymph nodes,
arriving at the sentinel node first. The surgeon can find the node when
it turns color (if the dye is used) or emits radiation (if the tracer
is used). Sentinel lymph node biopsy often has a lower risk of
lymphedema (swelling of the arm) than axillary lymph node dissection.
If the sentinel node is cancer-free, research has shown that there is a
good possibility that the subsequent nodes will also be free of cancer
and no further surgery of the lymph nodes is performed. If the sentinel
lymph node shows cancer is present, then the surgeon will perform an
axillary lymph node dissection.
- Women who undergo a mastectomy may wish to consider breast reconstruction, which is surgery to rebuild the breast. Reconstruction may be done with tissue from another part of the body, or with synthetic implants. A woman may be able to have this done at the same time as a mastectomy or at some point in the future.
Most patients with invasive cancer will undergo either sentinel lymph node biopsy or an axillary lymph node dissection. For those with sentinel nodes that indicate cancer, an axillary lymph node dissection is still considered necessary. Research is underway to determine if this continues to be true.
To summarize, surgical treatment options include the following:
- Lumpectomy or partial mastectomy and radiation therapy
- Total mastectomy, with or without immediate reconstruction, with or
without sentinel node biopsy and possible axillary lymph node dissection
- Modified radical mastectomy with or without immediate reconstruction
Women are encouraged to talk with their doctors about which surgical option is right for them. More aggressive surgery (such as a mastectomy) is not always better and may result in additional complications. The combination of lumpectomy and radiation therapy has a higher risk of the cancer coming back in the same breast or near the breast, but the long-term survival of women is the same as those who have a mastectomy.
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Adjuvant radiation therapy is given regularly for a number of weeks after a lumpectomy or partial mastectomy to eliminate any remaining cancer cells near the tumor site or elsewhere within the breast. Adjuvant radiation therapy is also recommended for some women after a mastectomy depending upon the size of their tumor, number of cancerous lymph nodes under the arm, and width of the tissue margin around the tumor removed by the surgeon. Adjuvant radiation therapy is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is rare.
Radiation therapy can cause side effects, including fatigue, swelling, and skin changes. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related pneumonia, is rare. In the past, with older equipment and techniques of radiation therapy, women treated for left-sided breast cancers had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare most of the heart from radiation damage. While exposure to radiation is thought to be a risk factor for cancer after many years, less than one in 500 survivors will develop a different kind of cancer, other than a breast cancer, within the area that was treated. Clinical trials comparing lumpectomy and adjuvant radiation therapy with mastectomy have not shown a difference in the number of patients developing or dying of other cancers within a 20-year time span.
The most common type of radiation treatment is called external beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. In this treatment, small radioactive pellets are placed in or near the site of the breast tumor within plastic catheters placed temporarily in the breast. A balloon catheter placed near the breast that delivers radiation therapy (called Mammosite) is another type of radiation therapy.
Standard radiation therapy after a lumpectomy or partial mastectomy is external-beam radiation therapy given for five days (Monday through Friday) for six to seven weeks. This usually includes radiation therapy to the whole breast first for four and a half to five weeks, followed by a more focused treatment to the site of the tumor bed in the breast for the remaining treatments. This focused part of the treatment, called a boost, is standard for women with invasive breast cancer because it reduces the risk of a recurrence in the breast. This boost is also usually given for women with in situ breast cancer and is the subject of an ongoing international clinical trial. Standard radiation therapy after a mastectomy is given to the chest wall for five days (Monday through Friday) for five to six weeks. If there is evidence of cancer in the underarm lymph nodes, radiation therapy may also be given to the lymph node areas in the neck or underarm near the breast or chest wall.
There has been growing interest in newer radiation methods to shorten the length of treatment from six to seven weeks to periods of three to four weeks. In one method (called hypo-fractionated radiation therapy), a higher daily dose is given to the whole breast each day so that the overall length of treatment is shortened to three to four weeks. This can also be combined with a higher dose given to the tumor bed in the breast either during or after the whole breast radiation treatments. Clinical trials from Canada and the United Kingdom have shown that these shorter schedules can be equally accepted by patients with the same cancer control rates and side effects as longer radiation treatment schedules. These shorter schedules may become more accepted in the United States and are one way to improve the convenience and time required to complete a course of radiation (see also partial breast irradiation below).
