Management of Breast Cancer
Breast cancer is the most common cancer in women, representing one-third of all
new cancer diagnoses in women in the United States annually (213,000 cases).
Fortunately, earlier diagnosis and a better understanding of the disease leading
to more effective, targeted therapies have led to a continued improvement in
prognosis and outcome.
In the next few weeks, you will be faced with
the impact of this diagnosis and have to maneuver
through an increasingly complex medical system
for tests, consultations, surgery and other therapies.
The following is a break down the steps involved
in this process and familiarize you with the
options in management.
If there has not been a recent mammogram at the
time of breast cancer diagnosis (within six
months), one should be ordered.
It is important to know whether multiple areas
of the breast are involved with tumor (multifocality
or multicentricity) and to screen the opposite
breast for tumors undetectable by traditional
imaging (mammograms or ultrasounds). Magnetic
Resonance Imaging (MRI) scanning of both breasts
may be recommended, especially in younger women
with dense breasts or in women whose cancers
were not detected by mammography.
Clinical staging of breast cancer involves an
assessment of the size of the tumor and whether
or not lymph glands under the arm (axilla)
appear to be involved. It is difficult for
doctors to accurately assess node involvement
on the basis of a physical examination or non-invasive
testing. For that reason, initial preoperative
clinical staging is considered preliminary.
Final pathologic staging occurs after surgical
results are available. Surgery results may
change the initial clinical stage.
The majority of patients present with early
stage breast cancer. Staging of breast cancer
is as follows:
Tumors less than
2 cm (~ 1 inch) without involved nodes
Tumors less than
2 cm with involved nodes
Tumors between 2-5 cm. with or without
Tumors greater than 5 cm. without involved
Tumors greater than
5 cm. with involved nodes
Tumors that are locally advanced (e.g.
involvement of the skin
Tumors with many involved nodes
that have spread outside the region of
It is unusual for breast cancer to have already
spread at the time of the initial diagnosis.
However, after the diagnosis of breast cancer
has been made, it is important to determine this.
X-rays and blood tests are typically ordered.
Not all patients require all these tests. Your
doctor’s assessment of how early or advanced
the tumor is and whether or not symptoms are
present will determine the need for various studies.
Common tests ordered include a chest
blood studies to include an assessment of liver
function, bone scan, CT
scans and PET
If abnormalities are found on initial testing,
further testing may be needed.
Breast cancer treatment is generally classified
into local therapy and systemic therapy. Local
therapy is what is done to the breast. Surgery
and radiation therapy are examples of local therapy.
Systemic therapy affects the whole body. In early,
potentially curable breast cancer, systemic therapy
reduces the likelihood that the tumor will come
back in other parts of the body. Decisions about
local and systemic therapy are separate.
Surgical treatment options
Most patients have a choice between breast-conserving
therapy and mastectomy. Breast-conserving therapy
consists of a lumpectomy with tumor-free surgical
margins, an assessment of the axillary lymph
nodes (see separate sheet on sentinel node
biopsy) followed by radiation therapy. In order
to be a good candidate for this form of breast
cancer treatment, there must be a single tumor
within the breast measuring less than 5 cm.
tumors need to be treated with mastectomy.
Also, the margins of tumor excision must be
tumor-free. If tumor is persistently present
at the surgical margins despite re-excision(s),
mastectomy is the recommended option. Women
that cannot undergo radiation therapy (e.g.,
pregnancy, prior radiation at the same site),
also need a mastectomy.
Lumpectomy with sentinel node biopsy or axillary
dissection is done under general anesthesia as
an outpatient. Complications are rare but include
bleeding, infection, allergic reactions to sentinel
node mapping agents. Arm swelling (lymphedema)
may be seen in 2-3 percent of patients undergoing
sentinel node biopsy and 10-15 percent of those
undergoing axillary dissection. Arm stiffness
and numbness can occasionally be seen. Recuperation
is generally 2-3 weeks.
If the final pathology shows tumor-involvement
of the surgical margins, additional operations
may be necessary to take more tissue out of the
breast. If the sentinel node is unexpectedly
found to be involved, an axillary dissection
at a later date may also be needed.
therapy is an integral part of this
treatment. It reduces local recurrence rates
by 50-75 percent. Lumpectomy alone is associated
with a 30-50 percent chance that the tumor may
come back in the treated breast (local recurrence).
With the addition of radiation therapy, that
rate is lowered to 10 percent. If a local recurrence
happens after lumpectomy and radiation therapy,
a mastectomy is needed because the tissue cannot
be radiated again.
Mastectomy is the operation that removes the
breast including the nipple-areolar complex.
The chest wall muscles are not removed. Some
lymph nodes are by necessity removed during this
operation as there is an overlap region between
the breast tissue and the lymphatic tissue near
the underarm region. Assessment of the axillary
nodes is the same as with breast-conserving therapy
(see sentinel node biopsy information sheet).
Some patients require mastectomy for medical
reasons (see above). Others may prefer a mastectomy.
