CLICK HERE FOR INFO! Cartersville Surgical Associates, PC 970 Joe Frank Harris Parkway Cartersville, GA 30120 Phone: 770.386.1261 Fax: 770.386.3873 Breast Cancer What is Breast Cancer? Breast cancer is a process in which malignant (cancerous) cells form in the tissue of the breast. Breast cancer is the second most common malignancy identified in women, with only skin cancer being more common. One in eight women in America will be diagnosed with breast cancer at some point in their life. There are two common types of breast cancer. The most common is ductal carcinoma, a conditgion in which the cells of the ductal system of the breast become cancerous. The second most common type of cancer is lobular carcinoma, which arises from the lobules or milk producing glands of the breast. Lobular carcinoma has a greater risk of involving both breasts than does ductal carcinoma. Ductal carcinoma in situ (DCIS) is a precancerous condition of the breast in which the ductal cells are abnormal but have not spread beyond the ductal system. Lobular carcinoma in situ (LCIS) is a precancerous condition of the lobular cells in which the abnormal cells are likewise confined to the lobular component of the breast. It is estimated that 211,240 new cases of breast cancer will be identified in 2005, and there will be 40,140 breast cancer related deaths. Breast cancer death rates may be decreased with the use of screening mammography. By appropriate screening, breast cancers may be identified earlier, and therefore at an earlier stage. The early breast cancers are identified, the better the chances of survival. Many factors influence treatment and outcome. These factors include age and menopausal status of the patient, stage of disease, histologic factors of the primary tumor, hormonal receptor status, and genetic factors. Patient evaluation of breast masses and abnormal mammograms All women with palpable masses (lumps) or abnormal mammograms need further evaluation. For a woman with a masses in her breast, the first step is a physical exam by an experienced practitioner. A mammogram is also an essential component of the workup and will usually be done prior to any biopsy to minimize the chance of a false reading on mammography. Ultrasonography may also be utilized and is very helpful in delineating solid versus cystic masses. If the lump is a cyst, the chance of the lump being a cancer is very small. Ultrasonography will also aid in differentiating benign solid tumors from cancers. If the lump is difficult to feel on exam, your surgeon may elect to perform an ultrasound directed biopsy. This type of biopsy can be done in the office under local anesthesia. For women who are found to have an abnormal screening mammogram, additional diagnostic views of the breast are often performed to help the radiologist better evaluate the abnormality. At times, the patient may have these studies done at the time of the initial screening, while at other times, patients may be contacted after the radiologist reviews the films and decides that additional films are needed for complete evaluation. If no mass is palpable, and the mammogram is suspicious, a needle localization biopsy or stereotactic biopsy may be performed. These types of biopsies are radiographically guided biopsies to assist the surgeon in identifying the area of concern. It is important to recognize that most masses identified on exam and most abnormal mammograms are in fact benign. However, all breast masses and abnormal mammograms merit thorough evaluation by experienced practitioners to determine which abnormalities warrant biopsy. Biopsy procedures Breast biopsy is one of the most common surgical procedures done in the United States, and has in recent years undergone a shift from traditional open surgical biopsy to less invasive methods of obtaining pathologic specimens for diagnosis of breast disorders. These methods include fine needle aspirate biopsy, core biopsy and most recently mammotome biopsy. These newer techniques are less invasive, less uncomfortable for the patient and less expensive than open biopsy. The traditional approach to breast biopsy has been an open surgical biopsy performed in the operating room, by surgeons. This type of biopsy is generally performed under a general anesthetic or heavy sedation, requires the resources of an operating room staff, and generall requires an incision several inches in length. The mass is removed and sent to the pathologist for examination to determine whether or not there is any evidence of cancer. This type of biopsy typically takes 30 to 45 minutes to perform. Patients are discharged from the hospital after the procedure and can usually resume normal activities the next day. Fine needle aspirate biopsy is a simple procedure done in the office setting in which a small needle is inserted into the breast mass and a sampling of cells is obtained and submitted for cytologic examination. The pathologist can then determine whether or not the cells or abnormal. This technique is limited to the evaluation of individual cells and tissue samples cannot be obtained utilizing this technique. This lack of tissue results in less accurate diagnosis and often leads to other biopsies to confirm the cytologic impression. Core needle biopsies result in larger samples of tissue, and unlike FNA, core biopsies obtain enough tissue to allow tissue (histologic) interpretation. However, core biopsies are still limited by relatively small tissue samples that can lead to sampling errors. The more recent advancement in minimally invasive breast biopsy is vacumn assisted mammotome biopsy. In this technique, the surgeon places either a 8 guage or 11 guage biopsy needle under the mass, utilizing ultrasound or mammographic guidance. This is done under local anesthesia. Once positioned, the biopsy device can retrieve multiple specimens resulting in larger amounts of tissue retrieval. In large studies comparing mammotome biopsy with open biopsy, the accuracy is equivalent in the two groups. The mammotome biopsy if performed through an incision approximately 3-5 mm in length and the procedure takes approximately 15 minutes. No sutures are required, and most women can resume their normal activities immediately after the biopsy. In the event that the area of concern can not be palpated, and is only detectable by mammography, a needle localization biopsy can be performed. In this type of biopsy, the radiologist will image the breast and identify the abnormality. After identifying the abnormality, the radiologist will place a thin wire into the breast, localizing the abnormality so that the surgeon can remove the area of concern. This type of biopsy is done as an outpatient and results in a small incision in the breast to remove