Breast Cancer Frequently Asked Questions
Now that I have been diagnosed with breast cancer, whom do I need to see?
Optimal breast cancer treatment uses a team approach. The initial treatment
is usually surgery although larger cancers are sometimes treated with
chemotherapy first to shrink the cancer before surgery. The role of your
surgeon is to remove the cancer from the breast and when required, to
remove lymph nodes to test for cancer spread. Many patients want to avoid
a mastectomy and when possible choose a lumpectomy to preserve the breast
(breast conservation). Your surgeon will describe your options on the
types of breast surgery possible (breast conservation or mastectomy),
and whether or not lymph node removal is necessary. The large majority
of patients who undergo lumpectomy for breast conservation and even some
patients who have a mastectomy need radiation therapy after the operation.
This is given by the radiation oncologist, a physician who specializes
in radiation treatments. You will also need a medical oncologist (the
physicians at Cancer Care Associates are medical oncologists) to coordinate
your care and also to prescribe treatments to reduce the risk of cancer
recurrence. These treatments may include chemotherapy and/or hormonal
(anti-estrogen) therapy. Every patient diagnosed at the breast centers
of Torrance Memorial Medical Center and Little Company of Mary Hospital,
Torrance, are reviewed at a weekly conference of the breast cancer team.
Decisions on initial treatment are made only after reviewing mammograms,
ultrasounds, MRI, and biopsy results with the mammographers and pathologists
and a team discussion of the specifics of each individual patient’s
Do I need to see a doctor who only specializes in breast cancer?
All board certified medical oncologists are by definition breast cancer
specialists, and are expert in the treatment of breast cancer which is
the most common major cancer diagnosed in women. Each physician at Cancer
Care Associates is extensively trained and experienced in treating breast
cancer. There are no university based training programs limited only to
breast cancer therapy anywhere in the United States and there is also
no board certification specifically for breast cancer treatment. All breast
cancer treatment should be based upon the latest scientific data that
is presented at national conferences and published in the major medical
journals. Given the extensive amount of research and data generated worldwide
on breast cancer therapy, no individual physician today should make up
a novel treatment approach unique to his/her practice. Sometimes patients
are referred to university breast centers like the Revlon/UCLA Breast
Center for a specific research program or experimental therapy. Cancer
Care Associates in collaboration with UCLA is very active in breast cancer research.
I have been told that I have DCIS. What is that?
DCIS refers to ductal carcinoma in-situ. This is a non-invasive or precancerous
condition often discovered at a small size by mammogram. With time DCIS
may become an invasive cancer and therefore treatment is needed to prevent
it. In-situ is Latin for "in place" and therefore DCIS typically does
not spread into lymph nodes or to other areas of the body. The usual treatment
of DCIS is removal of the abnormality by lumpectomy leaving the rest of
the breast intact. After lumpectomy, there is the possibility that you
will need breast radiation. Some situations of DCIS may require mastectomy
if the area of DCIS is large compared to the breast size, or if DCIS occurs
in multiple areas of the breast (multifocal). In some cases where the
DCIS is high grade, removal of a lymph node for testing may be recommended
using a technique called sentinel lymph node biopsy. You won't need chemotherapy
because DCIS should not spread from the breast to other areas of the body.
The use of anti-estrogen therapy with Tamoxifen is sometimes recommended
to reduce recurrence within the breast. Because the risk of relapse with
DCIS is low, the use of Tamoxifen is optional rather than mandatory.
What do I need to know about my pathology report if I have invasive breast cancer?
Following biopsy and surgery, a written report of your cancer is generated
by the pathologist describing all the important individual characteristics
after microscopic analysis. In breast cancer surgery, the three most important
pieces of information are the actual size of the cancer as measured microscopically
(tumor size), the completeness of the surgery as defined by whether the
margins of the removed breast tissue are free of cancer (margin status),
and whether or not the lymph nodes are involved with cancer (node status).
