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 situation.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 oncologist.

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.

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 cancer screening.

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.

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 supplements.

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.

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.

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.

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.

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.