Tigerlily Foundation: During Breast Cancer

There are several different types of breast cancer that can be divided into two main categories —noninvasive cancers and invasive cancers.

Noninvasive cancer may also be called carcinoma in situ. Noninvasive breast cancers are confined to the ducts or lobules (glands that make milk) and they do not spread to surrounding tissues. The two types of noninvasive breast cancers are ductal carcinoma in situ (referred to as DCIS) and lobular carcinoma in situ (referred to as LCIS).

Invasive (infiltrating) breast cancer breaks through normal breast tissue and invades neighboring areas.

In LCIS, the abnormal cells are found only in the lobules of the breast. Unlike DCIS, LCIS is not considered to be a cancer. It is more like a warning sign of increased risk of developing an invasive breast cancer in the same or opposite breast. While LCIS is a risk factor for invasive cancer, it doesn't actually develop into invasive breast cancer in many women.

There are several kinds of invasive breast cancers. The most common type is invasive ductal carcinoma (IDC), which appears in the ducts and accounts for about 80% of all breast cancer cases. Invasive means that it has "invaded" or spread to the surrounding tissues. It is ductal because the cancer began in the milk ducts—which are the "pipes" that bring milk from the lobules to the nipple. Carcinoma refers to any cancer that begins in the skin or other tissues that cover internal organs—such as breast tissue (breastcancer.org).

The other type of invasive breast cancer is known as invasive lobular cancer (ILC). Invasive lobular carcinoma, or ILC, accounts for about 10%–15% of all breast cancers. Lobular means that the cancer began in the lobules—the glands that actually make milk, then invaded the surrounding tissue.

Breast cancer is the most common cancer in women in the United States (US). According to the American Cancer Society, it's estimated that 212,920 women will be diagnosed with invasive breast cancer in the US in 2006, along with 61,980 new cases of non-invasive breast cancer; of those numbers, 40,970 women will die from the disease. These are disturbing statistics. In order to lower your risk for getting breast cancer, you need to stay educated about the disease.

Breast cancer is a malignancy that can occur in one or both breasts, (in male or females), that is caused by an uncontrolled growth of malignant breast cells.

According to breastcancer.org, “[even though] cancer is always caused by a genetic "abnormality" (a "mistake" in the genetic material), only 5–10% of cancers are inherited from your mother or father. Instead, 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and life in general.”Most women who get breast cancer have no known family history of the disease.

According to breastcaner.org, one of the best ways to detect breast cancer in the early stages is by performing a routine self examination. By doing this once a month, you familiarize yourself with the look and feel of your breasts, which will allow you to detect any irregularities, should one occur.

Breast Self Examinations can be uncomfortable emotionally for some women, and also frustrating, because you don’t know what the heck you are looking for at first. The most important thing to remember is that you need to know your breasts as intimately as possible. If you take the time to do this once a month, you are taking an important step in terms of your breast health. Regular breast self examinations, in conjunction with yearly exams by a doctor are important factors in early detection of breast cancer.

At first, it might seem like a challenge remembering to do the exam on a regular basis, but try to incorporate it into your usual routine, for example, if you get your hair done at the salon once a month, do your exam that day of the week, or it could be during the week you pay your bills, etc.

Examine yourself several days after your period ends, when your breasts are least likely to be swollen and tender.

If you feel a lump, don't panic. Most women have some lumps or lumpy areas in their breasts all the time. Eight out of ten breast lumps that are removed are benign, non-cancerous.

Breasts tend to have different "neighborhoods." The upper, outer area—near your armpit—tends to have the most prominent lumps and bumps. The lower half of your breast can feel like a sandy or pebbly beach. The area under the nipple can feel like a collection of large grains. Another part might feel like a lumpy bowl of oatmeal.

What's important is that you get to know the look and feel of YOUR breasts' various neighborhoods. Does something stand out as different from the rest (like a rock on a sandy beach)? Has anything changed? Bring to the attention of your doctor any changes in your breasts that:

Some women wonder why they need to have their doctors examine their breasts when they're doing regular self-exams on their own. Even though most lumps are found by women themselves, a breast exam by a doctor helps find lumps that women may miss. Sometimes, the abnormality in a breast can be so difficult to feel that only someone with experience would recognize it. Lumps, thickening, asymmetry—changes in your breasts that you may not notice or think are "normal"—may be picked up on by people who examine many breasts regularly.

Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.

Step 3: While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).

Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together.

Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage.

Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. Be sure to feel all the breast tissue: just beneath your skin with a soft touch and down deeper with a firmer touch. Begin examining each area with a very soft touch, and then increase pressure so that you can feel the deeper tissue, down to your ribcage.

Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

When a lump in the breast is detected, one of the major concerns is “what do I do now”? Well, there are a myriad of options available, including local treatment, systemic treatment and alternative treatments. All of these options require careful thought and consideration. How you proceed is very important. There are various factors involved in making this decision, including your family history, how large the tumor, your age, physical health and also any related pre-existing medical condition(s) that could impact cancer treatment and long-term health. Below, is information about treatment options.

