Inflammatory breast cancer accounts for 1-5% of breast cancer. It is characterized by rapid development of redness, warmth and swelling often without a lump. This can occur over a few weeks or months and is often mistaken for an infection.
99% of the time, if you have a swollen, red, painful breast a few days of antibiotics will treat your infection. However, if your breast does not quickly return to normal see a breast specialist to check for this rare but serious type of breast cancer.
In the case of inflammatory breast cancer, skin changes are due to cancer cells clogging the lymphatic vessels of the skin, which causes the skin to become thickened like an orange peel (peau d’orange).
This type of cancer is considered locally advanced. It is stage 3 or 4 at presentation. The first treatment is systemic chemotherapy, usually followed by mastectomy and radiation.
Although this type of breast cancer is rare, I saw two women with inflammatory breast cancer this week. Inflammatory breast cancer is more common in African-American women, and the average age at presentation is five years earlier than for other types of breast cancer (mid 50′s compared to early 60′s).
This aggressive form of breast cancer has seen a marked improvement in overall survival since the advent of trimodality treatment (chemotherapy, radiation and surgery). So make sure to see your breast specialist right away if you are concerned you may be experiencing any of these symptoms.
In June 1990, the National Cancer Institute Consensus Conference concluded that breast preservation (partial mastectomy or lumpectomy plus radiation) is the preferred treatment for the majority of women with Stage I and II breast cancer. This method of treatment is equal to mastectomy in survival and recurrence risk, while preserving the breast.
Women I counsel often think that more “drastic” surgery is better and that removing the entire breast will decrease the risk of the cancer coming back. The risk of recurrence after mastectomy is 6% equal to the risk after lumpectomy plus radiation (also 6%).
It amazes me that 20+ years later, mastectomy and even bilateral mastectomies are still commonly being performed on women who could be treated equally as well with breast preservation.
It is the surgeon’s obligation to carefully explain the options for treatment and dissuade a woman if she thinks more radical surgery is better.
A recent study has linked birth control pills to an increased risk of breast cancer. (Cancer Research August 1, 2014) This concern is not new. Previous studies have reported this, while other studies have not supported the link.
The study includes 23,052 women between ages 20 and 49, 1102 of whom were diagnosed with breast cancer. Women on high-dose estrogen pills (sold as Continuin or Femulen) and moderate-dose pills (sold as Ortho 75) were 2.7 and 1.6 times more likely to develop breast cancer. Those on low-estrogen pills had no increased risk.
Before you toss your pills please consider:
- The high-dose pills are rarely prescribed. There is no increased risk with low-dose pills.
- The elevated risk was only seen in women who had taken high and moderate-dose pills within one year. Their risk returned to normal one year after stopping birth control pills.
- Breast cancer is really rare. A women’s risk of developing breast cancer at 40 is 1.5% and only 2.38% at age 50. Increasing those numbers by a factor of 1.6-2.7 causes only a slight increase in overall risk.
- Elisabeth Bieber, the study’s author, and a scientist at the Fred Hutchinson Cancer Research Center, said the findings are not significant enough to recommend that you should change your prescription if you are on a high-dose pill.
- The pill has cancer-fighting effects. It’s been shown to slightly decrease a women’s risk of ovarian and endometrial cancer.
- Finally, all medicines carry a risk, even Aspirin! For the vast majority of women the benefit of the pill far outweighs any risk.
The most common and well-known hormonal therapy is Tamoxifen. Tamoxifen is an anti-estrogen treatment that is used in postmenopausal women with estrogen positive breast cancer. Tamoxifen treats the cancer you have and reduces your risk of getting cancer in the opposite breast by 50% (from 15 – 20% down to 7.5 – 10%). The side effects are milder than those of chemotherapy. The most common are hot flashes and muscle aches. Premature menopause is the most common long-term side effect. Other rare side effects are blood clots and uterine cancer.
Another anti-estrogen hormonal therapy now being used in women over the age of 50 (or postmenopausal) are Aromatase Inhibitors (AI’s). There are three AI’s that are used to block estrogen production from postmenopausal ovaries and adrenals. Some of the side effects associated with AI’s are similar to those of Tamoxifen. AI’s have a decreased risk of endometrial cancer related to Tamoxifen but are may lead to some joint pain. Switching from one AI to another will often lessen these symptoms if they do occur.
Hormonal therapy treatment is recommended following surgery, chemotherapy and radiation. Administration of hormonal therapy is taken in pill form, once a day, usually for the span of five years.
