Breast Cancer: Stages and Treatment

What Is Breast Cancer?

Breast cancer, a common cancer in women, is a disease in which cancer (malignant) cells are found in the tissues of the breast. Each breast has 15-20 sections called lobes, which have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts. The most common type of breast cancer is ductal cancer. It is found in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma. Lobular carcinoma is more often found in both breasts than other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer. In this disease, the breast is warm, red, and swollen.

The genes in your cells carry the hereditary information that you got from your parents. Sometimes, a test can be done to look for a gene that may be associated with a certain hereditary trait. Recently, a gene was found to be defective in 5% of breast cancer patients. Hereditary breast cancer makes up about 5%-10% of all breast cancer cases. Relatives of breast cancer patients who carry this defective gene may be more likely to develop breast or ovarian cancer. Tests are being developed to find who has the genetic defect long before any cancer appears.

You should see your doctor if you notice changes in your breast. Women older than 50 years of age should also have a special x-ray called a mammogram, which may find tumors that are too small to feel. Check with your doctor on how often you should have this xray.

Breast examIf you have a lump in your breast, your doctor may need to cut out a small piece and look at it under the microscope to see if there are any cancer cells. This procedure is called a biopsy. Sometimes the biopsy is done by inserting a needle into the breast and drawing out some of the tissue. If the biopsy shows that there is cancer, it is important that certain tests (called estrogen and progesterone receptor tests) be done on the cancer cells.

Estrogen and progesterone receptor tests may tell whether hormones affect the way the cancer grows. They may also give information about the chances of the tumor coming back (recurring). The results help your doctor decide whether to use hormone therapy to stop the cancer from growing. Tissue from the tumor needs to be taken to the laboratory for estrogen and progesterone tests at the time of biopsy because it may be hard to get enough cancer cells later, although newer techniques can be used on tissue that is not fresh.

About 15%-20% of breast cancers are sometimes called carcinoma in situ (found only in the duct area). They may be either ductal carcinoma in situ (sometimes called intraductal carcinoma) or lobular carcinoma in situ. Sometimes lobular carcinoma in situ is found when a biopsy is done for another lump or when an abnormality is found on the mammogram. Even though it is referred to as a cancer, it is not actually cancer. However, patients with this condition have a 25% chance of developing breast cancer in either breast in the next 25 years.

Your chance of recovery (prognosis) and choice of treatment depend on the stage of your cancer (whether it is just in the breast or has spread to other places in the body), the type of breast cancer, certain characteristics of the cancer cells, and whether the cancer is found in your other breast. Your age, weight, menopausal status (whether you still have menstrual periods), and general health can also affect your prognosis and choice of treatment.

Once breast cancer has been found, more tests will be done to find out if the cancer has spread from the breast to other parts of the body. This is called staging. To plan treatment, your doctor needs to know the stage of your disease. The following stages are used for breast cancer.


Stage IIIB is defined by either of the following:

  • The cancer has spread to tissues near the breast (skin or chest wall, including the ribs and the muscles in the chest).
  • The cancer has spread to lymph nodes inside the chest wall along the breast bone.
In SituAbout 15%-20% of breast cancers are very early cancers. They are sometimes called carcinoma in situ (found only in the duct area). There are two types of breast cancer in situ. One type is ductal carcinoma in situ (also known as intraductal carcinoma); the other type is lobular carcinoma in situ. Lobular carcinoma in situ is not cancer, but for the purpose of classifying the disease, it is called breast cancer in situ, carcinoma in situ, or stage 0 breast cancer. Sometimes lobular carcinoma in situ is found when a biopsy is done for another lump or abnormality found on the mammogram. Patients with this condition have a 25% chance of developing breast cancer in either breast in the next 25 years.
Stage IThe cancer is no larger than 2 centimeters (about 1 inch) and has not spread outside the breast.
Stage IIAny of the following may be true:

  • The cancer is no larger than 2 centimeters but has spread to the lymph nodes under the arm (the axillary lymph nodes).
  • The cancer is between 2 and 5 centimeters (from 1 to 2 inches). The cancer may or may not have spread to the lymph nodes under the arm.
  • The cancer is larger than 5 centimeters (larger than 2 inches) but has not spread to the lymph nodes under the arm.
Stage IIIStage III is divided into stages IIIA and IIIB.Stage IIIA is defined by either of the following:

  • The cancer is smaller than 5 centimeters and has spread to the lymph nodes under the arm, and the lymph nodes are attached to each other or to other structures.
  • The cancer is larger than 5 centimeters and has spread to the lymph nodes under the arm.