Local Treatment
Local treatment involves directly treating the target area. Doctors will usually perform diagnostic surgery, such a biopsy to determine whether or not the lump is cancerous.

During a biopsy, the doctor will remove cells/tissue to determine whether the lump is cancerous or not. There are three different kinds of biopsies. In an incisional/core biopsy, a sample of tissue is removed; a needle biopsy or aspiration is where the doctor uses a hollow needle to remove tissue or fluid, then study the tissue or fluid is studied to determine whether it is normal or abnormal; or the doctor can do an excisional biopsy and remove the entire tumor.

If it is determined that the issue is abnormal, and a diagnosis of breast cancer is made, the next steps are to explore surgery options.

A lumpectomy is known as breast-conserving surgery because it preserves a part of the breast, as opposed to a mastectomy, which involves removal of the breast. During a lumpectomy, only the lump is removed. The breast surgeon also removes the margins (normal tissue around the lump), to make sure that the lump and any cancer cells around it are taken out of the breast. If the doctor finds that cells in the margins are cancerous, the surgeon will do a re-excision to remove the additional cancer. A lumpectomy is usually followed by chemotherapy or radiation, or both.

A mastectomy involves the removal of the entire breast. There are several kinds of mastectomy options available.

A “simple" or "total" mastectomy is where the surgeon removes the entire breast but does not take out any axillary lymph nodes (nodes in the underarm area, also called the axilla). No muscles are removed from beneath the breast. Occasionally, lymph nodes may be removed because they are actually located within the breast tissue taken during surgery.

A modified radical mastectomy removes the entire breast and includes a procedure called axillary dissection, in which levels I and II (of three levels) of the axillary lymph nodes in the underarm area) are also removed. Most women who have mastectomies have modified radical mastectomies.

Radical mastectomy includes removal of the entire breast, all underarm lymph nodes, and chest wall muscles under the breast. Although common in the past, radical mastectomy is now rarely performed because modified radical mastectomy has proven to be just as effective and less disfiguring. Today radical mastectomy is recommended only when cancer has spread to the chest muscles under the breast.

You and your doctor will have to discuss whether a mastectomy is right for you; and decide on the type of mastectomy you have will be based on several factors - including whether or not cancer is found in more than one place in your breast, the size of your breast, your family history, health, age, and whether or not you will have more peace of mind having the whole breast removed.

In addition to surgery, the doctor could recommend radiation. After a lumpectomy or mastectomy, radiation is an additional treatment that involves the use of high-energy radiation from x-rays, gamma rays, neutrons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body in the area near cancer cells (internal radiation therapy, implant radiation, or brachytherapy).

Alternative Treatments
Alternative treatment is also known as holistic treatment. The goal of this type of treatment is to provide physical, mental, and emotional balance to the patient, while they undergo their medical treatment. Alternative treatments can help to relieve stress, provide relaxation and more peace of mind, lessen symptoms and help to make the patient’s quality of life better. (www.breastcancer.org)

What does a diagnosis of triple negative breast cancer mean? It means that your pathology report shows that the tumor is estrogen receptor-negative, progesterone receptor-negative and HER2-negative.

Many women find themselves very fearful, knowing that they have this diagnosis. Even though the over-expression of HER2 can be a more aggressive breast cancer, women who are progesterone positive or estrogen positive can receive treatments like Herception and Tamoxifen among others, to help prevent the cancer from recurring. Women who are triple negative, on the other hand, feel like aside from chemotherapy, there is no systemic treatment that they can have long-term to prevent recurrence.

"Triple negatives" are breast cancers that are characterized by three biological components that make the disease more difficult to treat. Oncologists base treatment decisions on the presence of three receptors known to fuel most breast cancers -- estrogen receptors, progesterone receptors and human epidermal growth factor receptor 2 or HER2. The most effective agents for breast cancer, such as tamoxifen and trastuzumab (Herceptin), work by targeting these receptors. Women with triple negative tumors lack all three.”

"Triple negative disease has not been adequately described or studied, particularly among minority populations," said Emory researcher and lead author Mary Jo Lund, Ph.D. "It has one of the worst prognoses because the tumors have some of the worst characteristics and preclude the use of targeted effective treatments," said Lund.

In a study of racial differences in the prevalence of triple negative invasive breast tumors, a team of researchers from Emory University's Rollins School of Public Health and Winship Cancer Institute, the Fred Hutchinson Cancer Research Center in Seattle, and the Centers for Disease Control, found the incidence of triple negative disease in African-American women to be more than twice that of white women.

More research needs to be done in regards to treating women diagnosed as triple negatives and determining the long term risks.

What is a cell?
Cells are tiny spheres that make up all of the organs and tissues in your body. Cells also make up cancerous tumors. Cells are too small to see with your eyes.

What is HER-2/neu?
HER-2/neu (also known as HER-2) is a protein that is found on the surface of breast cells.1 It sends messages to the cell from 'growth factors' outside the cell. Growth factors tell cells to grow and divide.