Here’s how chemotherapy works: Chemotherapy drugs interfere with the process of cancer cell division or reproduction. Often more than one drug is used to attack the cells at different points in the process. Unfortunately the drugs act on all cells that are rapidly dividing–not just cancer cells. This is why hair cells are affected during chemotherapy, leading to hair loss. (Just think of it as the chemotherapy doing what it is supposed to do.)
Bone marrow cells which produce red blood cells, white blood cells, and platelets, are also affected. For this reason chemotherapy is given with a time lapse in between doses, so the bone marrow can recover.
Seven drugs are commonly given as adjuvant treatment for breast cancer:
- Cyclophosphamide (Cytoxan) (C)
- Methotrexate (M)
- 5-fluorouracil (F)
- Doxorubicin (Adriamycin) (A); and
- Paclotaxel (Taxol) or docetaxel (Taxotere) (T)
These are usually given in combinations CMF or AC, followed by T.
Nausea and vomiting is a side effect in about 20% of women who get CMF and more of women who get AC. There are many drugs to prevent and treat the symptoms. Nobody should have to suffer.
Premature menopause is more common with CMF than AC. 15 – 35% of women younger than 40 and 60 – 90% of women over 40 will become menopausal.
Women who receive Adriamycin as part of their treatment will lose their hair, usually within 2 – 4 weeks. Women who receive CMF usually have gradual hair loss that is often mild and they may never need a wig.
Doxorubicin (Adriamycin) (A) can be toxic to the heart. However, this is rare. Taxol and Taxotere can cause a reversible neuropathy (pins and needles sensation) of the hands and feet.
It is important to be aware of possible side effects. It is equally important not to assume you will have all or any adverse reactions. Remember that if chemotherapy is needed the benefit in terms of survival outweighs any risks or side effects.
As always, let us know if you have questions or concerns we can help you with.
Invariably, in my early discussions with a woman newly diagnosed with breast cancer she’ll declare “I do not want chemotherapy!” or “Will I need to lose my hair?”
Chemotherapy gets a bad rap, but it happens to be one of the most powerful weapons against cancer. “Chemotherapy” literally means a chemical used to treat disease.
Systemic therapy used to treat breast cancer includes chemotherapy, hormone therapy and targeted therapy. Systemic therapies have the ability to affect the whole body, not just the breast.
Chemotherapy is the most important element of treatment, because it deals with the life-threatening aspect of cancer. Women do not get sick or die of breast cancer in the breast but of cells that spread elsewhere, commonly to the lung, liver, brain or bones.
Adjuvant systemic therapy is given at the time of initial diagnosis, when there is no evidence of metastatic disease. It is given after surgery and goes in every nook and cranny of the body to kill or disable any cancer cells that might escape the body’s immune system. These unchecked cancer cells could multiply and become life-threatening.
Neoadjuvant chemotherapy, is the term used when chemotherapy is the first treatment a woman receives after her diagnosis of breast cancer. If a woman’s tumor is larger than 3 cm, chemotherapy may be given before surgery. There is no survival advantage or disadvantage to getting chemotherapy first. However, this upfront systemic therapy has been shown to cause an 80% decrease in tumor size and in one third of women their tumors disappeared completely. Preoperative chemotherapy often allows women who would have needed a mastectomy to have a lumpectomy.
3-D mammography or tomosynthesis, is a test that takes many x-rays at different angles and creates a three-dimensional image of the breast. The procedure is nearly the same as a routine mammogram except that in mammography the machine is stationary, while in tomosynthesis it moves around the compressed breast.
A study was just reported in the New England Journal of Medicine (June 2014) and headlined in the New York Times (June 24,2014). It is retrospective (previous records were looked at rather than randomizing women to compare screening). The study compares tomosynthesis + mammogram to mammogram alone. 454,850 exams were evaluated from 13 centers (281,187 digital mammograms and 173,663 digital mammograms + tomosynthesis.)
For every 1000 women:
•Tomosynthesis improved cancer detection. 5.4 cancers were detected compared to 4.2 for mammogram alone.
•Adding tomosynthesis lowered “callback” rates. 107 women were called back per 1000 with mammography alone and 91 when tomosynthesis was added.
•Tomosynthesis + mammography resulted in more biopsies, 19.3 per 1000 scans compared to 18.1 if mammogram alone was used.
•More of the biopsies in the combined exam group did show cancer 29.2%, compared to 24.2% in the mammogram alone group.