Also significant to allow proper post surgery treatment planning, are
the biologic markers of your cancer including the estrogen receptor (ER),
progesterone receptor (PR), and Her-2 status. Achieving clean surgical
margins predicts for low relapse rates in the breast following lumpectomy
and radiation. If the lymph nodes are cancer free (node negative), the
chance of the cancer spreading is significantly lower and many patients
can avoid the need for chemotherapy. ER and PR positivity permit the use
of anti-hormone therapy such as Tamoxifen and aromatase inhibitors (Femara,
Aromasin, Arimidex). Her-2 is a non-inherited protein abnormality that
is found in about 20% of breast cancers and if you have Her-2 in your
breast cancer, Herceptin can be given to improve your cure rate.
Are there different types of invasive breast cancer?
Most invasive breast cancers (80% or more) are infiltrating ductal carcinomas.
These cancers arise from the breast ducts that carry breast milk to the
nipple during breast-feeding. Less common are infiltrating lobular carcinomas
that arise from the breast lobules, which are at the end of the ducts
and is where breast milk is made during lactation (milk production). Even
less common are medullary and tubular carcinomas, which generally are
more favorable in that they tend to spread less frequently. These types
of cancer are all treated similarly and require surgical removal and breast
conservation with radiation therapy when appropriate.
When is a mastectomy needed?
Mastectomy refers to the removal of the entire breast, including skin and
nipple, resulting in a horizontal incision scar overlyling the chest muscle,
the pectoralis major. Breast cancers which are large relative to the size
of the breast, or that occur in multiple areas of the breast simultaneously
(multifocal breast cancer) are more safely treated by mastectomy. Attempts
to conserve the breast in these situations result either in poor cosmetic
results or lower cure rates. Sometimes large breast cancers can be treated
with chemotherapy before surgery to preserve the breast. This is called
neoadjuvant or preoperative chemotherapy and has become more commonly
used over the past few years. Some patients who are candidates for breast
conservation choose to have mastectomy because of fear and feel less anxious
by having a mastectomy. A very important point to understand is that in
most patients, cure rates with mastectomy are not higher than cure rates
with breast conservation. This has been repeatedly shown in extensive
research studies over the past 20 years. If you have the type of breast
cancer situation that will have a higher cure rate with mastectomy, your
doctors will tell you. We only give choices when the cure rates are equal
with both approaches.
What are the risk factors for getting breast cancer?
This is a very complicated subject but in the majority of patients no specific
risk factor can be easily identified. It's very unlikely that you did
something recently to cause your breast cancer. Exposure to estrogen during
the early teens and twenties is important, including age of first menstrual
cycle, age of first pregnancy, lack of breast feeding, number of children,
postmenopausal use of estrogen, and more. Dietary factors seem to play
an important part but the greatest impact seems to be during puberty and
adolescence when high caloric, high fat diets increase estrogen levels
during breast development which lead to increased breast cancer risk many
decades later. This is thought to account for the high rates of breast
cancer in North America and Western Europe compared to less industrialized
countries. Dietary trends in mature adults seem much less important. Injury
or trauma to the breast does not cause cancer.
Did I get breast cancer because I took estrogen?
Although taking estrogen is a risk factor, the degree of risk is fairly
small and therefore the answer is probably no. Two studies are illustrative.
A study of nurses in the Harvard Health System over many decades linked
estrogen use to breast cancer. In nurses that took estrogen following
menopause, about 14% developed breast cancer. However nurses who never
took estrogen developed breast cancer at a rate close to 12%. The most
recent major study reported was from the Women’s Health Initiative.
Newspapers headlined the results that postmenopausal use of estrogen increased
breast cancer risk and postmenopausal women should stop taking hormone
replacement therapy. The actual calculated risk was however only one tenth
of one percent per year of use. That means if you took estrogen after
menopause for 10 years, you increased your chances of breast cancer by
1 percent. Therefore the actual increase in risk by taking estrogen to
any individual woman is very small compared to other risk factors.