Partial breast irradiation
Partial breast irradiation (PBI) is radiation therapy that is given directly to the tumor area, usually after a lumpectomy, instead of the entire breast, as is routinely done with standard radiation therapy. This treatment can be done with external-beam radiation therapy or internal radiation therapy. Radiation is given twice a day for only one week using external-beam radiation, a temporary radiation catheter, or catheters implanted within the breast. Only some patients may be eligible for PBI. Although preliminary results have been promising, PBI is the subject of a large, nationwide clinical trial, and the results proving the safety and effectiveness compared with standard radiation therapy are pending.
Targeting the radiation to the tumor area more directly may shorten the amount of time that patients need to undergo radiation therapy. A large national clinical trial, which began in 2005, is being done to compare the standard treatment of six weeks of conventional external-beam radiation therapy with a one-week treatment of PBI.
Intensity-modulated radiation therapy
Intensity-modulated radiation therapy (IMRT) is a more advanced way to deliver external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to target the tumor more precisely, give a uniform distribution of radiation throughout the breast tissue, and avoid damaging healthy tissue than is possible with traditional radiation treatment. IMRT may reduce the dose to nearby important organs, such as the heart and lung, and reduce the risks of some immediate side effects, such as peeling of the skin during treatment. This can be especially important for women with medium to large breast sizes, who are at greater risk for side effects such as peeling, compared with small-breasted women. IMRT also may help to reduce long-term effects on the breast tissue that were common with older radiation techniques such as hardness, swelling, or discoloration.
Two prospective, randomized clinical trials have compared IMRT to conventional radiation therapy after lumpectomy for women treated for breast cancer. Both studies showed an even distribution of radiation dose throughout the breast with IMRT. IMRT use also resulted in a decrease in areas of the breast that received a higher-than-desired dose of radiation, which led to a decrease in side effects. For example, in one clinical trial, there were fewer cases of moist peeling of the skin during IMRT. In the other clinical trial, there was an improvement in breast appearance and less fibrosis (hardness of the breast) five years after IMRT treatment. Additional research is being conducted to compare the long-term side effects, such as heart disease, between IMRT and conventional radiation therapy 10 years or more after treatment.
Adjuvant radiation therapy concerns for older patients and/or those with small tumors
The lowest risks of cancer recurrence in the breast after lumpectomy are associated with the use of radiation therapy. Early randomized clinical trials showed, in general, recurrence rates of 30% or more without radiation therapy, compared with 10% recurrence rates with radiation therapy. More recent studies have looked at the consequences of using no radiation therapy for women age 70 or older or those with a small tumor size. Overall, these studies demonstrate that radiation therapy minimizes the risk of breast cancer recurrence in the same breast, compared with no radiation therapy, but does not affect overall survival. Guidelines from the National Comprehensive Cancer Network (NCCN) continue to recommend radiation as the standard option after lumpectomy. However, they also indicate that women with very favorable characteristics (such being age 70 or older and having other medical conditions that could limit life expectancy within five years, a small tumor, no evidence of cancer in the lymph nodes or surgical margins, and an ER-positive cancer) could reasonably choose not to have radiation therapy and use hormone therapy (see below) alone after lumpectomy, if they are willing to accept a higher risk rate of local recurrence.
Systemic treatment:
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the drug and the dose used, but can include fatigue, hair loss, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers, but studies have shown that these side effects do not shorten a woman’s survival time.
Chemotherapy may be given orally (by mouth) or intravenously (injected into a vein) and is usually given in cycles. Chemotherapy generally does not require a hospital stay; it is given in an outpatient setting. Chemotherapy may be neoadjuvant therapy (given before surgery to shrink a large tumor) or adjuvant therapy (given after surgery to reduce the risk that the cancer returns). Chemotherapy may also be given at the time of a breast cancer recurrence. Patients in clinical trials may be offered new drugs or new combinations of existing drugs.