Stage IVThe cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain. Or, tumor has spread locally to the skin and lymph nodes inside the neck, near the collarbone.Inflammatory breast cancerInflammatory breast cancer is a special class of breast cancer that is rare. The breast looks as if it is inflamed because of its red appearance and warmth. The skin may show signs of ridges and wheals or it may have a pitted appearance. Inflammatory breast cancer tends to spread quickly.RecurrentRecurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the breast, in the soft tissues of the chest (the chest wall), or in another part of the body.

 

 

How Breast Cancer Is Treated

There are treatments for all patients with breast cancer. Four types of treatment are used:

  • Surgery (taking out the cancer in an operation)
  • Radiation therapy (using high-dose x-rays to kill cancer cells)
  • Chemotherapy (using drugs to kill cancer cells)
  • Hormone therapy (using hormones to stop the cells from growing).
  • Biological therapy (using your body’s immune system to fight cancer) and
  • Bone Marrow transplantation are being tested in clinical trials.

Surgery

Most patients with breast cancer have surgery to remove the cancer from the breast. Usually, some of the lymph nodes under the arm are also taken out and looked at under a microscope to see if there are any cancer cells. Different types of surgery are used:

Breast surgery

Surgery To Conserve The Breast:

Lumpectomy (sometimes called excisional biopsy or wide excision) is the removal of the lump in the breast and some of the tissue around it. It is usually followed by radiation therapy to the part of the breast that remains. Most doctors also take out some of the lymph nodes under the arm.
Partial or segmental mastectomy is the removal of the cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor. Usually some of the lymph nodes under the arm are taken out. In most cases, radiation therapy follows.

Other Types Of Surgery:

Total or simple mastectomy is the removal of the whole breast. Sometimes lymph nodes under the arm are also taken out.
Modified radical mastectomy is the removal of the breast, some of the lymph nodes under the arm, the lining over the chest muscles, and sometimes part of the chest wall muscles. This is the most common operation for breast cancer.
Radical mastectomy (also called the Halsted radical mastectomy) is the removal of the breast, chest muscles, and all the lymph nodes under the arm. For many years, this was the operation most used, but it is used now only when the tumor has spread to the chest muscles.

Reconstructive Surgery:

The TRAM Flap Procedure
TRAM1.gif
TRAM2.gif
TRAM3.gif
Identification of target
and donor sites
Raising the flap and trans-
posing it to the target site
Resulting reconstruction

Radiation therapy

is the use of high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by mouth or it may be put into the body by inserting a needle into a vein or muscle. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells outside the breast area.

If tests show that the breast cancer cells have estrogen receptors and progesterone receptors, you may be given hormone therapy. Hormone therapy is used to change the way hormones in the body help cancers grow. This may be done by using drugs that change the way hormones work or by surgery to take out organs that make hormones, such as the ovaries. Hormone therapy with tamoxifen is given for 5 years in patients with early (no lymph nodes involved). Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase your chance of getting cancer of the uterus. You should go to your doctor for a pelvic examination every year, and you should report any vaginal bleeding other than your menstrual period to your doctor as soon as possible.

If your doctor removes all the cancer that can be seen at the time of the operation, you may be given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer cells that may be left. Therapy given after an operation when there are no cancer cells that can be seen is called adjuvant therapy.

Biological therapy

tries to get your body to fight cancer. It uses materials made by your body or made in a laboratory to boost, direct, or restore your body’s natural defenses against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. This treatment is now only being given in clinical trials.

Bone marrow transplantation

is a newer type of treatment that is being studied in clinical trials. Sometimes breast cancer becomes resistant to treatment with radiation therapy or chemotherapy. Very high doses of chemotherapy may then be used to treat the cancer. Because the high doses of chemotherapy can destroy your bone marrow, marrow is taken from your bones before treatment. The marrow is then frozen and you are given high-dose chemotherapy with or without radiation therapy to treat the cancer. The marrow you had taken out is then thawed and given to you through a needle inserted into a vein to replace the marrow that was destroyed. This type of transplant is called an autologous transplant. If the marrow you are given is taken from another person, the transplant is called an allogeneic transplant.

