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Breast Cancer

Breast cancer is one of the most common cancers in women.  Although there can be many pitfalls in the course of breast cancer treatment, the following is intended to assist patients and their relatives to have a better understanding of the process and hopefully resulting in a better treatment outcome.  It is a difficult task to cover every single issue in relation to breast cancer, therefore I have chosen 10 most important problems that patients may face and listed them with a brief description.  Remember that you should discuss your medical problems with a physician and this pamphlet is not meant to substitute obtaining professional medical help from your doctor.  Michael H. Tirgan, MD

10 most common and important things to know once diagnosed with breast cancer are:

1-     Your doctor.

2-     Know the disease, the exact diagnosis and stage.

3-     Meet with all your doctors before having breast surgery.

4-     Get a Second opinion.

5-     Surgery

6-     Medical Oncologist

7-     Adjuvant Chemotherapy

8-     Radiation Therapy

9-     Metastatic Disease

10-   Family Issues, Genetic Testing and Counseling

1.     Your Doctor

Breast cancer is diagnosed by various doctors; primary care doctors, surgeons, Internists, etc.  Once diagnosed with this disease, first mistake to avoid it to make sure that you are being seen by the doctors who are most familiar with this disease.  They are Medical Oncologists and Surgeons.  Make sure that you talk to the people in your community to choose the best doctors there.  Once diagnosed with this cancer, one can expect to undergo a breast biopsy and Surgery to remove the tumor.  Choose an Oncology Surgeon over a General Surgeon if there is one in your reachable area.  The techniques of surgery have been improving and this is the sole reason to be operated on by an oncology surgeon.  Newer techniques are Lumpectomy and Sentinel node biopsy and removal of axillary lymph nodes.  Choose a hospital that has a cancer program and a designated Oncology Unit for your work up and evaluations and Surgery.  It is best to have all your records in one place. 

2.     Know the disease, the exact diagnosis and stage.

A- How was the diagnosis established?  Establishing the diagnosis of breast cancer can be an easy or a difficult task.  The diagnosis may be suspected based on the presence of a lump in the breast or an abnormal mammogram, however it is confirmed and established by study of a tissue biopsy.  The biopsy might have been taken via a needle (called needle biopsy) or a surgical biopsy.  The most accurate tests are actual evaluation of a large piece of the tumor under microscope.  There are various types of breast tumors, some less and some more malignant than the others and each different under microscope.  Each variety of breast tumors may require a different treatment.  So it is imperative for you to know the exact details of how the diagnosis was established and the exact type of the breast tumor.  Make sure that the doctor writes this down for you.  Obtain a copy of the pathology report from the doctor or the hospital where the biopsy was performed.  Knowing the exact type of the tumor will help you in your future research.

Once done with the diagnostic procedures and possibly surgery, make certain that you know the specifics of your illness.  The location of the tumor and the extent of the disease, whether the lymph glands under the arm are involved or not.  Whether the disease has spread to any other organ, like liver, lungs, bone, etc.  Maintain a file and keep copies of your records so that getting a second opinion is easy at any time.  Make sure you keep copies of the surgery report, pathology report, CT Scans, MRIs, etc.  Doing so helps you being able to obtain and search for information that is most appropriate for you.

B- ER, PR and HER2/NEU Status: The cancer tissue must be studied properly to determine its specifics. Among most important factors that determine the treatment plans in breast caner, are three laboratory test results.  The cancer tissue is tested for presence of special biochemical molecules on the surface of cells.  Presence or absence of these molecules has an impact on treatments plans and the overall prognosis of the caner.  Make sure that these tests are performed on the tumor tissue and that you know the result of them. Please visit www.tirgan.com to read more about these tumor markers in breast cancer.  The information about these markers is very important and crucial to have.  It is a mistake not to have this information and you must make sure that the doctors or the hospital where your surgery will take place has the ability to wither perform the tests or send a sample of the tumor tissue to another laboratory for performing.

3. Meet with all your doctors before having breast surgery.

It is imperative for patients to meet with their breast surgeon, oncologist and radiation therapist and also a plastic surgeon before any major steps are taken to undergo breast surgery.  Patients should meet with each doctor separately and ask the doctors to talk to each other about their treatment plan.  Management of breast cancer is teamwork and the doctors best talk to each other and make long term plan together for each patient, that is to plan for type of surgery, whether or not to use radiation, timing of chemotherapy and possibility of plastic surgery and reconstruction of the breast in future.  The type or extent of surgery shall be discussed and agreed upon by all doctors.  The necessity for radiation therapy shall also be discussed.   There are simply too many factors that come into play in making a treatment plan and they have to be considered before any major treatment plans are implemented.

4.  Get a Second Opinion

During the course of breast cancer, patients come in contact with various physicians, more importantly a surgeon and a medical oncologist.  It is a wise practice to obtain second opinions from other experts, even if you like to work with the doctors you already have.  It is wise to obtain second opinions from university hospitals or academic centers that are nearest to you.  Prior to undergoing surgery, it is wise to find an oncology surgeon, even if you have to travel a few hours to meet with one in a university hospital.  The same is true for a second medical oncology opinion.  Doing so will help you to prevent mistakes from happening and in most importantly makes you feel confident about the care you are receiving.