Different drugs are useful for different cancers, and research has shown that combinations of certain drugs are more effective than individual ones.
Hormone therapy
Hormone therapy is useful to manage a tumor that tests positive for either estrogen or progesterone receptors for both early-stage and metastatic cancer. This type of tumor uses hormones to fuel its growth. Blocking the hormones usually limits the growth of the tumor.
If it is determined that the tumor is hormone receptor-positive (uses estrogen or progesterone to grow, then adjuvant hormone treatment may be used alone or after chemotherapy. Examples of hormone therapy used as adjuvant therapy are tamoxifen, anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin).
Tamoxifen is the drug that researchers have studied the longest for use as a hormone therapy. It blocks estrogen from binding to breast cancer cells. It has been shown to be effective for reducing the risk of recurrence in the treated breast, the risk of developing cancer in the other breast, and the risk of developing cancer in women with no history of the disease but who are at higher than average risk for developing breast cancer. Current research shows that there is no benefit of taking tamoxifen longer than five years.
The side effects of tamoxifen include hot flashes, a small increased risk of uterine (endometrial) cancer and uterine sarcoma, and an increase in the risk of blood clots. Tamoxifen can be effective for both premenopausal and postmenopausal women.
In postmenopausal women who have an increased risk of developing breast cancer, raloxifene has shown to be another hormone therapy that is as effective as tamoxifen in preventing invasive breast cancer, but not as effective in preventing noninvasive cancer, such as DCIS. The side effects of raloxifene include a small risk of blood clots, leg and joint pain, hot flashes, pain during sexual intercourse, and vaginal dryness. Raloxifene has not been studied in premenopausal women, and it is not considered a substitute for tamoxifen for adjuvant therapy for women with hormone receptor-positive breast cancer.
An aromatase inhibitor (AI) decreases the amount of estrogen in postmenopausal women by blocking the aromatase enzyme, which is needed to make estrogen. These drugs include anastrozole, letrozole, and exemestane. The side effects of AIs may include joint pain and an increased risk of fractures (broken bones). Clinical trials are evaluating whether women benefit from an AI after tamoxifen, or by taking an AI for more than five years.
Targeted therapy
Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development.
- Trastuzumab is approved for both the treatment of advanced breast
cancer and as an adjuvant therapy for early-stage breast cancer for
tumors that have too much of the HER2 protein, called HER2 positive.
Data presented at the 2005 American Society of Clinical Oncology Annual
Meeting demonstrated an approximate 50% decrease in recurrence and an
improvement in survival for women with HER2-positive early breast
cancer who received trastuzumab either with or after adjuvant
chemotherapy. At this time, one year of trastuzumab is recommended.
Patients receiving trastuzumab have a 4% risk of heart problems, and
this risk is increased if a patient has other risk factors for heart
disease. These heart problems do not always go away, but they are
usually treatable with medication. Ongoing research is evaluating how
much trastuzumab is enough (from nine weeks up to two years).
- For women with HER2-positive breast cancer that no longer responds
to trastuzumab, a drug called lapatinib may slow the growth of breast
cancer when combined with capecitabine. The combination of lapatinib
and capecitabine is approved for the treatment of women with advanced
or metastatic HER2-positive breast cancer who have previously been
treated with chemotherapy and trastuzumab.
- Bevacizumab is used to treat metastatic or recurrent breast cancer (see below). This drug blocks angiogenesis (the formation of new blood vessels), which is needed for tumor growth and metastasis. When combined with paclitaxel, bevacizumab appears to shrink the tumor and remain smaller for a longer time in women whose breast cancer has spread compared with paclitaxel alone. This combination was approved by the U.S. Food and Drug Administration in 2008.
Recurrent and metastatic breast cancer
Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (a local recurrence); in the chest wall; or in another part of the body, including distant organs (such as the lungs, liver, and bones). Some patients live years after a recurrence of breast cancer.