Facts to consider before running out for your 3-D exam:
1) There are only 1100 mammography units in the country that can perform tomosynthesis.
2) The units are very expensive, so not all communities can afford one.
3) Insurance may not cover the extra cost and many clinics charge a fee.
4)Tomosynthesis uses more radiation than mammography, however, the amount is still low and considered safe.
5) Very important, there is no evidence regarding whether or not this technology will save lives. Mammography is the only test (not MRI, ultrasound or thermogram) proven to increase survival from breast cancer. The experts call tomosynthesis “extremely promising” however more research is needed.
6) Finally 3-D mammography is only as good as the radiologist reading the exam. If you decide to have tomosynthesis, you want to go to an experienced clinic. Two of the 13 centers in the study showed a lower detection rate and increased “callback”rate. This was felt to be due to inexperience.
As I discussed last week, the stage at the time of diagnosis is very important in deciding whether a woman will benefit from chemotherapy. Women with early-stage, estrogen-receptor-positive cancer now have the Oncotype DX test to further assist in guiding their treatment decisions.
Performed on a small sample of tumor tissue, the Oncotype DX test (developed by Genomic Health) measures the activity of 21 different genes to determine how a tumor is behaving. The report generated from the test provides a Recurrence Score between 0 and 100. Women with a lower Recurrence Score have a lower risk that their cancer will recur and are less likely to benefit from chemotherapy. Women with a higher Recurrence Score have a greater chance that their cancer will return, and they may gain a larger benefit from chemotherapy.
There have been exciting advances in breast cancer treatment during my tenure. Breast preservation and sentinel node biopsy are the most prominent; Oncotype DX is the latest. It allows women with larger tumors and a low score to avoid unnecessary chemotherapy that previously would have been recommended. Conversely, women with higher scores can take comfort that they are getting a benefit from chemotherapy.
Prior to the widespread acceptance of the Oncotype DX test, women with small tumors may not have received potentially life saving chemotherapy. Now a high Recurrence Score would indicate not only an increased risk of recurrence but also a benefit of chemotherapy despite a small tumor size.
Women diagnosed with breast cancer are very interested to know their stage. Staging is important in that it helps predict survival and guides women with decisions regarding the benefit of chemotherapy. Most women are diagnosed at an early stage and our plan for them is cure. Five-year survival ranges from 100% for stages 0 and I to 93% for stage II.
STAGE 0: Cancer cells are seen but are confined to the milk duct and therefore cannot spread.
STAGE I: Cancer can measure up to 2 cm and cannot have spread to any lymph nodes.
STAGE II: Cancer measures from 2 – 5 cm, and 1- 3 lymph nodes may be involved with breast cancer.
STAGE III: Breast cancer is considered locally advanced. It may measure greater than 5 cm and more than four lymph nodes may be involved. The breast cancer may be growing into the chest wall or into the skin. The five year survival is still 72% with careful treatment.
STAGE IV: Cancer has metastasized elsewhere in the body. Usually to the bone, lung, liver or brain. It is no longer considered curable. However, women may live several years.
Microcalcifications are a very common finding on routine mammography. We pay attention to them when there are five, ten or thirty of them large enough to cover up with a dime or quarter. This is called a cluster. They may be round, branching, or look like tiny arrowheads.
The calcium flecks themselves are harmless. The question is “why are they forming?” Approximately 90% of the time biopsy of these calcifications reveals one of many benign causes. However approximately 7% of women are found to have DCIS (stage 0) and 3% a tiny (stage 1) breast cancer. Finding these little red flags is a main reason why we do mammography.
These specks look like grains of salt on the mammogram and cannot be felt. The only way to biopsy them is with a mammogram guided biopsy called a stereotactic core biopsy.
If the calcifications reflect a benign process they do not have to be completely removed. There is nothing a woman does such as drinking milk, taking calcium supplements or antacids that causes calcifications. Macrocalcifications are even more common. They look like a large white dot on the mammogram and are invariably benign.
This week I am treating two women diagnosed with 2 mm and 3 mm cancers respectively related to microcalcifications seen on their routine mammograms. They will be cured with very little treatment necessary.
If you are found to have calcifications I feel your radiologist should either tell you they are benign and to return to yearly mammography or recommend a biopsy. A six-month follow-up mammogram doesn’t really help, as calcifications that increase, decrease or stay the same can all be problematic. That being said, because they represent a very early or benign process, scheduling of a biopsy is not urgent.