Is breast cancer inherited?
About 10-20% of breast cancers have an inherited risk. More than 80% of
newly diagnosed breast cancer patients do not have a relative who has
had breast cancer. There are clearly hereditary breast cancer families,
often associated with ovarian cancer as well.
Two genes have been identified which when abnormal, can substantially increase
breast cancer risk. They have been named BRCA1 and BRCA2. Other genes
are known to be important also but have yet to be identified. BRCA mutation
can be tested through a blood test. Patients without other family members
with breast or ovarian cancer are very unlikely to have a significant
BRCA mutation and testing is not recommended. The decision to test is
complicated. There are many mutations of BRCA and not every mutation is
important so that the implications of undergoing testing are very complex
as it relates to risk of breast and ovarian cancer, options for preventative
surgery or screening, testing of relatives including children, and the
potential for discrimination by insurance of employers. All the ramifications
of testing need to be explored prior to having the test.
What is sentinel lymph node mapping and when is it needed?
This is a technique that the surgeon uses to limit surgery on the lymph
nodes within the armpit (axillary lymph nodes) while trying to discover
whether or not the breast cancer may have spread to them. Very often if
a breast cancer spreads, it will first spread to these nodes within the
armpit. Whether or not lymph node spread has occurred has important implications
regarding chance for cure and need for preventative chemotherapy. Previously,
the standard surgery was an axillary dissection resulting in the removal
of a large number of lymph nodes. Unfortunately, axillary dissections
resulted in a significant number of patients having long-term numbness
and pain in the chest and arm area, and in a small number of patients
the complication of severe permanent swelling of the arm (lymphedema).
The technique of sentinel lymph node mapping was developed to try to limit
the amount of surgery under the armpit and removes only the lymph nodes
most likely to be involved with cancer. This is done by injecting into
the breast a tracing material just before breast surgery and then removing
only the lymph nodes which contain the tracing material through a small
incision under the armpit at the same time that a lumpectomy or mastectomy
is performed. This is now a proven accurate way to test for lymph node
spread. A sentinel lymph node cannot be found in every patient and then
an axillary dissection may be required. If a sentinel lymph node contains
a significant amount of cancer, another surgery for an axillary dissection
may be recommended.
What is hormonal therapy for breast cancer?
Hormonal therapy for breast cancer deprives breast cancer cells of estrogen
and is essentially anti-estrogen therapy. Any supplemental estrogen should
be stopped. Patients who receive hormonal therapy have cancers that possess
either estrogen or progesterone receptors (ER or PR positive). This test
is performed on the biopsy and is specific for each individual patient.
Hormonal therapy includes the use of drugs which block estrogen receptors
such as Tamoxifen, aromatase inhibitors (Femara, Aromasin, Arimidex) that
lower estrogen levels, drugs that prevent production of estrogen by ovaries
such as Depolupron, and drugs that degrade the estrogen receptor such
as Faslodex. Tamoxifen belongs to a class are called SERMs (selective
estrogen receptor modulators) and include Fareston and Evista. It is very
important to know the menopausal status of a patient, as not all drugs
will be effective in both premenopausal and postmenopausal situations.
The aromatase inhibitors are only effective in postmenopausal women with
low estrogen levels. It's important to keep in mind that aromatase inhibitors
won't work in patients who aren't clearly postmenopausal such as women
just entering menopause. Most patients with invasive breast cancer who
are ER or PR positive will receive a hormonal therapy for at least 5 years
as part of the comprehensive treatment program. This treatment will both
lower the recurrence risk within the breast and lower the risk of spreading
cancer. Hormonally therapy has much less impact in treating DCIS because
there is essentially no risk of cancer spread and therefore the benefit
is restricted to lowering a low risk of recurrence within the breast after
lumpectomy and radiation.
How do you decide between Tamoxifen and AIs (aromatase inhibitors)?
