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The treatment options available to you will depend on a number of factors, including: the type of tumor, the extent of the disease at the time of diagnosis, your age and your medical history. However, your personal feelings about the treatment, your self-image and your lifestyle will also be important considerations in your doctor’s assessment and recommendation. You and your doctor should discuss these treatment methods and how they apply to your situation. Understanding all of your options from the beginning of your diagnosis allows you to have all of the information you need to make an informed and rational decision about your care.
Right now you are probably asking yourself, “Why me?” Cancer has suddenly intruded on your life and threatened your health and well-being. You have not lost control of your personal health. You will continue to take care of yourself by working in a partnership with the health care professionals responsible for your treatment and safe recovery. By becoming informed, asking questions, and participating in treatment decisions, you will have a positive influence on your own well-being.
The two-step treatment method involves having a biopsy one day; then, if the lump is cancerous, the treatment takes place within the next few weeks. In many cases, the biopsy can be done on an outpatient basis - often in the doctor’s office or mammography suite. Most biopsies can be performed under local anesthesia. Your surgeon will discuss the specific type of biopsy with you.
The short time between biopsy and treatment (which will not reduce the chances for success) allows time to examine the permanent section slides, perform additional tests to determine the extent of the disease, discuss treatment options, gain another medical opinion, make home and work arrangements, and prepare emotionally for the treatment.
Once a diagnosis of invasive cancer is made, you may go through a staging process to determine if the tumor has spread to any other organs in the body. This usually includes a chest X-ray, liver function tests and a bone scan. In certain instances, your physician may request a PET scan, MRI, or CAT scan. An abnormality in these does not mean the tumor has spread, but that further testing is needed. Most people, however, do not need to have a full staging performed. Your surgeon and medical oncologist will discuss, with you, whether you need these tests.
Mastectomy is the medical term for surgical removal of the breast. It refers to a number of different operations, ranging from those that remove the breast, chest muscles and underarm lymph nodes, to those that remove only the breast lump.
The different types of breast surgery are described below. Based on the size and location of the lump, your doctor will recommend the type of surgery that offers you the best chance of successful treatment.
Most medical and surgical procedures carry some risk. The risks are categorized small or serious, frequent or rare. Because there is such a wide range of potential risks and benefits from various treatments for the different stages and kinds of breast cancer, you should discuss with your doctor the particular benefits and risks of treatment methods suitable for you.
This procedure removes the breast, the underarm lymph nodes and the
lining over the chest muscles. It is also called “total mastectomy with
axillary (or underarm) node dissection.”
Today, it is the most common treatment of early stage breast cancer where lymph node involvement has been proven.
Advantages: Keeps the chest muscle and the muscle strength of the arm. Swelling is less likely, and when it occurs, it is milder than the swelling that can occur after a radical mastectomy. It leaves a better appearance than the radical mastectomy. Survival rates are the same as for the radical mastectomy when cancer is treated in early stages. Breast reconstruction is easier and can be planned before surgery.
Disadvantages: The breast is removed. In some cases, there may be swelling of the arm due to the removal of all of the lymph nodes. (8 percent -10 percent risk of lymphedema).
This type of surgery removes only the breast. It is often combined with a sentinel node biopsy if the nodes need to be sampled.
Advantages: Most or all of the underarm lymph nodes remain, so the risk of swelling of the arm is greatly reduced. Breast reconstruction is easier. People most often avoid radiation therapy.
Disadvantages: The breast is removed.
When removing the whole breast during a modified radical mastectomy, an
ellipse of skin is removed with all the breast tissue. This is performed
when reconstruction is not being added. However, if a woman desires
breast reconstruction, most of her skin can be left. This allows the
plastic surgeon to place the implant or tissue flap into the woman’s own
The mastectomy is performed through a small incision, often by removing only the nipple areolar complex. The entire breast tissue is removed, only the skin remains.
Advantages: Leaves natural skin envelope for a superior reconstruction.
This procedure removes the tumor plus a wedge of normal tissue
surrounding the cancer. Occasionally, the skin and the lining of the
chest muscle below the tumor will need to be removed to obtain clear
margins. A margin of normal tissue must be removed to insure the tumor
has been completely removed. (A 5mm margin of normal tissue is optimal,
but a 2mm margin is mandatory to decrease the risk of local recurrence
after radiation therapy.) It is followed by approximately six weeks of
Advantages: If a woman is large breasted, most of the breast is preserved. There is little possibility of loss of muscle strength or arm swelling.
Disadvantages: May require a second surgery to obtain adequate normal tissue all the way around the cancer. If a woman has small or medium-sized breasts, the procedure may noticeably change the breast’s shape. We incorporate oncoplastic techniques to try and improve the cosmetic results. But, the breast may be smaller than the opposite breast after surgery.
Axillary lymph node evaluation has been the standard of care in breast cancer treatment. This procedure involves this removal of two levels of lymph nodes from the axilla (armpit) to determine if the cancer has spread locally. This is considered part of the staging of the breast cancer and is routinely done at the time of the definitive breast cancer surgery.
