Breast Cancer

Breast cancer is the most common cancer in women, affecting one in eight women in their lifetime. Fortunately, it is usually fully treatable for a cure. Surgery is usually required as a major part of treatment, and having an experienced and expert  Surgeon is vitally important to ensure the best care and outcome.  Other treatments are often necessary including radiation, anti-hormonal medication, and chemotherapy depending on the type and extent of disease.  The goal of treatment is to have a patient become cancer free with the best possible cosmetic results and the minimum lifestyle impairment.

What is breast cancer?

Breast cancer (also called carcinoma) occurs when normal breast tissue changes into a tumor that can grow and spread in an uncontrolled way.  This cancerous tissue can grow on the lining of milk ducts (intraductal or in-situ cancer), or spread through the breast tissue (invasive breast cancer).  Sometimes both can be present.  Breast cancer usually arises from the milk ducts (ductal cancer) 90% of the time, and from the lobules (lobular cancer) 10% of the time.  Common types of breast cancer are DCIS (ductal carcinoma in-situ), invasive ductal carcinoma, and invasive lobular cancer. All three of these types typically require surgery and other treatments to be cured.  A fourth type, LCIS (lobular carcinoma in-situ) does not usually need surgery when it is present by itself.  Instead, it is thought to be a marker of a patient’s high risk of developing an invasive breast cancer in the future.

Breast cancer (both ductal and lobular) requires full removal of the breast with surgery, as well as other treatments to be cured.  Invasive cancer is thought to be more dangerous than in-situ cancer as it can spread (metastasize) to surrounding lymph nodes or distant organs rather than grow just within the breast.

Breast cancer is also tested to determine specific genetic markers or receptors (places on the cell surface where hormones attach) that help determine how it will behave and how to treat it.  Estrogen and progesterone are female hormones that are normally produced in the body to regulate the menstrual cycle and help control the reproductive organs.  Cancers that are positive for estrogen or progesterone receptors usually behave better and are easier to treat than those that don’t have these receptors. The HER-2 receptor is also very important.  Cancers that have this receptor are usually more aggressive in behavior.  Until recently, these cancers were much harder to treat.  But new medicines (Herceptin and Perjeta) have been developed to specifically attack and destroy these cancers. These are given with other medicines as the first step in treating these “HER-2 positive” types. When none of these three receptors are present, the cancer is known as “Triple-negative”.  This type of breast cancer is particularly dangerous, and usually, requires all treatment modalities to be cured.

Risk factors for breast cancer

Anyone can develop breast cancer, but certain factors will increase a person’s risk.  Women are at much higher risk than men. Family history is the most common risk factor, with breast cancer in an immediate relative (parent or sibling)  doubling a woman’s risk of developing the disease herself.  More distant relatives (grandparents, aunts, cousins) also increase the risk to a lesser extent.

About 1% of women who develop breast cancer will have a specific increased risk factor known as a genetic mutation called BRCA1 or BRCA2. These are deletions or “errors” in a person’s DNA that are passed from parent to child, and predispose a person to develop breast cancer. The increased risk is so high in fact, that most women that carry one of these gene mutations are advised to have their breast tissue removed prophylactically before cancer has a chance to develop. Most men with breast cancer are carriers of the BRCA2 gene.  These mutations also increase the risk of other cancers such as ovarian and prostate. Your doctor will advise you as to whether you should be tested for these gene mutations, and the several others that can increase a patient’s risk.

Increasing age is also an important risk factor, as the development of new breast cancer increases in a woman’s 50’s and 60’s.  High breast density may increase risk as it makes it harder to detect breast cancer with physical exams and mammograms.