5. Surgery

Surgery is commonly the first step in treatment of majority of patients with breast cancer.  Make sure it is done by the best surgeon you can find in your area, preferably an oncology surgeon.  Surgery may not be all that a patient will need and the decision as to whether further treatments, such as chemotherapy and radiation treatments are needed depends on the findings during surgery and also on the result of pathological study of the breast tumor tissue, estrogen receptor status, CT scans of the chest, abdomen, and other staging tests. If the disease is felt to be localized to the breast and no obvious spread elsewhere, then the most critical factor is the matter of involvement of lymph glands in the axillary area (the area under the arm) and the size of the tumor in the breast.  Surgery is not all that is needed for breast cancer, even in early stages.  Great majority of patients should be treated with adjuvant chemotherapy.  Make sure that you get a copy of the pathology report and surgery report before you leave the hospital. 

There are two types of surgery for early stage breast cancer, Mastectomy, that is removal of the whole breast, or Lumpectomy, that is removal of the tumor and some of normal breast tissue surrounding it.  Those who undergo lumpectomy must receive radiation therapy to the involved breast.

What are your choices for surgery, Lumpectomy or Mastectomy?

This is of most important step towards management of early stage breast cancer.  It seems that Lumpectomy (removal of the tumor and some of the surrounding tissue) followed by breast radiation is as good as mastectomy (removal of breast).  The issue with Lumpectomy is that patients will require radiation therapy to the involved breast.  Although mastectomy is cosmetically unacceptable to mot women, additional radiation to the breast is not the best thing for the general health of the patients either.  As mentioned earlier, there are various forms of breast tumors and some have lower risk of recurrence and some have higher.  It is critical to consider all the factors in making the decision about the type of surgery.  I personally prefer mastectomy, since there will be no need for radiation therapy.  Since most patients will be treated with adjuvant chemotherapy, those who undergo lumpectomy will be exposed to the combination of both Chemotherapy and Radiation.  This combination has been linked to development of Leukemia and other malignant blood disorders in subsequent years following the initial breast cancer treatment.  This is an important factor to keep in mind while deciding about lumpectomy plus radiation vs. mastectomy.

6. Medical Oncologist

Make sure that you are referred to a medical oncologist as soon as diagnosed with breast cancer.  Some Internists or surgeons delay such a referral and by doing so, precious time is wasted.  The medical oncologists render most care for breast cancer patients.  Being referred to an oncologist at an early stage gives you time to decide if you like him, if he has time and patience for you and whether he is the person that you can work with over years to come.  Choosing of the medical oncologist is very important.  Most surgeons have attitude and some upset patients, but if they are very good at what they can do for your cancer, it is OK to put up with them.  After all you don’t have to see them as often as you will see your medical oncologist.

7. Adjuvant Chemotherapy

Adjuvant chemotherapy is indicated in early stage breast cancer.  Chemo is administered by or under supervision of a medical oncologist in his office or an outpatient setting in a hospital.  This treatment should start between 4-6 weeks after surgery and if the patient has fully recovered from surgery.

This treatment lasts from 4-6 months.  Patients should have a port-a-cath to receive the treatments.   This regimen of treatment is well tolerated however some patients develop significant side effects or complications, which may require hospitalization.  The most common side effects are lowering of blood cells, hair loss, menstrual changes, and nausea. Patients should receive pre-medication with medicines to prevent nausea or vomiting prior to each course of chemotherapy.  Blood counts must be followed and checked once a week. 

8. Radiation Therapy

Radiation to the breast and surrounding tissues is of most importance to the patients who undergo lumpectomy.  Radiation is also used in patients whose cancer has spread to the neck area or there is extensive involvement of the Axillary area.  Radiation is given over a period of many weeks.  Make sure that you meet with the radiation therapy physician was in advance, as part of a teamwork approach to the cancer.  Learn whether the radiation facility has a modern set of equipment to administer radiation therapy. Find out how old the equipments are.  Modern centers use linear accelerators that are the proper equipments to use. 

9. Metastatic Breast Cancer

In cases where cancer has spread beyond the regional axillary lymph nodes, (referred to as metastatic disease) there is a definite need for chemotherapy and other treatments may also be needed.  If the disease spreads to the Bones, i.e. to spine, to the hips, etc, radiation therapy should be used to control the localized site of the disease in the involved areas.

In advanced Breast cancer, the first line of treatment shall be a combination of two to three chemotherapy drugs. A new drug combination that has been recently approved for advanced and relapsing Breast cancer is Taxol in combination with Cisplatinum.   Newer drugs for treatment of breast cancer are Herceptin that is used only in HER2/NEU over expressed tumors.  The tumor tissue should be tested for HER2/NEU prior to treatment with Herceptin.

10. Family Issues, Genetic Testing and Counseling

There is no longer any question that hereditary and genetic factors contribute to breast cancer.  This is the least discussed issue with breast cancer patients.  The value of genetic evaluation is even more for the relatives and family members of the patient in addition to the patient himself.  There are various forms of hereditary breast cancer and the risk of the relatives having the disease or being at a higher risk for developing the same illness varies from each hereditary entity to another.  Most hereditary cases occur in younger patients. Such patients may have tumors in more than one location in their breast or even in other organs of their body, like ovaries.  Once suspected, there are various blood tests that can be performed, both on the patients and their relatives to determine whether one is dealing with a hereditary cause of breast cancer and also whether any one else in the family is at risk of developing similar cancer.  Make certain that you bring up this issue with your doctor.  If indicated, the family members may need to be counseled.