the tissue surrounding the guide wire. Like most open biopsies, most patients can resume their normal activities the following day. Stereotactic biopsy is a minimally invasive way to biopsy breast lesions that cannot be identified ultrasonographically or by physical exam. In this procedure, multiple views of the breast are obtained and a computer system computes the location of the lesion in the horizontal, vertical and deep plane. This procedure is very accurate and mammotome biopsies or true cut biopsies can be obtained. Treatment of Breast Cancer Treatment of breast cancer requires a multi-specialty team approach to provide comprehensive care for the patient. The key components of breast cancer treatment are surgery, radiation therapy, chemotherapy and hormonal therapy. Most patients are initially evaluated by their primary care physician and referred to a surgeon for evaluation. Your surgeon will review your medical history, perform and exam and review your mammogram and ultrasound. If a biopsy is warranted, this is usually performed by the surgeon, though in some centers radiologists are becoming more involved in the biopsy process. In the event that a cancer is diagnosed, your surgeon will coordinate interaction with the other specialists to develop a treatment plan. For patients with early breast cancers, (stage I and II), surgery is usually the first step in the treatment process. Studies have shown that outcomes are the same whether the patient chooses lumpectomy and radiation or mastectomy. In a lumpectomy, the mass and a margin of surrounding normal tissue is removed. The patient then usually must undergo radiation for treatment of the remaining breast. In a mastectomy, the entire breast is removed and typically no radiation therapy is required. The exception to this would be if more than 4 lymph nodes are found to contain cancer at the time of lymph node excision. For patients with DCIS, the traditional approach was a simple mastectomy, in which the entire breast, but no lymph nodes, is removed. Studies now demonstrate that patients with DCIS can undergo breast conservation therapy with lumpectomy, followed by radiation therapy to treat the remainder of the breast. More recent studies have shown that select patients with small, low grade DCIS tumors may be treated with lumpectomy alone, and not require radiation therapy. Sentinal lymph node biopsy is a new method of assessing the lymph node status of patients with breast cancer. This procedure was developed to minimize the impact of acomplete axillary dissection. With a less invasive procedure, the risk of lymphedema (swelling of the hand and arm as a consequence of removal of the axillary lymph nodes) is lessened. In addition, a more thorough evaluation of the lymph nodes can be performed by the pathologist. In this procedure, a radioactive tracer, often combined with a blue dye, is utilized to identify the lymph nodes that are the first to be involved in cancer (the sentinal nodes). Typically, 2-3 lymph nodes are identified through a small axillary incision, then sent for pathologic evaluation. If these lymph nodes are negative, no further axillary lymph node dissection is needed. If there lymph nodes contain cancer, the remaining axillary lymph nodes are removed. This procedure is known as an axillary dissection. In experienced hands, sentinal lymph node biopsy is a very accurate procedure. The sentinal lymph node (or nodes) or identified in 92-98% of patients, and the concordance between the findings of sentinal lymph node biopsy and complete axillary dissection is very high (97-100% of cases). The false negative rate (the sentinal lymph node is negative, but there is in fact tumor present) is between 0 and 10% in large series. The surgeons experience with sentinal lymph node dissection is a critical part of the success of this procedure. In general, the recommendation is for 20-30 sentinal lymph node dissections followed immediately by complete axillary dissection before the surgeon does sentinal lymph node dissection alone. This is done to make sure that the surgeon has adequate experience with the sentinal node procedure before abandoning the complete axillary dissection. For patients who have a mastectomy, reconstruction can be done after surgery (delayed reconstruction) or at the same setting as the cancer operation (immediate reconstruction). Some patients chose to have no reconstruction. Reconstruction options include saline implants, silicone implants, as well as various tissue transfer reconstructions such as TRAM flaps. The decision to proceed with a particular reconstructive technique or whether to proceed with reconstruction at all is a decision that the woman can make in conjunction with her physicians. Radiation therapy is another key component of breast cancer treatment. Postoperative radiation is utilized in patients that have had a lumpectomy, to treat the residual breast tissue, and is also utilized in selected high risk patients following mastectomy. Radiation therapy can decrease the risk of local-regional recurrence in high risk patients. Criteria for post mastectomy radiation include those with 4 or more positive lymph nodes, grossly evident capsular nodal extension, large primary tumors, and very close or positive deep margins of resection. In other patients, postmastectomy radiation has not been of proven benefit. Chemotherapy is another of the key components of breast cancer treatment. Chemotherapy has been shown to have a significant reduction in mortality regardless of nodal status, ER status, (estrogen receptor status of the tumor), and whether or not tamoxifen was given. The degree of benefit of chemotherapy does vary significantly according to patient age and menopausal status. The Gail model has been introduced as a method of assessing risk and providing guidelines for the degree of benefit of chemotherapy. Factors to be considered in the decision of whether to initiate chemotherapy include the menopausal status of the patient, nodal status, tumor size, estrogen and progesterone status, tumor grade and type, and patient age. Chemotherapy is usually instituted shortly after surgery, and is given intravenously at regular intervals over 4 to 6 months, depending on the chemotherapeutic regimen selected. Most patients require placement of a vascular access site to facilitate chemotherapy. Common side affects of chemotherapy for breast cancer include nausea, vomiting, myelosuppresion (fall in blood count), alopecia (hair loss) and fatigue. Less commonly, certain types of chemotherapy can lead to heart failure, thromboembolic events (blood clots) and premature menopause. A more exhaustive review of breast cancer diagnosis and treatment can be found at www.cancer.gov and www.nih.gov.