Latest Developments in Breast Cancer Treatment

We have developed new ways to operate to remove breast masses. This work began with removal of silicone breast implants. We have been able to remove breast masses without severe deformity that is commonly seen with mastectomy. See section on FRS for Breast Masses and read all of this.

Any breast mass requires our full educational program. You must read all this material even if you only have silicone leakage. We want all women educated.

Breast Cancer

Breast cancer occurs most often in women, although men can also develop this disease. Each year, more women in the United States are diagnosed with breast cancer than with any other cancer, with the exception of skin cancer. Here, we focus on breast cancer in women and recommend that men who have been diagnosed with breast cancer speak to their doctor for information specific to them.

Breast cancer can develop at any age, but the risk of developing it increases as women get older. It is the second leading cause of cancer death, behind lung cancer, for American women. While 5% to 10% of breast cancers are related to an inherited defect in one of two genes (BRCA-1 or BRCA-2), the majority of cases develop for reasons we do not yet understand. As a general rule, those at higher risk of developing breast cancer include women whose close relatives have had the disease, women who have not had children and women who had their first child after the age of 30.

Breast cancer may be divided into three stages, reflecting the extent to which the cancer has spread in the body.

Early stage breast cancer is usually confined to the ducts that transport milk to the nipple during lactation (breast feeding) or to the lobules (small areas of tissue where milk is produced in the breast) and is known as noninvasive cancer. If the cancer is confined to the ducts, it is called ductal carcinoma in situ (DCIS) and if it is confined to the lobules, it is called lobular carcinoma in situ (LCIS). At this stage, the cancer cannot be felt as a lump in the breast, but DCIS can sometimes be detected by mammography.
Invasive stage breast cancer is characterized by a spread of the cancer beyond the ducts or lobules and into the surrounding areas of breast tissue. At this stage, the cancer may be detected through a breast self-exam, by a clinical breast exam performed by a health care professional, or by mammography.
Metastatic stage breast cancer is cancer that has spread (metastasized) to other areas of the body, including nearby lymph nodes. At this stage, treatment requires the combined effort of several specialists, including surgeons, oncologists, and radiologists.

Laboratory Tests

There are a variety of laboratory tests that can be performed to diagnose and monitor breast cancer and its treatment. These tests can be broken down into four groups, based on the purpose of testing:

To diagnose: cytology (microscopic examination of cells obtained through fine needle aspiration) and surgical pathology (microscopic examination of tissue sampling via biopsy)
To determine treatment options: evaluation of HER-2/neu gene amplification status, estrogen and progesterone receptor status
To monitor (identify recurrence): CA 15-3 / CA 27.29
To determine genetic risk: examination of mutations that may be present in the BRCA-1 and BRCA-2 genes

When a radiologist detects a suspicious area (calcifications or a non-palpable mass) on a mammogram, or a lump has been found during a clinical or self-exam, a doctor will frequently order a needle or surgical biopsy or a fine needle aspiration. In each case, a small sample of tissue is taken from the suspicious area of the breast so that a pathologist can examine the cells microscopically for signs of cancer. This pathological examination is done to determine whether the lesion is benign or malignant. This determination will guide treatment.

The microscopic evaluation of biopsy material for cancer evaluates cells under a microscope for evidence of malignancy (change from normal to cancerous breast cells). Signs include change in the size of cell nuclei and evidence of increased cell division. Needle aspirations are limited due to the small sample that is obtained. A tissue biopsy is needed to determine if the cells are early stage or invasive. If the pathologist's diagnosis is carcinoma, there are several tests that may be performed on the cancer cells. The results of these tests provide a prognosis and help the oncologist guide the patient's treatment. The most useful of these are HER-2/neu and estrogen and progesterone receptors.

Her-2/neu is an oncogene . Its gene product, a protein, is over-expressed in approximately 20% to 30% of breast cancers. The overexpressed protein is present in unusually high concentration on the surface of some malignant breast cancer cells, causing these cells to rapidly proliferate. It is important because these tumors are susceptible to treatment that specifically binds to this overexpressed protein. The chemotherapeutic agent Herceptin (Tastuzumab) blocks the protein receptors, inhibiting continued replication and tumor growth. Two common techniques are used to determine HER-2/neu status in breast cancer: immunohistochemistry (a method for detecting the oncoprotein) and fluorescent in situ hybridization (FISH), a technique for detecting gene amplification. Currently, the gold standard for assessing HER-2/neu status is immunohistochemistry (IHC), and the results are scored as 0, 1+, 2+ and 3+ where 0 and 1+ are considered negative results and 2+ and 3+ are considered positive. A positive result suggests the patient is a good candidate for Herceptin therapy. FISH may be used to confirm HER-2/neu positive status by IHC or to help when IHC generates an unclear result.
Estrogen and progesterone receptor status are also determined by immunohistochemistry. These are very important prognostic markers in breast cancer, and the higher the percentage of overall cells positive as well as the greater the intensity, the better the prognosis. Estrogen and/or progesterone receptor positivity in breast cancer cells is an indication the patient may be a good candidate for hormone therapy.

Other laboratory tests may be used to help determine whether or not the tumor is responding to therapy or if it has recurred. The CA15-3 (or CA 27.29) tumor marker is one such laboratory test, and is used after treatment, to monitor a patient for breast cancer recurrence. However, it is important to understand that some cancer-free individuals have normal, low levels of these substances in their blood and/or urine. Therefore, only a medical professional can evaluate whether the results of such a test are cause for concern. In general, CA 15-3 is a poor screening test but an excellent surveillance test in some patients; it is unreliable for detecting cancer but can be used to follow it once it has been diagnosed.

There are additional tests that may be used in breast cancer cases, such as DNA ploidy, Ki-67 or other proliferation markers. However, most authorities believe that HER-2/neu, estrogen and progesterone receptor status are the most important to evaluate first. The other tests do not have therapeutic implications and, when compared with grade and stage of the disease, are not independently significant with respect to prognosis. Some medical centers use these tests for additional information in evaluating patients and it is important to discuss the value of these tests with your cancer management team.

Women who are at high risk because of pre-menopausal cancer or a positive family history of early onset breast cancer or ovarian cancer can find out if they have the BRCA-1 or BRCA-2 gene mutation by taking a blood test. Since the normal function of the BRCA genes is to protect a woman from developing breast cancer, a mutation in either gene indicates that the patient is at significantly higher lifetime risk (up to 80%) for developing the disease. It is important to remember that most cases of breast cancer occur in women who lack mutations in either BRCA gene. A trained health care provider should explain the meaning of the results and offer advice about options for decreasing risk. Counseling should be considered both before testing takes place and after receiving test results.

In addition to laboratory tests, there are non-laboratory tests that are equally important. These include:

Mammography is widely recommended as a screening tool. A screening mammogram uses X-ray technology to produce an image of the breasts and can reveal breast cancer up to two years before a lump is large enough to be felt during a clinical or self-exam.
Newer technologies, such as digital mammography and computer-aided detection, may yield a clearer image than a mammography in some cases. In particular, younger women, whose breast tissue is often too dense to show tumors clearly on the X-ray film used for a standard mammogram, may benefit from ultrasound exams or magnetic resonance imaging (MRI).
Ductal lavage may also be used as a screening tool - particularly for women at high risk for developing the disease. In this procedure, a doctor extracts cells via a tiny tube inserted through the patient's nipple. Those cells are then examined for signs of cancer.

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