After the Diagnosis: What Are My Options? Once you have been diagnosed with breast cancer, you will be asked to participate in decision making about a number of different treatment modalities used against breast cancer. In broad categories, these treatment regimens involve combinations of surgery, radiation, chemotherapy and hormonal therapy. You will work with a surgeon, a medical oncologist and a radiation oncologist to come up with a treatment plan that is particular to your cancer and your situation. To do this well requires a high level of communication with and among your various physicians and is best carried out with a “team” approach. Other members of your team include breast cancer support services, genetics counselors, oncology nurses, and clinical trial coordinators along with your primary care doctor. Do I Need a Mastectomy? Do I Need a Mastectomy? Twenty years ago, nearly every woman who was diagnosed with breast cancer underwent mastectomy, often while under anesthesia for the biopsy itself with no participation in a discussion about treatment options. That should never happen today. Women do have options for managing this disease, and active participation in those choices can help women feel less victimized by the process. Women (and surgeons) can be ambivalent about considering options short of mastectomy. “Is it really safe to do less than remove the whole breast if there is cancer in it?” is a common and sometimes unvoiced concern. This is an important question, and, thanks to two large clinical studies initiated by some brave and intelligent women and physicians back in the 1970s, we have an answer. These two large trials, one conducted in Europe and one conducted in the United States, randomly assigned women with breast cancer to treatment with either mastectomy or breast conserving surgery (also known as “lumpectomy”) coupled with breast radiation. These women were followed for the next 25 years to see if there was any survival advantage to either approach. There wasn’t. Women who underwent breast conserving therapy lived as long as their sisters who underwent mastectomy but obviously avoided the emotional and physical effects of losing their breast. Armed with this information, women who are newly diagnosed with breast cancer need to have a thorough discussion with their surgeons about whether breast conservation or mastectomy is right for them given the particular nature of their disease and circumstances. What is a Nipple Sparing Mastectomy? What is a Nipple Sparing Mastectomy? Nipple sparing mastectomy is a procedure that removes the breast tissue but leaves the nipple and areola, creating a more natural appearance to the reconstructed breast. The incision is made along the underside of the breast at the bra line so it is hidden once the reconstruction is complete. This is an attractive option for anyone choosing mastectomy for risk reduction and can be used for the treatment of breast cancer in certain situations. It is not the best choice if the cancer is located just beneath the nipple as we might leave cancer cells behind leading to increased risk of recurrence. In that setting, removing the nipple areolar complex with the cancer is a better option and a 3D nipple tattoo can produce a very realistic looking nipple that matches the other breast. Another thing we consider when recommending nipple sparing mastectomy is the size and shape of the breast along with the position of the nipple. Nipple sparing mastectomy works best when the breast is a B-C cup with the nipple pointing outward. When the breast is larger, the nipple often points down and that position does not result in a good cosmetic result. In a woman with this type of breast who is considering nipple sparing mastectomy for risk reduction, we generally perform a breast lift first to create the perfectly shaped breast with appropriate nipple position and then perform the definitive risk reduction nipple sparing mastectomy approximately 4 months later when she has healed completely. In women also pursuing ovarian cancer risk reduction, removal of the ovaries can be done at the time of the breast lift for surgical efficiency. This approach makes nipple sparing mastectomy a real option for many women who would otherwise be denied, and it warrants a discussion with both your Breast and Reconstructive Surgeon. When we are contemplating nipple sparing mastectomy for a cancer in a heavy breasted woman, we have to be creative about reshaping the breast and repositioning the nipple in order to get the desired cosmetic result while ensuring that she also receives all necessary elements of her cancer treatment plan in a timely fashion. In this setting, we may have the option of removing the cancer while performing a breast lift/reduction, then completing the nipple sparing mastectomy once healing, and other therapies are complete. Clearly the discussion about nipple sparing mastectomy is complex and deeply personal, and women should expect a thorough conversation with their Breast Surgeon about its risks and benefits in their particular circumstances. About 3-D Nipple Tattoos 3-D nipple tattoos have become a very attractive option for a women who undergo a standard mastectomy that removes her nipple areolar complex. The tattoo is performed by a skilled 3-D tattoo artist after the breast reconstruction is complete and the results are very realistic and durable. We now have a number of 3-D tattoo artists providing this service in a medical setting here in the Omaha, NE area, and a consultation can be arranged to see if that approach might be right for you. Learn More » Is the Disease in My Lymph Nodes? Is the Disease in My Lymph Nodes? Determining whether the breast cancer has spread to the lymph nodes under the arm is a critical part of staging the cancer. Statistically, about 30% of those diagnosed with breast cancer have disease in their lymph nodes and 70% do not. Traditionally, an “axillary dissection”, which removes all of the nodes under the arm along the chest wall, was performed in order to distinguish between these two groups. This procedure puts women at risk for developing painful swelling and arm immobility, and confers no benefit to those whose nodes are negative. For these reasons, a new technique known as the sentinel lymph node biopsy was developed. This procedure allows the surgeon to identify and test the first lymph node in the chain of nodes under the arm rather than just removing them all. The technique is simple. A tracer solution with a faint radioactive signal is injected