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By Dr. L. Sarrel
It's important to learn about the types of breast cancer, different diagnostic tests and the treatment options that are available today. Luckily, in the vast majority of cases, there is no need to make instant decisions when you are diagnosed with breast cancer. You are likely to be told that you can safely take a few weeks or even longer to have further tests, gather information (usually to get additional medical opinions), mull over your options and then choose a course of treatment. Sometimes your doctor will strongly urge particular treatments; in other cases she or he will leave more of the decision making to you. This is reasonable because the results of different treatment approaches are often the same. Therefore, the most important factor is how you feel. During this time, you can expect your own recall and understanding to be less than optimal because of the stress you are under. It can be helpful to have someone accompany you on your doctor visits-your husband, a grown child or a close friend. They can even take notes or tape record the discussions. You will learn from your doctor that not all breast cancers are the same. Information about your particular condition will usually be gathered by way of a biopsy (a bit of the tumor is removed by a surgeon and studied by a pathologist). Other tests such as blood tests, x-rays, nuclear medicine scans, ultrasounds, CT scan, or MRI (magnetic resonance imaging) can supplement this information. Since you may have several tests done by different specialists, possibly even in different localities, it is important that you have one doctor who coordinates all the information for you. This might be your family doctor, internist, general surgeon who specializes in breast cancer, or a medical oncologist (a doctor who specializes in the medical rather than surgical treatment of cancer). --------------------------------------------- Doctors often refer to the process of assessing cancer as a "staging study." With breast cancer, this means learning: 1. the site of the cancer 2. the size of the tumor 3. whether signs of cancer have spread to underarm lymph nodes 4. whether the cancer has spread to other parts of the body (metastasized) - most commonly to bone, liver or lungs 5. which treatments would be most appropriate 6. your "prognosis" - what you can expect in terms of possible cure or disease-free span of life A reminder: The majority of women with breast cancer will be completely cured. Lymph node studies When breast cancer cells have spread to nearby underarm lymph nodes, the chance that cells have spread into other parts of the body is greater. Knowing how extensively the cancer has invaded the lymph nodes, if it has at all, is important information when deciding on the best course of treatment. Until about ten years ago, doctors usually removed most of the adjacent lymph nodes at the time of mastectomy (removal of the breast) or lumpectomy (removal of the cancerous area only). Sometimes they removed a sample of the closest nodes (we have about 10-15 under each arm). Removing underarm lymph nodes can have unwanted consequences such as painful arm swelling that may be permanent. In addition, studies also suggest that lymph node removal in and of itself does not affect the cure rate. A new way of gathering information about lymph node status has recently become available. Using a blue dye and/or a radioactive tracer, doctors can identify the first node in your underarm that receives lymph node drainage. This is called the "sentinel" node. When this node is free of cancer there is little chance cancer is in any of the other nodes. If there is cancer in this node, the doctor will do further lymph node removal to evaluate the extent that the disease has spread. Hormonal Studies Finding out if either of the female hormones, estrogen or progesterone, has stimulated the cancer growth is a test that can be performed primarily for breast cancer patients. The tissue removed in surgery is tested for 'hormone receptors." In some ways it can be considered good news if your tumor is found to be "hormone receptor positive." That's because you may benefit from a "hormone antagonist," a substance that can be used to treat the cancer by blocking hormone stimulating effects. The most commonly used hormone antagonist is "Tamoxifen" (Nolvadex). Women who have "receptor positive" breast cancers show the highest long-term cure rates. Treatment Choices - Local control Once you have been diagnosed with breast cancer, the next thing to consider is treatment. "Local control" is treatment of the cancer in the breast and the regional lymph system. Surgery or a combination of surgery and radiation usually accomplishes this. Until about 1960, breast cancer was treated by removal of the entire breast and varying amounts of surrounding tissue, an operation called a "radical mastectomy." Now lumpectomy, an equally effective