FAQs After a New Diagnosis of Breast Cancer
Related narrative: Breast Cancer Overview
Frequently Asked Questions after a New Diagnosis of Breast Cancer
1. What is breast cancer?
Origin: Most breast cancers arise from the ducts (~80%) or lobules (glandular elements)(20%) of the breast and are the type of cancer called carcinomas (cancers arising from epithelial/surface structures). There are a few other rare forms of cancer that arise in the breast.
In situ: When an early breast cancer has not yet broken through the surrounding basement membrane, it is called "in situ" and does not have the capability to spread malignant cells through lymphatic or venous channels to the rest of the body.
Invasion: Once the tumor has broken through the basement membrane, it is called invasive (invasive ductal/IDC, or invasive lobular/ILC carcinoma). Ductal carcinoma in situ has the potential to progress to invasive ductal. Lobular carcinoma in situ (LCIS) is not thought to progress to invasive lobular, but is a warning sign of increased risk of developing a subsequent breast cancer, usually ductal in nature. When invasive lobular does occur, it is a true invasive cancer.
Hormones: Breast tissue cells have varying quantities of protein receptors to which natural hormones like estrogen and progesterone bind and promote cell growth. The presence and quantity of such receptors determines the possibility of effective hormone-blocking therapy. Another receptor which binds a growth factor, HER2neu, is measured and offers additional information to guide hormone therapy.
Genetics: A small percentage of individuals have a strong family history of breast cancer and a genetic mutation which predisposes to breast cancer, often at a younger age.
2. How is breast cancer detected?
Imaging plus examination: Breast cancer can be detected by imaging (X-ray, magnetic resonance/MRI), self-breast exam, or clinical breast exam (by a health care provider). Imaging is most sensitive and can detect lesions at a much smaller size than by palpation, and thus at a much earlier stage.
Mammography: Digital mammography is the current primary screening imaging modality. Current mammography recommendations in the United States are for yearly mammograms starting at age 40 unless other factors point to a higher risk, in which case an earlier mammogram might be indicated. Mammography can guide diagnostic core biopsy of a lesion to obtain tissue for microscopic examination, and guide placement of a localizing needle for surgical excision of a non-palpable suspicious finding.
MRI: MRI is a sensitive modality that can give additional information about the extent of a mammographically detected lesion and can identify other suspicious areas. It is not usually used for primary screening at this time.
Ultrasound: Ultrasound is a focused imaging technique for distinguishing whether a palpable lump is cystic (fluid-filled cavity) or solid, and for guiding core biopsy of a mass. Ultrasound reveals the characteristics (borders, shape, size) of a solid mass. A palpable lump can be diagnosed directly by core biopsy after ultrasound determines it is solid. Ultrasound is not a generalized screening technique.
Tissue processing: Once tissue is obtained and a diagnosis of malignancy is made, the tissue is also stained to determine the quantity of protein receptor molecules present on the surface of the cells. Estrogen and progesterone receptors (ER/PR) allow binding of these hormones, which in turn stimulate the breast cells to grow. The greater the presence of receptors, the more the cancer will be stimulated to grow by these naturally occurring hormones. Most breast cancers are hormone receptor positive. Another, less common, type of protein receptor is for a growth factor (HER2neu) which also stimulates breast cell growth.
3. How is breast cancer staged?
TNM: The stage of the breast cancer is determined by three components comprising the TNM classification:
Tumor: Tumor status, lymph node status and metastasis (spread). The tumor is classified by gross size in centimeters as measured by palpation, X-ray and ultrasound, and by aggressiveness judged by histology (microscopic characteristics/grade).
Nodes: The presence of tumor cells in the lymph nodes and the extent of involvement determines nodal status.
Metastasis: Metastasis is either present or absent judged by chemical, radiographic and nuclear scan tests.
Stage: The combination of these elements determines the stage from I-IV, and the stage is related to prognosis, worsening from I to IV. Clinical staging is established by the initial work up, and definitive pathologic staging is established after surgical excision of the tumor and lymph nodes.
4. What happens once a breast cancer is diagnosed?
Staging work up: Routine laboratory blood tests and chest X-ray would be done for early (stage I and II) breast cancers, and additional scans (CT scan of the chest, abdomen and pelvis) might be ordered as indicated by mammogram, symptoms or laboratory findings. In a more advanced cancer where there is a concern for metastasis, additional scans such as bone and PET scan may be ordered.