Occasionally, a prophylactic mastectomy of the
uninvolved breast is recommended, especially
in cases where a significantly positive family
history is present.
Mastectomy can be done with or without an immediate
reconstruction. If mastectomy is done for local
recurrence following radiation therapy, the reconstructive
options are more limited.
Generally, with the option of mastectomy, radiation
therapy is not needed. However, there are circumstances
where post-mastectomy radiation is recommended.
These include tumors that are large (greater
than 5 cm.) or locally advanced, involvement
of more than four axillary nodes, or direct extension
of the tumor to the chest wall. The need for
post-mastectomy radiation will affect the reconstructive
Mastectomy with or without reconstruction is
done under general anesthesia as an inpatient.
The length of stay in the hospital is 1-2 days
for a mastectomy alone or with a simple reconstruction.
More complicated reconstructions result in a
5-7 day hospital stay. Recuperation is from 4-8
Complications following mastectomy are unusual.
Significant bleeding is uncommon, even with complicated
reconstructions. Transfusions are rarely needed.
Infection or tissue loss can occur but are uncommonly
seen. The risk of lymphedema is related to the
extent of axillary surgery. With a sentinel node
alone, the risk of arm swelling is 2-3%. With
an axillary dissection, the risk is 10-15 percent.
Arm stiffness can occur but responds well to
exercises (see sheet) and physical therapy. Other
rarer complications can occur, as with any surgical
Radiation therapy as part of breast-conserving
therapy traditionally involves treatment of
the whole breast, a process that takes six
weeks. A boost to the primary site may be given
at the end. Radiation starts 2-4 weeks following
surgery. However, if chemotherapy is needed,
that comes first after surgery and radiation
would follow 2-4 weeks after completion of
In selected cases, partial breast radiotherapy
can be given. These are usually early, favorable
tumors that have a low risk of being multifocal
and a low risk of recurrence. Partial breast
radiotherapy can be delivered by placement of
a MammositeÒ balloon. This device is placed
into the lumpectomy site in the operating room
or the surgeon’s office. The device has
two exiting ports, one for inflation and deflation
of the balloon, and one that attaches to the
radiation unit. Radiation is delivered through
the catheter in two sessions daily six hours
apart for one week. Once radiation is completed,
the catheter and balloon are removed. This type
of radiotherapy would be given shortly after
the lumpectomy, before chemotherapy, as opposed
to external beam whole breast radiation which
is generally given after chemotherapy.
Adjuvant systemic therapy
Systemic therapy involves chemotherapy and/or
hormonal therapy. Decisions about the need
for adjuvant systemic therapy depend on the
likelihood of recurrence of the tumor. This
is assessed by the size of the tumor, involvement
of the axillary nodes, presence or absence
of hormone receptors or her2neu, and other
factors. In hormonally-responsive tumors, when
the benefit of chemotherapy is not clear-cut,
tumors may be sent out for further testing
to look at the gene profile of the individual
tumor. This test is called Oncotype DX . It
looks at a 21-gene panel and assesses the likelihood
of tumor recurrence on the basis of those genes.
Tumors that are at low risk for recurrence
can be treated with hormonal agents alone.
Those that are at intermediate or high risk
should get chemotherapy followed by hormonal
Chemotherapy for breast cancer usually involves
a combination of drugs, generally given intravenously
every 2-3 weeks for 4-8 cycles. If the tumor
is positive for her2neu, a targeted drug called
Herceptin will be recommended and that is given
for one year.
Most breast tumors have receptors for estrogen
and progesterone. When these receptors are present,
medications that block either the receptor itself
(e.g. Tamoxifen) or the production of estrogen
(aromatase-inhibitors, e.g. Arimidex) are recommended.
Aromatase-inhibitors are only effective in post-menopausal
women. The use of these drugs not only reduces
the chance of recurrence of the original tumor,
but also reduces the likelihood of developing
another breast cancer in either breast. These
drugs are given orally for five years.
Breast cancer treatment team
You will need to be seen by various specialists
in the treatment of breast cancer. These include
the breast surgeon, medical oncologist, radiation
oncologist, and plastic surgeon (if mastectomy
is being done). Genetic counseling may be recommended
in cases where a significant family history
of breast and ovarian cancer is present. Supportive
care services are provided by the Joan Karnell
You may wish to get more than one opinion about
your treatment options. This is commonly done
in cases of breast cancer. Breast cancer is rarely
an emergency. You have time to research your
disease and get all the information necessary
to make informed choices. You may decide to have
individual members of your breast cancer treatment
team at different institutions. It is important
to feel comfortable with your providers, as you
will need to be followed lifelong.
A Message from the Integrated Breast Center
This is a difficult time for patients newly diagnosed
with breast cancer. Keep in mind, however, that
great strides have been made and continue to
be made in the struggle against this disease.
The majority of patients with breast cancer have
an excellent prognosis. Every year, new drugs
and therapies become available that will further
improve outcome. There is every reason to be