Clearly all premenopausal patients with invasive breast cancer who are
ER or PR positive should receive Tamoxifen because aromatase inhibitors
are only effective in postmenopausal patients. Patients who become postmenopausal
from chemotherapy should first receive Tamoxifen due to persisting higher
levels of estrogen, despite the lack of menstrual periods. After postmenopausal
status is definitively established, the Tamoxifen is switched to one of
the aromatase inhibitors (Arimidex, Aromasin, or Femara). Tamoxifen has
rare significant complications including a small risk of blood clots and
a very slight increased risk of uterine cancer. These risks of Tamoxifen
treatment became apparent only after 25 years of widespread use as they
occur infrequently. In postmenopausal patients, aromatase inhibitor are
preferred over Tamoxifen as they are slightly more active against breast
cancer and have also have fewer side effects. The most common side effect
of aromatase inhibitors is a tendency to cause joint or muscle aches which
are usually minor. A more serious side effect is osteoporosis ( softening
of the bones) which requires either monitoring with bone density tests
or use of preventative medications. At the present time, all 3 aromatase
inhibitors are considered basically equal.
When is chemotherapy used?
There are two different situations in newly diagnosed breast cancer when
chemotherapy is used. Large cancers are treated with chemotherapy before
surgery to reduce the size and often permit lumpectomy rather than mastectomy.
This is called preoperative or neoadjuvant chemotherapy. Patients who
have surgery first tend to have smaller cancers and after surgery may
require chemotherapy because to lower the risk of cancer spread. This
decision is usually based on the tumor size and lymph node status. Chemotherapy
following surgery is called adjuvant chemotherapy. Chemotherapy given
around the time of surgery and before obvious spread to other organs will
lower the recurrence risk. It is very important to maximize initial cure
rates in early breast cancer because widespread breast cancer is unfortunately
not currently considered curable.
What factors are used to decide if chemotherapy is needed?
Each patient’s case is individualized and not all patients require
chemotherapy. The two main deciding factors are lymph node status and
tumor size which have the highest correlation to risk of spreading cancer.
Increased number of lymph nodes containing cancer and larger breast cancer
size predicts for an increased risk of cancer spreading. An increasing
risk of relapse corresponds to a greater need to use chemotherapy to prevent
it. Biologic factors are also important but to a much lower degree. Cancers
that are ER and PR negative and cancers that are Her-2 positive tend to
be somewhat higher risk. Sometimes gene profile tests such as Oncotype
DX are used to help estimate an individual's recurrence risk if chemotherapy
is witheld. At one time elderly patients were not given chemotherapy,
but with modern treatment techniques, many older patients receive treatment
successfully. The decision regarding chemotherapy requires an assessment
of an individual patient’s risk of recurrence and an estimate of
the patient’s ability to tolerate treatment taking into account
age and overall health. These factors result in the significant variability
in treatments from patient to patient that is very apparent at breast
cancer support group meetings.
What is chemotherapy sensitivity testing?
This is an attempt to replicate the very successful technique of antibiotic
sensitivity testing in the treatment of infections. In cancer treatment,
the ability to grow cancer cells from an individual’s cancer in
test tubes and to test the ability of various chemotherapy drugs to kill
the cells has been available through a number of commercial laboratories
for more than 20 years. The vast majority of studies do not support the
use of this technique in cancer therapy, as it has, by and large, been
ineffective in predicting chemotherapy response. This is mainly due to
the vast differences between bacteria that as individual cells grow easily
in test tubes as well as within the human body, compared to cancer cells
that grow in a much more complicated manner. Within the human body, cancers
require cohesion and grow in a very complex and intricate manner, with
multi-level interactions between cancers cells and normal cells to facilitate
a growth pattern quite unlike that which occurs in a test tube. An additional
significant problem is that many chemotherapy drugs are inactive until
they are metabolized within the body. The use of chemotherapy sensitivity
testing was reviewed in 2005 by the national oncology organization, ASCO,
with the conclusion that it not be used because of lack of demonstrated
effectiveness. Major cancer research is going away from the approach of
chemotherapy sensitivity testing and instead university cancer centers
are now focusing on genomics and proteomics to try to guide treatment
on a genetic level. It is anticipated that an individual cancer will have
unique protein and genetic fingerprints which will guide treatment.