Multidiscipline clinic: Once the initial test results are back, the patient is seen by teams of specialists (surgery, medical oncology, radiation oncology, geneticists, physical therapists and social workers) in multidiscipline clinic and discussed by those groups in multidiscipline conference.
5. What happens after multidiscipline conference?
Communication: The therapeutic recommendations are communicated to the patient by the various specialties and the patient is give a choice of options according to the stage of disease.
Early disease: Fortunately, many cancers are now detected early (defined as a cancer that has not spread beyond the breast and axillary lymph nodes) by mammography and can be treated with less radical local and systemic treatments. There is little or no risk of decreasing survival with an interval of up to 4 weeks between detection and definitive treatment of early breast cancer. Most women treated for early breast cancer will not die of the disease.
Advanced initial disease: In cases of locally advanced initial disease (e.g. large tumor, skin or chest wall invasion), the recommendation may be to begin with chemotherapy (neoadjuvant/induction chemotherapy) to shrink the tumor and improve the chances for negative margins, possibly allow less radical surgery, and to treat cancer cells which have escaped from the breast to other parts of the body and prevent them from implanting and growing.
Local and systemic treatment: Local treatment may include surgery and radiation therapy. Systemic treatments are chemotherapy and hormonal therapy, and in the case of HER2neu overexpression, targeted monoclonal antibody therapy.
6. What are surgical treatment options?
Breast conservation/lumpectomy: The goal of local treatment is to remove all tumor with a margin of normal tissue around it. Surgery is the current standard for removal of the tumor. For a mammographically detected lesion that cannot be felt, a needle-directed excision is usually the next step (lumpectomy/breast conservation therapy) after initial diagnosis by core biopsy. A localizing needle is placed under mammographic guidance and the surgeon removes the tissue around the needle, confirming the results with a specimen radiograph before the patient wakes up. Pathologic processing of the specimen takes 3-5 days.
If the margins are negative for tumor, no further surgery is necessary, if positive, reexcision may be necessary. There is a greater likelihood of need for reexcision with lumpectomy versus mastectomy. Most women are satisfied with the appearance of the breast after lumpectomy. Radiation to the remaining breast tissue is usually indicated after lumpectomy to reduce the risk of local recurrence.
Mastectomy: If the lesion is larger; multicentric; if the breast is small and excision would cause unacceptable deformity; if there is a genetic component; or if the patient chooses, a mastectomy may be the better surgical choice. There is a slightly higher risk of local recurrence with breast conservation/radiation (~10% at 10 years) than with mastectomy (~6% at 10 years).
Lymph nodes: If the preliminary core biopsy showed an invasive tumor, the lymph node status must be determined at the time of surgery. The current standard of care to determine lymph node status for a patient without palpable axillary nodes is sentinel lymph node biopsy, injecting a radioisotope under the areola prior to surgery. The isotope travels rapidly through the breast lymphatics to the first node in the axillary (underarm) group that drains the breast. This radioactive node(s) is/are detected intraoperatively by a gamma probe, excised and sent for rigorous sectioning and microscopic examination.
Axillary lymph node dissection: If a node is known to contain tumor by pre-operative core biopsy, a dissection of the remaining axillary nodes may be done at the time of the tumor excision (axillary lymph node dissection). If the sentinel node contains tumor, the standard of care has been to do a completion axillary lymph node dissection at a second operation. There is a trend evolving toward less aggressive axillary lymph node dissection, especially if there is minimal involvement of the sentinel node.
Reconstruction: If mastectomy was performed and the disease appears to be early stage, immediate reconstruction by plastic surgery may be done. This frequently involves placing a tissue expander (inflatable fluid-filled flexible bag) beneath the chest (pectoralis) muscle. Alternative tissue flap reconstructions are also options either initially or delayed. These involve more extensive surgery.
7. What are the potential complications of surgery?
Anesthesia: Anesthesia counsels the patient about complications related to general anesthesia, separate from the surgical counseling.
Bleeding and infection: The most common compilations of any surgery are bleeding and infection. Great care is taken to control all bleeding at the time of operation, and closed suction drains are placed at the time of surgery to remove residual oozing and help prevent infection by removing the blood, which is a good culture medium for bacterial growth. In addition, after determining the patient is not allergic to particular antibiotics, a dose of antibiotics is given intravenously a half hour before the surgery is started to establish a therapeutic level in the blood stream during the procedure. Sterile precautions in caring for the wound and drains after the surgery help prevent later infection.