One of the debilitating side effects of axillary dissection has been lymphedema (arm swelling). This occurs in approximately 8-10 percent of patients. The arm may also become numb above the elbow at the level of the tricep muscle. You must protect your arm from cuts and scrapes for the rest of your life to prevent lymphangitis (an infection in the lymphatics of the arm).
In an attempt to better diagnose lymph node metastasis and decrease complications associated with axillary dissection, a method of lymph node mapping adopted from melanoma treatment has been used to identify the “guard” or sentinel (the first line of defense) lymph node.
Two methods are used to identify your sentinel node. First, the radiologist injects a radioactive tracer called technetium sulfur colloid. It may be injected the day of the surgery or occasionally the day before surgery. This tracer makes the sentinel node “hot”, and a hand held gamma probe is used to identify it in the operating room. At the time of surgery, a blue dye will be injected below your areola. The dye travels to the sentinel node and turns it blue. The dye will make your urine green and may stain your skin for a while.
All hot or blue nodes are removed. There may be one sentinel node or five sentinel nodes. Everyone has a different number of “guard nodes.” If the sentinel nodes are normal, the rest of the lymph nodes can be left alone. If the node has cancer in it, you will probably need the rest of the lymph nodes removed with a level I and II axillary lymph node dissection. The need for this further surgery will be discussed with your surgeon, radiation oncologist and medical oncologist.
Axillary node dissection refers to the staging procedure performed in conjunction with lumpectomy for breast conservation or mastectomy. The procedure involves an axillary incision below the hairline when performed with a lumpectomy and is performed through the mastectomy incision with removal of the breast.
Removal of level I and II lymph nodes includes the tissue between the axillary portion of the breast and the area above the axillary vein underlying the pectoral muscles. The axillary nodes (level III nodes) lying superior to the pectoral major muscle are preserved to decrease the incidence of arm edema. It may also remove a small nerve in the process, resulting in numbness to the posterior aspect of the arm. Determining whether the lymph nodes are involved with the tumor will stage the cancer to determine if chemotherapy will be needed.
As you consider mastectomy as a treatment option, you should be aware of breast reconstruction, a way to recreate the breast’s shape after a natural breast has been removed. This procedure is gaining in popularity, although many women are still unaware of it.
Today, almost any woman who has had a mastectomy can have her breast reconstructed. Successful reconstruction is no longer hampered by radiation damaged, thin skin, tight skin, or the absence of chest wall muscles. The options for immediate reconstruction after mastectomy will be discussed with your surgeon and again when you consult with a plastic and reconstructive surgeon.
Reconstruction is not for everyone and may not be right for you. After mastectomy, many women prefer to wear artificial breast forms or prostheses inside their surgical bras. Both a general surgeon and a plastic surgeon may help you decide whether to have breast reconstruction.
You should discuss breast reconstruction before your surgery because the position of the incision may affect the reconstruction procedure. A procedure called a skin-sparing mastectomy has been able to greatly enhance the final reconstruction results and should also be discussed with your surgeon prior to the operation.
Having breast reconstruction at the time of your cancer surgery can lead to better cosmetic results, decreased risks from additional anesthesia and added psychological benefits to you. All of these benefits can result from immediate reconstruction, without compromising the curative aspects of your cancer operation.
Radiation therapy as a primary treatment is a promising technique for women who have early stage breast cancer. This procedure allows a woman to keep her breast and involves lumpectomy followed by radiation (X-ray) treatment. Once a biopsy has been done and breast cancer has been diagnosed, radiation treatment usually involves the following steps:
For external radiation therapy, a machine beams X-rays to the breast and possibly the underarm lymph nodes. The usual schedule for radiation therapy is five days to a week for about 5-7 weeks. In some instances, a “boost” or concentrated dose of radiation may be given to the area where the cancer was located. This can be done with an electron beam. A boost done internally with an implant of radioactive materials is done less frequently.
If you are having radiation therapy as primary treatment for early stage breast cancer, a qualified, board-certified radiation therapist who is experienced in this form of treatment should do it.
Advantages: The breast is not removed. Lumpectomy with radiation therapy as a primary treatment for breast cancer appears to be as effective as mastectomy for treating early stage breast cancer. Long-term studies continue to show this similar survival rate. Usually, there is not much deformity of surrounding tissues. The skin usually regains a normal appearance.
Disadvantages: A full course of treatment requires short, daily visits to the Hospital as an outpatient for approximately five weeks. Treatment may produce a skin reaction, like sunburn, and may cause tiredness. Itching or peeling of the skin may also occur. Radiation therapy can sometimes cause a temporary decrease in white blood cell count, which may increase the risk of infection. You maintain your breast, and therefore, have a variable risk of local recurrence which would necessitate mastectomy should cancer return. Post-mastectomy reconstruction options are limited after radiation therapy to the breast.
In the past, there have been several modes of radiation therapy delivery to treat breast cancer. Most involve treatment of the entire breast as well as a boost to the tumor bed to decrease the risk of local recurrence. Small catheters were inserted into the breast to deliver the boost to the tumor bed.
These catheters had several problems with cosmesis and patient tolerance. At the present time, we are revisiting the use of partial breast irradiation for the treatment of small Stage I breast carcinomas.
