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.
The most common genetic test related to breast and ovarian cancer is the BRCA test. This test is performed via a blood or saliva sample, and results become available in about 2 -3 weeks. The test checks for a harmful mutation in the BRCA1 or BRCA2 genes that produces hereditary breast-ovarian cancer syndrome in affected families.
Who should get tested and/or counseled:
- Women diagnosed with breast cancer at less than 50 years of age
- Women with a first degree relative (mother, sister, or daughter) with the BRCA gene have a 50/50 chance of carrying the gene
- Anyone with a diagnosis of multiple breast cancers
- A history of both breast and ovarian cancer
- Anyone with a family history of male breast cancer
- Ashkenazi Jewish ethnicity are also red flags for possible gene mutation.
It’s important to note that the BRCA mutation is rare and accounts for only 5-10% of breast cancer.
Researchers are desperately looking for ways to identify women at increased risk for breast cancer. You may hear the abbreviation GWAS to describe their research. It stands for genome-wide association studies. There are two non-BRCA risk assessment tests currently on the market. They are still considered investigational. Unlike the BRCA test they will probably not be covered by insurance.
BREVAGen and OncoVue are two non-BRCA proprietary genetic tests. They evaluate single nucleotide polymorphisms (SNPs) associated with breast cancer. SNPs are the most common genetic variations. They represent a difference in a single DNA building block. When these individual genetic variations are identified, they are multiplied by a woman’s Gail model risk assessment (a risk assessment tool based on age, menstrual history, family history and history of abnormal biopsy). A personalized risk estimate is discovered. The combined SNPs score has shown to be only modestly better in predicting risk than the Gail model alone, and the cost is significantly higher.
Further research is necessary to determine the usefulness of the SNPs panel for breast cancer risk prediction. The National Comprehensive Cancer Network (NCCN) identifies these limitations of multigene cancer panels:
1) the importance of some variants is unknown,
2) the level of risk associated with most variants is uncertain and
3) risk management for carriers of most of the variants is unclear.
For breast cancer risk assessment the Gail model or other risk models are recommended. To access the Breast Cancer Risk Assessment tool, visit the National Cancer Institute website,.
Can you suck some from here and put it up here? If only I had a dollar for every time I’ve been asked that question. The answer is this: We are getting close! I attended a combined plastic surgery and breast surgical oncology conference in March, where fat grafting was a hot topic.
The Society of Plastic Surgery approves the use of fat grafting to improve the contour of implants after mastectomy. It has not, however, endorsed the use of fat grafting for cosmetic breast augmentation.
In the case of mastectomy, liposuction is used to harvest fat from the abdomen, thighs or flanks. The fat is then processed using a centrifuge. The pure fat cells are injected to fill any hollows around the breast implant. (For all you willing donors, at this time, fat cannot be donated from one person to another.)
Fat transfer is not approved for cosmetic breast augmentation mainly because we don’t know if the fat cells could tip a woman’s breast cells from the normal state to a cancer inducing state. There are female hormones and natural occurring chemicals in the fat that might induce or speed up the development of breast cancer. There is no data that clearly proves or disproves this. Fat grafting can also affect mammography. Injected fat can cause cysts and calcifications, potentially contributing to false-positive results. This could result in unnecessary anxiety, further testing and even biopsies.
Existing evidence suggests that fat grafting does not increase the risk of breast cancer recurrence in women post-mastectomy (most all the breast tissue is removed). In women postmastectomy and post- breast reconstruction, fat grafting is particularly effective for increasing volume, contour and fullness in the cleavage area. Several fat grafting sessions may be necessary for optimal results.
Many women are told that they have fibrocystic breasts. This is a “waste basket” term used to describe a wide variety of vague conditions. “Fibrocystic disease” or “fibrocystic change” are terms used to label women with lumpy, tender breasts. It is estimated that 40 to 90% of women have some evidence of fibrocystic condition.
Fibrocystic condition refers to tenderness, enlargement and waxing and waning of lumpiness related to the menstrual cycle. One to three tablespoons of fluid may enter the breast premenstrually readying the breast for possible pregnancy. If pregnancy does not occur the fluid is absorbed. The pain associated with fibrocystic breasts may range from mildly annoying to extremely painful and may vary in severity from month-to-month.