Other risk factors are related to the amount and duration of estrogen being present in a woman’s bloodstream over the course of her life. This is because high estrogen levels over many years tend to increase breast cancer risk. These include:

• Beginning menstruation before age 12
• Entering menopause after age 50
• Not having children or having a first pregnancy late in life
• Avoiding breastfeeding
• Obesity
• Heavy alcohol consumption
• Estrogen replacement therapy (in some patients)

Symptoms of breast cancer

The most well-known sign of breast cancer is a lump in the breast. However, it is not the only sign and not all lumps are breast cancer. A thickening or progressive firmness of an area of the breast may indicate growing cancer. Some women may experience changes in the appearance of their breasts, such as inverted nipples or indentation of the skin. A fluid that is bloodstained may discharge from the nipple. The affected area of the breast may have a different texture or color. Monthly self-exams can keep you familiar with your breasts and more likely to spot changes early.  Routine physician exams are also an important part of the screening. Any suspicious physical change in the breast should lead to further measures to diagnose possible cancer.

Diagnosing breast cancer

Breast cancer is often first diagnosed through regular Mammograms.  Official recommendations for when to begin mammograms vary depending on a woman’s risk factors, but they should usually begin with routine screening between age 40 and 50.  Mammograms detect breast cancer by looking for concerning patterns of density or suspicious calcium deposits. Early breast cancer such as DCIS, or precancerous tissue (atypia), is best detected with mammography. Ultrasound is used to look closer at areas of concern, and help in performing a needle biopsy (sampling a small area of tissue) to confirm cancer is present. Breast MRI is another way of looking at the breast, and is very good at finding a small invasive cancer, but not very sensitive for finding in-situ ones.  Depending on the situation, all three types of imaging tests may be used. A preliminary needle biopsy is almost always necessary to confirm the presence and type of cancer before proceeding with surgery or other treatments.  For patients at risk for metastatic spread, a PET/CT scan can help find areas of cancer not directly connected with the breast or surrounding lymph nodes.

Stages of breast cancer

Breast cancer is typically divided into stages based on how advanced it is.  In general terms, the stages are:

• Stage 0. Cancer that is detected early, usually in-situ.

• Stage I. This is small early invasive cancer, not involving lymph nodes.

• Stage II. The invasive cancer is larger and may have spread to a few lymph nodes

• Stage III. These cancers may be larger and have more extensive lymph node spread.

• Stage IV. Tumors are considered metastatic and have spread beyond the breast and lymph nodes to other organs such as bone, liver, lungs or brain.

Breast cancer treatment

Breast cancer is treated specifically to each patient’s situation, taking into account the tumor type, size, location, and possible spread into lymph nodes.  In each case, every effort is made to provide the very best cosmetic results while still fully treating the cancer. Some very small tumors can be cured with surgery alone, removing the area completely with a lumpectomy. Radiation is added after most lumpectomies to reduce the risk of cancer recurrence in the breast. One or more lymph nodes are usually sampled during surgery to determine if cancer has spread, with the aid of an injected tracer dye, known as a sentinel lymph node biopsy.  For cancers that are high risk or have positive lymph nodes, chemotherapy is given to reduce the chance of recurrence at a distant site (metastasis). Some cancers are too large or spread out to be removed with a lumpectomy.  Removal of the breast tissue completely (mastectomy) is used in these cases.  Often the breast surgeon will work with a plastic surgeon to restore a normal appearance (breast reconstruction), and many times this can be done preserving completely the nipple and areola.  In these situations, the surgery can be barely detectable after recovery.  Another option for large cancers is to give chemotherapy first, before surgery. This will shrink the tumor and allow for a smaller surgery at a later time.  For HER-2 positive and Triple negative cancers, chemotherapy is particularly important.  A medication to block or reduce estrogen is given to patients with cancer positive for this receptor. These are administered as a daily pill and are very effective at preventing cancer from recurring.

An experienced and skilled Breast Surgeon is important at every step in diagnosis and treatment of breast cancer. More than just operating, this physician is best suited to guide a patient through all the diagnosis and treatment decisions needed to become and remain cancer free. Proper selection and timing of surgical and medical treatment options is essential to achieve the best results. Optimal care should always focus on achieving the best possible chance for cure, AND the best possible cosmetic results. Additionally, expert surgical techniques by an experienced Surgeon makes an incalculable difference in becoming cancer free with the minimum noticeable changes.