This treatment involves the use of HDR (High Dose Radiation) to treat the tumor bed in women whose cancers have a low risk of local recurrence. Brachytherapy treatment lasts one week as opposed to six weeks for conventional external beam radiation.
A balloon catheter is inserted with ultrasonographic (US) guidance in an outpatient setting. Once the position is confirmed by CT scan images, the treatment is given twice a day for one week. The radiation oncologist can easily remove the catheter in his or her office.
Advantages: Five days of radiation as opposed to 5-7 weeks.
Disadvantages: Limited long-term data. There is a risk of infection when the balloon catheter is used. Only certain women qualify for this procedure.
Clearly you must discuss your particular case with your care management
team to determine if you are eligible for this form of radiation.
Intensity Modulated Radiation Therapy (IMRT) is a new radiation delivery technique. It allows the radiation oncologist to decrease the amount of harmful radiation to normal tissues. The anterior border of the heart and left lung are particularly vulnerable to radiation exposure. This new technique can spare the normal tissues while adequately treating the breast.
Left-sided breast cancers are the ones that will benefit most from this form of radiation therapy.
Ask your Radiation Oncologist if IMRT would be correct for you.
Recent studies have shown that women with early stage breast cancer may benefit from adjuvant (additional) therapy following primary treatment (mastectomy or lumpectomy with radiation therapy). These studies indicate that many breast cancer patients whose underarm lymph nodes show no signs of cancer (known as node negative) may benefit from chemotherapy or hormonal therapy after primary treatment.
The use of chemotherapy in node negative patients will be determined by your age at diagnosis, stage of the cancer, tumor markers, tumor biology and future risk of systemic recurrence. (These findings do not apply to women with pre-invasive or in-situ breast cancer).
Until now, women whose underarm lymph nodes were free of cancer usually received no additional therapy because they had a relatively good chance of surviving the disease after primary treatment. However, scientists know that cancer may return in about 30 percent of these women. Adjuvant therapy can potentially prevent or delay the return of cancer.
During your treatment, you are likely to meet several health professionals who will perform the various tests and treatments your doctor recommends. It may be difficult at first to talk with them about your illness and your feelings about treatment, but each of them can offer information to help you feel more at ease. By talking with the professionals who care for you, you will come to understand more about cancer and its treatment and be better able to cope. In addition to the surgical and medical treatment of your cancer, you may also want to consider integrating holistic therapies into your treatment plan to enhance and promote your healing process.
These are some of the specialists you may meet and hear about:
Anesthesiologist: A doctor who administers drugs or gases to put you to sleep before surgery.
Medical Oncologist: The doctor who administers anti-cancer drugs or chemotherapy.
Pathologist: A doctor who examines tissue removed by biopsy to see if it is cancerous.
Personal Physician: Your doctor, who will be responsible for coordinating your treatment and working with you to ensure that treatment is satisfactory. Your personal physician may be a surgeon, radiation oncologist, medical oncologist or family physician.
Physical Therapist: A specialist who helps in rehabilitation after surgery by using exercise, heat, light and massage.
Plastic Surgeon: A doctor who specializes in reconstructive and cosmetic surgery. Plastic surgeons perform breast reconstruction.
Radiation Oncologist: A doctor who supervises radiation therapy.
Radiation Therapy Technologist: A specially-trained technician who helps the radiation oncologist give external radiation treatments.
Surgeon: A doctor who performs surgery, such as biopsy, mastectomy or axillary node dissections.
When surgery is recommended, most health care facilities require patients to sign a form stating their willingness to permit diagnosis and medical treatment. This certifies that you understand what procedures will be done and that you have consented to have them performed. Before consenting to any course of treatment, ask your doctor for information on:
You are likely to discover that your anxiety over treatment decreases as your understanding of breast cancer and its treatment increases.
Important decisions are always hard to make, particularly when they concern your health. However, there are a number of things you can do to make decisions about breast cancer treatment easier. One is gathering information. You can:
Remember, you have time to consider options. Except in rare cases, breast cancer patients do not need to be rushed to the hospital for treatment as soon as the disease is diagnosed. Most women have time to learn more about available options, make arrangements at medical facilities where treatments will be given, and organize home and work lives prior to treatment. A long delay, however, is not advised because it may interfere with the success of your treatment.
Anesthesia: Loss of feeling resulting from the administration of drugs or gases.
Benign: Not cancerous.
Biopsy: Removal of a sample of tissue to see if cancer cells are present.
Chemotherapy: Treatment with drugs to destroy cancer cells. Most often used to supplement surgery or radiation therapy.
Lymph Nodes: Part of the lymph system that removes wastes from body tissue and carries the fluids that help the body fight infection. Lymph nodes in the underarm are those most likely to be invaded by cancer cells, and therefore are removed during breast cancer surgery.
Lymphedema: Swelling in the patient’s arm caused by excess fluid that collects when the lymph nodes and vessels are removed during surgery or are damaged by X-ray. The patient’s arm and hand become more prone to infection.
Mastectomy: Surgical removal of the breast.
Pectoral Muscles: Muscles that overlay the chest wall and help support the breast.
Cancer Care Program