Breast cancer may also spread to other organs such as the brain, the opposite breast, adrenal glands, spleen, and ovaries and is called metastatic breast cancer. This type of cancer is treatable, but not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the growth of the tumor.
Generally, a recurrence is detected when a person has symptoms. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research has shown that having such tests do not improve the response to treatments used for advanced disease, nor do they prolong life.
Signs and symptoms depend on the site of the recurrence and may include:
- A lump under the arm or along the chest wall
- Bone pain or fractures, which may signal bone metastases
- Headaches or seizures, which may signal brain metastases
- Chronic coughing or trouble breathing, which may signal lung metastases
Other symptoms may be related to the location of metastasis and may include changes in vision, changes in energy levels, feeling ill, or extreme fatigue. A biopsy of the recurrent site is often recommended to be certain of the diagnosis and to check for ER, PR, and HER2 status, because this may have changed from the time of the original diagnosis.
The treatment of metastatic or recurrent breast cancer depends on the previous treatment(s) and the characteristics of the tumor (such as ER, PR, and HER2 status). For women with a recurrence within the breast after initial treatment with lumpectomy and adjuvant radiation therapy, the treatment is mastectomy. For women with a recurrence of the chest wall after an initial mastectomy, resection (surgical removal of the recurrence) followed by radiation therapy to the chest wall and lymph nodes is the treatment, unless radiation therapy has already been given (radiation therapy cannot be given to the same area more than once). Often hormone therapy is used if appropriate. Chemotherapy and targeted therapies may also be used to treat metastatic cancer. Radiation therapy and surgery may be used in certain situations for women with a distant metastatic recurrence.
Once metastatic disease is detected, the treatment may involve surgery to remove the metastasis and/or chemotherapy, hormone therapy, radiation therapy (if it hasn’t been already given), and targeted therapy (see above) to control it. In some circumstances, radiation therapy may also be given to relieve symptoms.
Nothing guarantees that you won't develop breast cancer. But there are some things you may be able to do to reduce your risk of the disease.
Chemoprevention
Chemoprevention is the use of certain medications to decrease breast
cancer risk. Two drugs used for breast cancer prevention in high-risk
women come from the class of drugs known as selective estrogen receptor
modulators (SERMs):
- Tamoxifen (Nolvadex). Tamoxifen is approved for use as a preventive agent in women age 35 and older who have an elevated risk of developing breast cancer within the next five years. Data from several clinical prevention trials found that tamoxifen use in women at higher than average risk results in a relative risk reduction of about one-third for noninvasive breast cancer and about one-half for invasive breast cancer.
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Raloxifene (Evista). Raloxifene is approved for prevention of invasive breast cancer in postmenopausal women at high risk of the disease, as well as in women with postmenopausal osteoporosis. In the second group, the drug is approved for both breast cancer prevention and osteoporosis treatment. Large clinical trials have also suggested that raloxifene is as effective as tamoxifen in preventing estrogen receptor positive breast cancer in high-risk postmenopausal women who don't have a personal history of breast cancer.
The Gail model computerized risk assessment is a simple and helpful tool to estimate a woman's risk of developing invasive breast cancer. A five-year Gail model score higher than 1.66 percent is considered high risk. This tool is available online at the National Cancer Institute.
Preventive surgery
Although it's a radical step, preventive surgery also reduces breast cancer risk in high-risk women. Options include:
- Prophylactic mastectomy. This preventive surgery involves removing one or both of your breasts to prevent or reduce your risk of breast cancer. You might consider this option if you're at high risk of breast cancer, you've already had cancer in one breast, you have a family history of breast cancer, you received positive results from genetic testing, or your doctors have identified early signs of cancer in your breast.
- Prophylactic oophorectomy. This preventive option involves surgically removing your ovaries. Although the procedure is usually performed to reduce ovarian cancer risk, having an oophorectomy before you reach menopause also reduces your risk of breast cancer.