into the breast around the nipple just before the operation. This tracer solution is picked up by the lymphatic channels and carried to the axillary lymph node chain. Then, in the operating room, a blue dye is injected similarly, and the dye travels quickly in those same lymphatics to the sentinel node. A small incision is then made under the arm, and the blue node that has a faint radioactive signal is identified and removed. The pathologist looks at this node under the microscope and if no cancer is present there, then no further lymph node removal is required. If cancer is found in the sentinel node, then an axillary dissection in order to ensure that no cancer is left behind. Women who undergo a sentinel node biopsy generally recover uneventfully from that procedure with no long term consequences for their arm function. Women who have a positive sentinel node and then undergo an axillary dissection are at risk for chronic swelling of the involved arm, known as “lymphedema,” as well as chronic pain and changes in sensation and mobility that can be bothersome. These women benefit from physical therapy with a lymphedema specialist who can help them prevent or control the swelling and regain their arm mobility after the operation Will I Need Chemotherapy? Will I Need Chemotherapy? Breast cancer cells gets their start in the breast, but at some point, these cells acquire the ability to travel to other parts of the body, a process known as “metastasizing.” As a general rule, the larger the cancer, the more likely it has acquired the ability to metastasize. An important route that cancer cells take to leave the breast are through the lymphatic channels to lymph nodes, primarily under the arm. These lymph nodes are checked using the sentinel node procedure, and if disease is found, it is likely that cancer is present in other parts of the body as well. In this situation, chemotherapy is usually recommended in order to destroy those metastasizing cancer cells. Sometimes, the cancer can leave the breast directly through the blood vessels, bypassing the nodal system. In this setting, the sentinel node will be negative but there may be circulating cancer cells that need chemotherapy to be controlled. To sort this situation out, your doctor may order an OncoType DX Recurrence Score on your cancer. This test is performed on the tumor itself and it determines what genes are turned on in your specific cancer. Based on the pattern of genes found in your cancer, we can predict whether or not chemotherapy will be of benefit. A low OncoType DX Recurrence Score is associated with a cancer that is generally very responsive to hormone blocking strategies and do not respond much to chemotherapy. In this setting, a hormonal blocking agent is prescribed instead of chemotherapy. If the OncoType DX Recurrence Score is high, the tumor will benefit from chemotherapy in addition to a hormonal blocking agent. While chemotherapy is usually delivered after the tumor is removed from the breast and the status of the lymph nodes is known, in some cases, there are benefits to delivering the chemotherapy before the operation. This kind of treatment is known as “neoadjuvant chemotherapy.” By giving the chemotherapy before the tumor is removed, the oncologist has the opportunity to see firsthand how responsive that particular tumor is to the selected chemotherapeutic regimen. About 20% of the time, the tumor will shrink completely with chemotherapy alone. While the part of the breast that the tumor developed in must still be removed surgically in order to avoid recurrence of the disease, those women who have such a good response have a better prognosis than would have been predicted otherwise. For those women who do not have a complete response to chemotherapy, a different drug may be offered to improve her response. An added benefit of neoadjuvant chemotherapy is that, in many cases, a woman who would have required a mastectomy due to the large size of her tumor, becomes a candidate for breast preservation after the tumor shrinks. The prospect of chemotherapy can be the most frightening part of breast cancer treatment for many women. While these drugs are very powerful and do have side effects, oncologists have become very good managing them. Many of these women describe their chemotherapy experience as “not as bad as I had expected” once they have completed their treatment. What About Hormonal Therapy? What About Hormonal Therapy? Breast cancers often use a woman’s own hormones in order to grow. Given this dependence, a powerful way to prevent a tumors growth is to block its access to these hormones. We can tell if a cancer is hormone dependent by measuring hormone receptors on the tumor cell surface. Your doctor will refer to these as “ER” and “PR” meaning “Estrogen Receptor” and “Progesterone Receptor.” When these are positive, use of estrogen blocking drugs, such as tamoxifen, or the aromatase inhibitors are important components of the overall treatment plan. Tamoxifen has been used extensively in treating breast cancer with good long term follow up that proves its effectiveness. It is taken as a pill once daily for 5 years and it fundamentally changes the breast’s environment in a way that discourages the growth of cancer. This effect lasts long after a woman stops taking the drug. While it is generally well tolerated, it can cause hot flashes in some, and it is associated with a small risk of developing uterine cancer or blood clots. Aromatase Inhibitors such as “Arimidex” and “Femara” work in a fundamentally different way than tamoxifen. They block the production of estrogen by fatty tissue throughout the body, including the breast itself. Estrogen is produced in these tissues using an enzyme called aromatase, and this becomes the most important source of estrogen after menopause. These drugs are only effective in women who are beyond menopause and are not used in women who still have active menstrual cycles. The aromatase inhibitors haven’t been around as long as tamoxifen so we don’t have the same kind of long term follow up, but we do have strong evidence that they reduce the chance that the cancer will recur and they are better at preventing disease development in the opposite breast. These drugs do not carry the same risk of uterine cancer or blood clots as Tamoxifen does and they are quickly becoming the drug of choice for postmenopausal women with hormone receptor positive breast cancer. Hormonal therapies can be given in addition to chemotherapy, but in some cases, they can be used