Nerves: Injury to surrounding structures is an uncommon potential complication of any surgery. In the case of mastectomy, two nerves lying beneath the lateral (outside) side of the breast are carefully identified. These two nerves, the thoracodorsal and long thoracic, are motor supply to the latissimus dorsi which moves the arm downward and backward, and to the serratus anterior which holds the scapula against the chest wall. Injury to these nerves could result in loss of function of these muscles. If axillary dissection is done, the vessels leading to and from the arm, and the nerves supplying the arm (brachial plexus) are carefully protected from harm. There is a minor nerve (intercostobrachial) that runs through the axillary fat pad and supplies sensation to the medial side of the upper arm. This often needs to be divided to remove the axillary lymph nodes. The resulting numbness often resolves with time. There may also be transient numbness of the edges of the skin flaps, particularly the lower one after the surgery.
Lymph nodes: Axillary dissection disrupts some of the lymphatic channels which drain fluid from the arm. Modern surgical technique aims to take the necessary axillary lynch nodes while preserving sufficient lymphatics to prevent arm swelling (edema). Lymphedema of the arm can increase the chance of infection in the arm and can cause troublesome swelling.
8. What happens after surgery?
Tumor board: When the pathology examination is completed, usually at 5-7 days, the patient is informed and the results are discussed at a multidisciplinary tumor board conference.
Pathologic stage: Depending on the pathologic margin clearance and stage, discussion centers on the need for additional local and/or systemic therapy.
Breast conservation: If breast conservation is done, margins are clear and the sentinel node is negative for tumor cells, no further excisional surgery is needed. If breast conservation was done, radiation to the remaining breast tissue is the current standard of care to reduce the risk of local recurrence by 50%.
Nodal status: If one or more sentinel nodes contains tumor, the standard of care has been to go back and remove the remainder of the nodes (axillary lymph node dissection). This strategy is in evolution toward less radical approaches, especially if involvement of the sentinel node is minimal.
Chemotherapy: If chemotherapy is recommended, this is usually the first modality applied after healing is relatively complete (3-4 weeks). For early stage disease, a test (oncotype) screening multiple genetic factors may help refine the probably risk of recurrence to low, medium, or high, and help guide the decision whether to recommend chemotherapy or not. Various combinations of chemotherapeutic drugs may be chosen depending on the stage of disease and the patient's general health.
Radiation: If mastectomy was performed and the margins were negative for tumor cells, chest wall radiation is not recommended. However if lymph nodes were positive, axillary radiation may be recommended. If radiation is also indicated, it follows completion of any chemotherapy. Standard radiation course is five treatments per week for six weeks. The chance of serious complications (heart, lung injury, a new cancer) from radiation therapy is low (~5%). Fatigue, skin darkening and increased density of the breast may result from radiation. If cancer recurs in the radiated breast, the next step would be mastectomy.
Hormonal therapy: If the hormone receptors (ER/PR) were positive, hormonal therapy will usually be recommended. Hormone therapy involves taking a weak form of estrogen called a selective estrogen receptor modulator (SERM, e.g. Tamoxifen, Reloxifene) which binds to the receptors and prevents stronger native estrogen from binding and stimulating the breast cells. Another option is taking an agent which blocks the conversion of testosterone to estrogen (aromatase inhibitor). The latter can be used only in postmenopausal women, while SERMs can be used both pre- and postmenopausally. The hormonal treatment usually is a 5-year course, and reduces the risk of local recurrence by 50%.
HER2: If there is overexpression of the HER2 protein, a monoclonal antibody (Herceptin) against the receptor would be recommended in addition. In the absence of evidence of metastasis, chemotherapy, radiation and hormonal therapy are called adjuvant and are aimed at destroying and suppressing tumor cells that may have escaped from the local tumor sites. If there is metastasis, application of these modalities is called therapeutic.
9. What is the follow-up? After the immediate post-op care, the surgeon will examine the patient every three months for the first year, then every 6 months thereafter for life. Mammograms will be done yearly. Depending on systemic therapy, the patient will continue to see the medical oncologists according to their schedule. Additional testing will be guided by clinical findings and symptoms.