Lifestyle factors
Some lifestyle strategies may help reduce breast cancer risk:
- Ask your doctor about aspirin. Taking an aspirin just once a week may help protect against breast cancer, but be sure to talk to your doctor before you start. When used for long periods of time, aspirin can cause stomach irritation, bleeding and ulcers. More serious aspirin side effects include bleeding in the intestinal and urinary tracts and hemorrhagic stroke. In general, you're not a candidate for aspirin therapy if you have a history of ulcers, liver or kidney disease, bleeding disorders, or gastrointestinal bleeding.
- Limit alcohol. Drinking alcohol is strongly linked to breast cancer. The type of alcohol consumed — wine, beer or mixed drinks — seems to make no difference. To help protect against breast cancer, limit the amount of alcohol you drink to less than one drink a day or avoid alcohol completely.
- Maintain a healthy weight. There's a clear link between obesity — weighing more than is appropriate for your age and height — and breast cancer. The association is stronger if you gain the weight later in life, particularly after menopause.
- Avoid long-term hormone therapy. The link between postmenopausal hormone therapy and breast cancer has been a subject of debate for years, partly because research results have been mixed. Estrogen exposure clearly contributes to breast cancer risk, but for most women, the size of the contribution over a lifetime is small — particularly in the absence of other risk factors, such as family history of the disease. If you're approaching menopause and having frequent symptoms, it's probably safe to take hormones for as long as four to five years. Any longer does increase your breast cancer risk, without conferring any clear benefits. The same is true of hormone therapy after age 60.
- Stay physically active. No matter what your age, aim for at least 30 minutes of exercise on most days. Try to include weight-bearing exercises such as walking, jogging or dancing. These have the added benefit of keeping your bones strong.
- Eat foods high in fiber. Try to increase the amount of fiber you eat to between 20 and 30 grams daily — about twice that in an average American diet. Among its many health benefits, fiber may help reduce the amount of circulating estrogen in your body. Foods high in fiber include fresh fruits and vegetables and whole grains.
- Emphasize olive oil. Oleic acid, the main component of olive oil, appears both to suppress the action of the most important oncogene in breast cancer and to increase the effectiveness of the drug Herceptin.
- Avoid exposure to pesticides. The molecular structure of some pesticides closely resembles that of estrogen. This means they may attach to receptor sites in your body. Although studies have not found a definite link between most pesticides and breast cancer, it is known that women with elevated levels of pesticides in their breast tissue have a greater breast cancer risk.
New directions in research
Scientists are investigating a number of potential preventive therapies for breast cancer, including:
- Retinoids. Natural or synthetic forms of vitamin A (retinoids) may have the ability to destroy or inhibit the growth of cancer cells. Unlike other experimental therapies, retinoids may be effective in premenopausal women and in those whose tumors aren't estrogen positive. Research is ongoing.
- Flaxseed. Flaxseed is high in lignan, a naturally occurring compound that lowers circulating estrogens in your body. Flaxseed appears to decrease estrogen production — acting much like tamoxifen does — which may inhibit the growth of breast cancer tumors. Lignans are also antioxidants with weak estrogen-like characteristics. These characteristics may be the mechanism by which flaxseed works to decrease hot flashes. Further research should clarify the connection.
Alternative medicine for fatigue
Many breast cancer survivors experience fatigue during and after
treatment that can continue for years. Doctors aren't sure what causes
cancer-related fatigue and it can persist despite treatment. When
combined with your doctor's care, complementary and alternative
medicine therapies may help relieve fatigue. Ask your doctor about:
- Gentle exercise. If you get the OK from your doctor, start with gentle exercise a few times a week and work your way up to more if you feel up to it. Consider walking, swimming, yoga or tai chi.
- Managing stress. Take control of the stress in your daily life. Try stress reduction techniques such as muscle relaxation, visualization and spending time with friends and family.
- Relaxation strategies. Balance activity with periods of relaxation. Try listening to music, writing in a journal, meditating or taking a warm bath.
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Sources: NIH News In Health/National Institutes of Health/National Library of Medicine/Dept of Health and Human Services_______________________________________________________________________________________________________