Peripheral blood stem cell transplant

is another type of autologous transplant. Your blood is passed through a machine that removes the stem cells (immature cells from which all blood cells develop) and then returns your blood to you. This procedure is called leukapheresis and usually takes 3 or 4 hours to complete. The stem cells are treated with drugs to kill any cancer cells and then frozen until they are transplanted to you. This procedure may be done alone or with an autologous bone marrow transplant.

A greater chance for recovery occurs if your doctor chooses a hospital that does more than five bone marrow transplantations per year.

Treatment By Stage

Anatomy of breast tissueTreatment for breast cancer depends on the type and stage of your disease, your age and menopausal status, and your overall health.

You may receive treatment that is considered standard based on its effectiveness in a number of patients in past studies, or you may choose to go into a clinical trial. Not all patients are cured with standard therapy and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Clinical trials are going on in most parts of the country for all.

Treatment For Breast Cancer In Situ

Your treatment depends on whether you have ductal carcinoma in situ or lobular carcinoma in situ. Since it is difficult to distinguish between these two types, it may be helpful to have a second opinion by having your biopsy preparations (slides) studied by pathologists at another hospital.

If you have ductal carcinoma in situ, your treatment may be one of the following:

  1. Surgery to remove the whole breast (total mastectomy).
  2. Surgery to remove only the cancer (lumpectomy) followed by radiation therapy.
  3. Clinical trial of surgery to remove only the cancer (lumpectomy) followed by radiation therapy with or without hormone therapy.

Rarely, some of the lymph nodes under the arm may also be removed during the above surgeries.

If you are going to have a mastectomy, you may want to think about having breast reconstruction (making a new breast mound). It may be done at the time of the mastectomy or at some future time. The breast may be made with your own (non-breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater and not silicone gel, may also be used. Before you decide to get an implant, you may call the FDA (1-800-532-4440) to get more information, then discuss any questions you have with your doctor.

If you have lobular carcinoma in situ (LCIS), you have a marker for a higher risk of an invasive cancer in both breasts: about a 25% chance over 25 years. LCIS is not breast cancer, and many women with LCIS never develop breast cancer. The treatment options for LCIS are varied and quite controversial. Your treatment may be one of the following:

  1. Biopsy to diagnose the LCIS followed by regular examinations and yearly mammograms to find any changes as early as possible.
  2. A large clinical trial is testing hormone therapy with the drug tamoxifen to see whether it can prevent cancer from occurring. You can call the Cancer Information Service for more information (1-800-4-CANCER).
  3. Surgery to remove both breasts, called total mastectomy.

Treatment For Stage I Breast Cancer

Your treatment may be one of the following:

  1. Surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or to remove part of the breast (partial or segmental mastectomy); both are followed by radiation therapy. Some of the lymph nodes under the arm are also removed. This treatment provides identical long-term cure rates as those from mastectomy. Your doctor’s recommendation on which procedure to have is based on tumor size and location and its appearance on mammogram.
  2. Surgery to remove the whole breast (total mastectomy) or the whole breast and the lining over the chest muscles (modified radical mastectomy). Some of the lymph nodes under the arm are also taken out.

Adjuvant therapy (given in addition to the treatments listed above):

  1. Chemotherapy.
  2. Hormone therapy. If you receive a drug called tamoxifen, you will probably take it for 5 years.
  3. Clinical trials of adjuvant chemotherapy in certain patients.
  4. Clinical trials of no adjuvant therapy for patients with a good chance of recovery (prognosis).
  5. Clinical trials of treatment to keep your ovaries from working.

If you are going to have a mastectomy, you may want to think about having breast reconstruction (making a new breast mound). It may be done at the time of the mastectomy or at some future time. The breast may be made with your own (non-breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater and not silicone gel, may also be used. Before you decide to get an implant, you may call the FDA (1-800-532-4440) to get more information, then discuss any questions you have with your doctor.