and less radical approach is often used. It involves removal of the lump or mass, along with a small area of surrounding normal tissue. This is followed by radiation treatment aimed at the cancer site and, less intensively, to the rest of the breast. In most cases this produces only minor to moderate cosmetic alteration to the breast. Mastectomy may still be necessary for a woman when there is a large breast mass, when biopsy findings show particular cell types or when there is extreme involvement of the lymph system adjacent to the breasts. There is another type of breast cancer, ductal cancer in situ (DCIS), in which mastectomy is often recommended. It is recommended, not because of the severity of the cancer (it is rarely life - threatening), but because it is diffused through the breast and is resistant to radiation. It is not unusual for doctors to recommend double mastectomy when DCIS is diagnosed. It is sadly ironic that the least threatening form of breast cancer should require such radical treatment. Hopefully new ways of treating DCIS will be found. We should also mention that some women who are not very concerned about breast preservation might decide to choose mastectomy over lumpectomy and radiation. Of course, once a woman understands the implications of her choices, the ultimate decision rests with her. Reconstruction Women having a mastectomy can have breast reconstruction at the time of the mastectomy, or at a later date. The cosmetic result is often superior when done at the time of mastectomy. Usually consultation with a plastic surgeon is recommended before a mastectomy, when reconstruction is being considered. Reconstruction is not recommended at the time of mastectomy for a woman who will have chemotherapy. This is because any problems with healing or infection could delay chemotherapy and that is not advisable. Beyond the breast - Systemic control We all know that cancer cells can spread to other parts of the body and grow there, destroying and displacing normal tissue. This is referred to as metastatic disease. When breast cancer is first detected, there is no way to be absolutely sure it hasn't already spread. But with certain tests, your doctor can tell what the odds are that your cancer will spread. Treating breast cancer that has metastasized to other parts of the body is a separate, complex topic. One important treatment to note is adjuvant therapy. Adjuvant therapy is the use of hormonal or chemical agents throughout the body in an attempt to reduce the possibility of developing metastases. These agents work by killing off tiny deposits of cancer cells that may be in the body. Chemotherapy Chemotherapy involves chemical agents are administered intravenously and kill off fast growing cells. Treatments occur periodically, over a period of months. Unfortunately these chemicals also affect certain normal cells and thus cause unwanted side affects - mouth sores, loss or thinning of hair, nausea and vomiting, fatigue and other symptoms. Once the chemotherapy is complete, the side effects go away. There are also many drugs to aid with side effects and many women find that, most of the time, they can carry on a fairly normal routine. Hormonal Treatment As described above (under "hormonal studies"), your doctor may recommend a hormone antagonist either before or after chemotherapy, or as the only adjuvant treatment. The hormone-like drugs enter a cancer cell and turn it off by interfering with internal messages coming from genes in the cell. These drugs have few side effects, are taken in pill form, and are usually discontinued after five years. Other forms of cancer There are some other forms of breast cancer we have not discussed here. If you have one of these more unusual types, the treatment options described do not apply. In fact, each and every woman with breast cancer has her own, unique situation. What we have described are very general guidelines. What is on the horizon? As you read this, new and exciting methods for early diagnosis and treatments are under investigation. Cancer antibodies are being tested. There are gene products that may be able to target breast cancer cells without harming normal cells. So in the future, there may be treatments that have virtually no side effects and are more effective than anything in our current arsenal. New drugs, which appear to reduce the risk of developing breast cancer, are also being studied. Alternative Treatments We have described traditional, well-tested approaches. If you would like information on alternative therapies, consult with your doctor. You can also obtain information directly from the American Cancer Society, whose headquarters are in Atlanta Georgia, and which has branch offices in many major US cities. You can also contact the Office of Alternative Medicine at the National Cancer Institute, 9000 Rockville Pike, Building 31, Room 5B35, MSC2182, Bethesda, Md., 20892 |
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