Most important in the treatment of fibrocystic breast condition is reassurance that any associated pain is due to the breast’s response to normal fluctuations of hormones. Contrary to popular myth, there is no evidence that coffee or chocolate increase fibrocystic symptoms so you may enjoy without guilt.
What can you do for relief?
1. Reduce salt intake as this may limit the fluid retention.
2. Wear a comfortable, supportive bra–overnight as well, if it relieves symptoms.
3. Take ibuprofen or acetaminophen for pain relief, and apply heat.
Most important, though fibrocystic breasts are sometimes a nuisance, this condition does not increase your risk for breast cancer.
Last week we talked about what’s normal when it comes to nipples. This week, I thought I’d share some information about the rest of the breast—how it’s constructed and how that can translate into a wide range of breast variations.
The breast is made up of tissue and fat. Breast tissue is white and rubbery (kind of like cooked lobster) and the fat is just like the fat you peel off a chicken breast. The breast becomes more fatty as you age.
Breast tissue is made up of ducts and lobules. A cartoon illustration of the breast might look like several bunches of grapes with the big stem going out to the nipple for breast-feeding and all the little stems going back to the grapes which are the lobules where milk is formed. Of course, in reality it’s a whole lot smaller than a bunch of grapes; the duct and lobule system can only be seen under a microscope.
The breast sits in an envelope of skin, which is part of the integumentary (skin) organ system. So issues involving the skin overlying the breast, like sebaceous cysts, freckles, moles, etc. are not breast issues, they are skin issues.
Infections of the breast, and rarely some breast cancer, may manifest in this overlying skin envelope.
Underneath, the breast is attached to the skin, sort of like sod to the underlying ground. It is not a clear separation, which is why even with a mastectomy some breast tissue will always remain
Breast tissue usually feels firm with a lumpy surface like an expensive cultured carpet with skin and soft fat overlying it. At one extreme, and this is rare, a woman’s breast tissue can feel like a bag of marbles and on the other end of the spectrum, some breasts feel like a foam pillow. Most breasts lie somewhere in between, and all are normal.
The nipples, also known as the nipple areola complex, include the part that sticks out as well as the flat ring of colored skin surrounding it. Because they are not generally exposed—many women aren’t aware of how much this part of our anatomy can vary from one woman to the next.
Color and size: Nipples range widely in color from the palest pink to dark brown, and it’s normal for nipples to darken after childbirth. The whole complex can range in diameter from as small as one inch to four inches in women with larger breasts
Shape: When we’re born, nipples are flat. Over time, the whole complex gets softly pushed out by breast tissue. Nipples may be inverted from birth (think: “inny” belly button) or one or both may gradually invert due to duct ectasia (dilated central ducts). If this happens, they can usually be everted with gentle pressure. If your nipple is newly inverted on one side only, it is good to get it checked out, only because in rare instances this can be related to a cancer pulling it in. Normal nipples may stick out a little bit or be long enough to “hang”. They get longer with childbirth and breastfeeding. If you are uncomfortable with the way your nipples look beneath your clothing, a padded bra or strategically placed Band-Aid will help.
Texture: The multiple bumps on the areola are completely normal. They are called Montgomery glands. These glands secrete an oily substance that keeps the skin soft. They can get infected, so it’s important not to pick at them. Occasionally a nipple duct will get blocked and it will look like a whitehead on the tip of your nipple. Once again avoid the temptation to squeeze. Warm compresses might encourage it to resolve, but it will go away on its own.
Irritation: We’re just getting out of the “itchy nipple” season. This is a common complaint in winter when women take long hot showers. I recommend applying a generous amount of Vaseline-like ointment with a nursing pad to protect your bra and clothes.
If you experience a dry crustiness of the nipple, it may be eczema—and a Vaseline like ointment—with or without steroid—can help. This can also be a symptom of Paget’s disease, but it is extremely rare. As always, if something feels abnormal and does not get better in a few weeks, see your doctor.
If you’re in the Montclair area, and we can be of help, please don’t hesitate to call.