Treatment For Stage II Breast Cancer

Your treatment may be one of the following:

  1. Surgery to remove only the cancer and some surrounding breast tissue (lumpectomy) or to remove part of the breast (partial or segmental mastectomy). Some of the lymph nodes under the arm are also removed. Radiation therapy is given following surgery. This treatment provides identical long-term cure rates as those from mastectomy. Your doctor’s recommendation on which procedure to have is based on tumor size and location and its appearance on mammogram.
  2. Surgery to remove the whole breast (total mastectomy) or the whole breast and the lining over the chest muscles (modified radical mastectomy). Some of the lymph nodes under the arm are also taken out.

Adjuvant therapy (following surgery):

  1. Chemotherapy with or without hormonal therapy.
  2. Hormone therapy. If you receive a drug called tamoxifen and your lymph nodes are not involved, you will probably take it for 5 years
  3. Clinical trial of chemotherapy before surgery (neoadjuvant therapy).
  4. Clinical trials of high-dose chemotherapy with bone marrow transplantation for patients with cancer in more than three lymph nodes.

Woman who has had chemo wearing scarfIf you are going to have a mastectomy, you may want to think about having breast reconstruction (making a new breast mound). It may be done at the time of the mastectomy or at some future time. The breast may be made with your own (non-breast) tissue or by using implants. Different types of implants can be used. The Food and Drug Administration (FDA) has announced that breast implants filled with silicone gel may only be used in clinical trials. Saline-filled breast implants, which contain saltwater and not silicone gel, may also be used. Before you decide to get an implant, you may call the FDA (1-800-532-4440) to get more information, then discuss any questions you have with your doctor.

Treatment For Stage III Breast Cancer

Stage III breast cancer is further divided into stage IIIA (can be operated on) and IIIB (biopsy is usually the only surgery performed).

Stage IIIA cancer:

  1. Your treatment may be one of the following surgeries: Surgery to remove the whole breast and the lining over the chest muscles (modified radical mastectomy) or the whole breast and the chest muscles (radical mastectomy). Some of the lymph nodes under the arm are also taken out.
  2. Radiation therapy given after surgery.
  3. Chemotherapy with or without hormone therapy given with surgery and radiation therapy.
  4. Clinical trials are testing new chemotherapy with or without hormonal drugs; they are also testing chemotherapy before surgery (neoadjuvant therapy).
  5. Clinical trials of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.

Stage IIIB Cancer:

Your treatment will probably be biopsy followed by radiation therapy to the breast and the lymph nodes. In some cases, a mastectomy may be done following radiation therapy.

  1. Chemotherapy to shrink the tumor, followed by surgery and/or radiation therapy.
  2. Hormonal therapy followed by additional therapy.
  3. Clinical trials are testing new chemotherapy drugs and biological therapy, new drug combinations, and new ways of giving chemotherapy.
  4. Clinical trials of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.

Treatment For Stage IV Breast Cancer

You will probably have a biopsy and then be given one or more of the following:

  1. Radiation therapy or, sometimes, a mastectomy to reduce your symptoms.
  2. Hormonal therapy with or without surgery to remove your ovaries.
  3. Chemotherapy.
  4. Clinical trials are testing new chemotherapy and hormonal drugs and new combinations of drugs and biological therapy.
  5. Clinical trials of high-dose chemotherapy with bone marrow or peripheral stem cell transplantation.

Treatment For Inflammatory Breast Cancer

Your treatment will probably be a combination of chemotherapy, hormonal therapy, and radiation therapy, which may be combined with surgery to remove the breast. The treatment is usually like that for stage IIIB or IV breast cancer.

Treatment For Recurrent Breast Cancer

Hands covering breastsBreast cancer that comes back (recurs) can often be treated, but usually cannot be cured when it recurs in another part of the body. Some patients with recurrence in the breast can be cured, however. Your choice of treatment depends on hormone receptor levels, the kind of treatment you had before, the length of time from first treatment to when the cancer came back, where the cancer recurred, whether you still have menstrual periods, and other factors.

Your treatment may be one of the following:

  1. Hormonal therapy with or without surgery to remove your ovaries.
  2. For the small group of patients whose cancer has come back only in one place, surgery and/or radiation therapy.
  3. Radiation therapy to help relieve pain due to the spread of the cancer to the bones and other places.
  4. Chemotherapy.
  5. A clinical trial of new chemotherapy drugs, new hormonal drugs, biological therapy, or bone marrow transplantation.

Speak Your Mind

*