instead of chemotherapy. The stronger the hormone receptor status is, the more benefit the woman enjoys. Older women with strongly receptor positive disease are particularly good candidates for using hormonal treatment as their primary systemic therapy instead of chemotherapy. For most others, a combination of chemotherapy and hormonal therapy is optimal. A very useful website for estimating the relative benefits of hormonal therapy and chemotherapy after breast cancer surgery is available at AdjuvantOnline.com. This website was developed by Mayo Medical Clinic, and it uses a vast database of breast cancer patients and their outcomes in order to give both patients and physicians a realistic look at what each of these therapies have to offer in terms of preventing recurrence and improving survival. Radiation Therapy Radiation Therapy Women who undergo a lumpectomy in treatment of their breast cancer need to complete breast radiation to help prevent the cancer from recurring in the breast. The radiation kills the individual cancer cells that that we know exist in the breast tissue around the tumor but we cannot see with the microscope. Traditionally, the radiation is applied to the whole breast in brief exposures five days a week for six weeks. Therapy generally starts about a month following the breast operation, or after chemotherapy. Radiation therapy does not hurt, nor does it make one sick or lose hair. Women can develop some skin changes similar to a sunburn but these changes resolve with time. The underlying heart and lungs receive minimal exposure to the radiation beams so the risk of a serious complication involving these vital organs is extremely small. We have a long experience with this technique and it is very effective at controlling the disease in the breast. It is considered a standard therapy for any women who undergoes a lumpectomy for her breast cancer. Newer Radiation Options Radiation therapy is an important part of breast cancer treatment when a lumpectomy is performed. This treatment has traditionally been delivered as a daily basis, 5 days a week for 6 to 7 weeks. Several large studies have now shown that we can achieve the same excellent cancer control without compromising the appearance of the breast while delivering the treatment over 3 weeks instead. This shortened course is referred to as “hypofractionated breast radiation” and your radiation oncologist will discuss with you whether that approach is appropriate for your disease. Small very favorable cancers may be well treated with these more localized radiation techniques. "Accelerated Partial Breast Irradiation" with a Mammosite balloon catheter is one such technique. With this technique, a balloon shaped device is placed in the space left in your breast when the tumor is surgically removed. The balloon is attached to a flexible tube that allows delivery of radiation directly into the tumor bed through the balloon. Using this technique, radiation therapy generally begins within a week after the breast operation and is delivered twice daily for 5 days, and then the balloon is removed. Experience to date suggests that the technique results in similar control of local recurrences as the whole breast approach, but with a much shorter time frame. This feature has obvious appeal to both patients and physicians alike, but it is important to make sure that local control of the disease over the long term is not compromised by the more limited approach. To this end, a formal clinical trial comparing the two techniques directly is ongoing and women are invited to participate in order to answer this critical question. Another technique for more limited breast radiation is actually performed in a single treatment delivered in the operating room as part of the lumpectomy. This technique known as "Intraoperative Radiotherapy" has been studied in a clinical trial setting and when used in women with small favorable breast cancers, it has been shown to be equivalent to traditional whole breast radiation in terms of controlling disease without causing undo side effects. These early results are certainly promising. However, the technique requires special equipment that is not available at every hospital the way other techniques are. Hopefully with the growing evidence for its safety and effectiveness, the technique will become more widely available to all women whose cancers qualify for it. Radiation After Mastectomy Women who undergo mastectomy in treatment of their breast cancer generally do not need to have radiation. However, there are certain circumstances under which we know that a cancer can come back even after a mastectomy, and we can reduce that chance by radiating the chest wall after the mastectomy. These circumstances include having a tumor that is large (greater than 5 centimeters) or having 4 or more lymph nodes containing disease. In some instances, those with lesser lymph node involvement ( 1-3 nodes involved) may also benefit from radiation after mastectomy if their breast tumor has other aggressive features. Radiation to a mastectomy that has been reconstructed with an implant can dramatically affect the appearance of that breast and can cause complications that may result in implant loss. As such, it is important for any patient considering mastectomy with reconstruction to discuss the need for post mastectomy radiation in order to make the best decision about her reconstructive options. Clinical Trials Clinical Trials There are a number of clinical trials available to patients newly diagnosed with breast cancer. Clinical trials have the potential to make available to patients cutting edge therapies that may improve outcomes or limit morbidity. Avid participation in breast cancer clinical trials by a generation of brave women before us has allowed the science of treating this disease to advance dramatically. Our understanding of breast cancer grows dramatically each year as results from large clinical trials addressing important clinical questions report their findings and give new direction to treatment guidelines. Women have traditionally participated actively in these clinical trials as a way of gaining access to new and hopefully better treatment strategies for themselves as well as providing better treatment options for future generations. Recognizing when a clinical trial is appropriate for a given patient and making that trial available is an essential part of the breast cancer evaluation, and I routinely collaborate with my colleagues to ensure that all patients have this opportunity.