What does it mean to be HER-2/neu positive?
Everyone has the HER-2/neu protein. But in some breast cancers, the cells produce many more HER-2/neu proteins than normal. These breast cancers are called 'HER-2/neu positive cancers.' Breast cancers that have very few HER-2/neu proteins, or none at all, are called 'HER-2/neu negative cancers.' It is sometimes unclear whether women with low levels of HER-2/neu are actually Her-2/neu positive or negative. HER-2/neu positive breast cancers grow faster than HER-2/neu negative breast cancers.

What treatments are available for women with HER-2/neu positive breast cancer?
On September 28, 1998, the Food and Drug Administration (FDA) approved trastuzumab (Herceptin®), a monoclonal antibody given through an intravenous (IV) infusion, for use in combination with paclitaxel (Taxol®), as a treatment for patients with HER-2 positive, advanced metastatic breast cancer. Herceptin is a drug that can block HER-2/neu and prevent HER-2/neu positive cancers from growing. It is an effective treatment in many women with metastatic, HER-2/neu positive breast cancer. But the drug has little effect on women with HER-2/neu negative breast cancer. As a result of clinical trials, the FDA has approved Herceptin to be effective among patients with early stage HER-2/neu positive breast cancer. However, the data given to the FDA for evaluation comes from two clinical trials that were stopped early due to better-than-expected results among the women given Herceptin.2 While the studies show substantive improvements in recurrence-free survival and overall survival among those treated with Herceptin, NBCC believes that long-term follow-up of study participants is necessary in order to fully assess the impact of Herceptin on breast cancer in this population. On November 16, 2006, the FDA expanded the use of trastuzumab (Herceptin®) as a treatment for patients with HER-2 positive breast cancer after lumpectomy or mastectomy surgery in combination with other cancer drugs. The approval was granted based on the results, of the two clinical trials mentioned previously, that were combined and analyzed in 2005. For NBCC's full analysis of these trials, go to Adjuvant Trastuzumab (Herceptin®) Combined with Chemotherapy Increases Disease-Free Survival and Overall Survival for Women with HER2-Positive Early Breast Cancer.

On March 13, 2007, the FDA approved lapatinib (Tykerb®), an oral cancer drug, for use in combination with capecitabine (Xeloda®) as a treatment for patients with HER-2 positive, advanced metastatic breast cancer who have already received treatment with other cancer drugs. Like the infusion drug trastuzumab, lapatinib inhibits the over-expression of epidermal growth factor receptors and HER-2/neu cell receptors, which have been associated with rapid cell growth and tumor progression in breast cancer. Recently published interim results from an international, phase III clinical trial3 showed that among women with HER-2 positive, metastatic breast cancer that received lapatinib plus capecitabine, the median time to progression was almost double that among women treated with only capecitabine. It was data from this pivotal trial upon which FDA primarily based its approval of lapatinib.

Lapatinib (Tykerb®) approved by the FDA for second-line treatment of HER-2 positive, metastatic breast cancer

1 Slamon D, et al. (2001) Use of chemotherapy plus a monoclonal Ab against HER-2 for metastatic breast cancer that overexpresses HER-2. N Engl J Med 344:783-792.
2 Romond EH, et al. (2005) Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. N Engl J Med 353:1673-1684.
3 Geyer CE, Forster J, Lindquist D, et al. Lapatinib plus capecitabine for HER-2 positive advanced breast cancer. New Engl J Med 2006 Dec 28; 355(26): 2733-43.
FDA News. 16 November 2006 (updated 12 December 2006). http://www.fda.gov/bbs/topics/NEWS/2006/NEW01511.html.

Lesson #6: Making Decisions

Decades ago, women were wheeled into the operating room not knowing if they would wake up with a breast still in place or not. Today, there's a great deal of emphasis on the doctor and patient sharing the decision-making process. There's also a lot more information available. While having power and information is a good thing, it can also be very stressful. Many women feel—if only at times—that it'd be much easier if their doctor would deliver a firm, old-fashioned order about what they should do.
In the short term, making your own decisions may seem difficult. But in the long term you're less likely to feel anxious and depressed about what's happened to you if you took an active part in the decision-making process.
The most important thing to remember is that your treatment choices depend on your unique situation: the size and nature of the tumor, and your style of making decisions. If your doctors tell you that in your particular situation, lumpectomy and radiation is likely to be equally as effective as mastectomy, then you can feel confident in either option. You are not risking your life by keeping your breast.
Ask yourself, "Do I want to try to keep my breast?" Many women's first reaction is to say that they don't care about their breasts—the "just save my life" response. After the shock of diagnosis wears off and you've had time to think about it, you may find that keeping your breast does in fact mean a great deal to you; particularly when you feel reassured that you are not compromising your life.
" Patients are so much more involved with the entire process today than in the past. There's just more stuff to do before you have surgery, and that's because there are so many more options available. On the flip side, there are many more consultations that you need to coordinate. We break it down and slow it down, so that when people make a decision they feel more in control, and more committed to their decision." —Anne L. Rosenberg, M.D.