What is Herceptin and who should receive it?
Herceptin is a new class of anti-cancer agent called monoclonal antibodies
and is considered a targeted therapy rather than a chemotherapy. Targeted
therapies act to deter cancer cell growth by targeting specific genetic
abnormalities on the cancer cell. Herceptin targets Her-2 and therefore
can only be considered in patients who are Her-2 positive (sometimes termed
Her-2 overexpressed). Herceptin can lead to cancer cell destruction when
used by itself and when combined with chemotherapy, significantly increases
the effectiveness of chemotherapy. In 2005, Herceptin was incorporated
into pre- and post-operative chemotherapy programs when Her-2 is present
in the cancer. Herceptin added to chemotherapy significantly reduces recurrence
risk. Herceptin use is not without potential risk and can cause weakness
of the heart muscle in some patients.
When is radiation therapy used?
Most patients who undergo lumpectomy for breast conservation for invasive
breast cancer and DCIS receive radiation therapy. Many studies confirm
that appropriately treated breast conservation patients have the same
cure rates as patients who undergo mastectomy. Some patients with small
low grade DCIS have such a low rate of relapse that for them, radiation
therapy may not be needed. Elderly patients with small invasive cancers
are sometimes given the option of omitting radiation if the estimated
recurrence risk within the breast is low. Radiation treatment is also
given after mastectomy for either large cancers or for significant lymph
node spread. The radiation is given by linear accelerator in the form
of photons. The treatments are 5 days a week for 5 to 6 weeks. Each treatment
visit takes about 10 minutes and is given under the direction of the radiation
What is MammoSite radiation therapy?
Mammosite is a new device that attempts to administer radiation therapy
in a more limited and rapid fashion. This is essentially a balloon, which
is inserted into the lumpectomy cavity into which a radiation source is
placed for over a period of 5 days. Although appealing in concept, there
are a number of concerns with this technique. It is very new, with less
than several hundred patients treated at the time of FDA approval, compared
to the tens of thousands of patients treated over 25 years with more standard
radiation technique. Also the Mammosite treats only an area of the breast
about 1cm around the radiation source and therefore is in essence, the
equivalent of performing a large lumpectomy. Cancers close to the skin
cannot be treated with this device because of inflammation and hardening
of the overlying skin. Other studies of more limited breast treatment
raise a concern that there may be an increased risk of late recurrence
within the breast. The advantage of the Mammosite is that it may permit
breast conservation in areas of the country having limited radiation therapy
facilities where patients may have to travel several hours for each session
of treatment. The effectiveness of Mammosite will not be established for
at least 10 years and is not currently recommended in areas where radiation
facilities are easily accessed. National studies of this technique for
radiating the breast are now in progress.
Are there tumor markers for breast cancer?
Tumor markers are blood tests that may correlate with disease status and
activity. The concept is very appealing but at this time the available
markers (CEA,CA15-3, CA27-29) are unfortunately very inaccurate. Many
patients can have advanced breast cancer and normal marker levels while
some patients can have elevated markers for reasons other than cancer.
This circumstance has led to reports of patients with elevated markers
undergoing treatment for metastatic breast cancer when in fact they were
cancer free based upon subsequent review. Studies reporting marker ineffectiveness
in breast cancer led to the finding by the American Society of Clinical
Oncology (ASCO) Tumor Markers Panel in 2001, that the markers were of
no value in predicting or detecting cancer relapse and that they not be
used in the routine follow-up of breast cancer patients or for breast
Do scans need to be performed at the time of diagnosis or as part of follow-up?
As explained in the website section on laboratory and radiology testing,
all current tests including CT scans, MRI, and PET scans, are limited
by the inability to detect small amounts of disease. Therefore normal
scans do not mean that cancer has not spread, and not all abnormalities
on scan are due to cancer. For this reason, in the majority of cases,
scans cannot be used to guide therapy in newly diagnosed breast cancer,
and ASCO has recommended against routine use of scans either at the time
of initial diagnosis or as part of regular follow-up.
Do changes in diet matter after the diagnosis of breast cancer?
A number of studies have looked for a relationship between diet and breast
cancer survival. A very exciting study conducted in the United States
and reported in 2005 showed that a low fat diet resulting in weight loss
reduced the risk of breast cancer relapse. The patients in the study were
all postmenopausal but there is no reason that think that premenopausal
patients might not also similarly benefit from a lower fat diet and weight
reduction. This may lower relapse risk by lowering estrogen levels because
fat tissue contains an enzyme, aromatase, which produces low levels of
estrogen. Weight loss also lowers insulin levels which can have a stimulatory
effect on breast cancer. The National Institutes of Health (NIH) recommends
the intake of 5 servings of fresh fruits and/or vegetables a day. Eating
fresh fruits and vegetables seems to be more beneficial than taking vitamin
Can exercise be part of the treatment regimen?
Certainly most patients who exercise regularly can continue to do so while
on treatment with minor modification due to recovery from surgery or temporary
side effects of chemotherapy and radiation. More importantly, in 2005,
the Nurse's Health Study showed that breast cancer patients who exercise
at least 3 times a week after breast cancer treatment have a lower risk
of relapse. This may be because exercise lowers estrogen levels and insulin
levels, both which can be stimulatory to breast cancer cells. Careful
weight lifting or resistance training is also helpful in preventing osteoporosis.
Can alcohol be used during treatment?
Limited alcohol use is allowed while on chemotherapy. Patients who are
using narcotics for treatment related discomfort such as that following
surgery or radiation should refrain from alcohol use.
Can I take any type of estrogen after being diagnosed with breast cancer?
Estrogen should generally not be used after breast cancer diagnosis. This
is based on the theoretical potential for estrogen to stimulate the growth
of breast cancer cells and cause a relapse. However, clinical studies
do not indicate a higher risk of relapse in patients who are on estrogen
at the time of breast cancer diagnosis. A number of studies of patients
taking estrogen after diagnosis have conflicting results. However it is
reasonably prudent to avoid taking estrogen after breast cancer. Many
patients need to take small amounts of vaginal estrogen to relieve symptoms
of vaginal dryness and discomfort. Although controversial, this is often
allowed and it is recommended that only the lowest amount of estrogen
be used needed to correct the problem. There are a number of vaginal estrogen
preparations and they are prescribed by your gynecologist.
Can I take soy products?
Soy products have mild plant estrogen activity. Many pharmaceutical estrogens
are made from plants. Taking daily soy by eating tofu or drinking soymilk
is unlikely to lead to significant plant estrogen intake. Whether it is
safe to take large amounts of soy products to control hot flashes is at
this time unclear. Until there is more data, it's probably better to not
take soy supplements but okay to eat soy based foods in moderation.
How can I control hot flashes without taking estrogen?
So called hot flashes are the result of changes in body estrogen levels
that occur from menopause. Whether this occurs naturally or as a result
of chemotherapy does not seem to make a difference. Decreases in estrogen
level affect the area of the brain that controls blood vessel diameter
and lead to sensations of being too hot or too cold. These symptoms naturally
subside over time, generally over months rather than weeks. Severe symptoms
may require treatment especially if sleep is interrupted. At this time
the most effective treatments seem to be with low dose antidepressants
called SSRIs such as Zoloft, Paxil, and related drugs such as Effexor.
Sometimes a low dose of older type antidepressants such as Trazadone is
effective. Recent studies show that acupuncture may significantly reduce
hot flashes. Many women attempt to take a number of non-prescription remedies,
switching from one to another month to month. As the symptoms normally
subside on their own without intervention, considerable confusion exists
as to whether or not these remedies are effective and safe.