Breast Cancer 101 (Part II)

The process of identifying breast cancer requires a biopsy which is the removal of fluid or tissues of the area. A biopsy is the only procedure that can help determine cancerous growth. There are two different types of biopsies core-needle and surgical biopsy.

Once the biopsy is performed, sample tissues are examined under a microscope by a pathologist to verify a cancer diagnosis, staging and identify prognostic (treatment) indicators.

Once the indicators are identified, then treatment like surgery (lumpectomy vs. mastectomy) chemotherapy, and/or radiation therapy can be determined.


Your Biopsy

According to the National Breast Cancer Foundation, a breast biopsy is a test that removes tissue or fluid from a suspicious area where the removed cells are examined under a microscope.

The biopsy is performed under image guidance but can also be performed in surgery. When the biopsy is performed during surgery, it is called an excisional biopsy.

The tissue is “excised” or cut away from the normal breast tissue. After the removed tissue is examined, prognostic indicators also called treatment indicators help you and your doctor decide how to treat your cancer.

Certain things that are determined with your biopsy are:

  • Invasive or Non-invasive
  • American Joint Committee on Cancer (AJCC) Staging (0, I, II, III, IV)
  • Prognostic or Treatment indicators (Estrogen Receptor (ER), Progesterone Receptor (PR), Human epidermal growth factor receptor 2 (HER2)

Breast Cancer Staging

We have already discussed the invasive vs. non-invasive components of your breast cancer. Staging is critical for the treatment of all cancers. Specifically, cancer staging determines

1) Whether the cancer is invasive or non-invasive

2) The size of the tumor

3) Whether lymph nodes are involved

4) Whether cancer has spread (metastasized).

Typically stage “0” is the best type of cancer to have while stage IV is the worst type of cancer diagnosis.


Prognostic or Treatment Indicators

Breast cancer cells have certain receptors which mean they grow in response to the estrogen and progesterone hormones. Your cancer may be:

Estrogen receptor and Progesterone receptor positive

HER2 positive

Triple positive (positive for estrogen receptor, progesterone receptor, and HER2)

Triple negative (not positive for estrogen receptor, progesterone receptor, and HER2).

When your breast cancer has a significant number of receptors for estrogen or progesterone, it is considered hormone receptor positive. About 80% of all cancers are ER-positive, while 65% are also PR positive. HER2 positive breast cancers consist of about 20% of breast cancers.

On the other hand, triple negative breast cancers consist of between 10% and 20% of all cancers. Treatment will depend on the breast cancers indicators. For example, some breast cancers are treated with hormone therapy, while others are treated with a combination of chemotherapy and radiation therapy.

Treatment (Surgery)

Surgical options consist of breast-conserving surgery also known as a lumpectomy or a mastectomy. When a surgeon removes just the tumor or the “lump” it is called a lumpectomy.

The lump is identified or “localized” prior to surgery with imaging and the placement of a wire which tells the surgeon exactly where the tumor or lump is located. When a surgeon removes the entire breast, it is called a mastectomy. A surgeon may perform an excisional biopsy.

According to the American Society of Breast Surgeons, an excisional biopsy is performed when a core-needle biopsy is not indicated. Please consult your physician to decide which surgical option is best for you, however, keep in mind that an excisional biopsy leaves a scar and may disfigure your breast.

Also, if you decide to have a mastectomy, a plastic surgeon should be consulted so the breast reconstruction is coordinated with your general surgeon or breast surgeon. Ideally, you should have the procedure performed by an oncoplastic surgeon.

Treatment (Chemotherapy)

The ACS explains that chemotherapy is given before surgery (neoadjuvant chemotherapy), is used to shrink breast cancer tumors and allows your physician to see how your breast cancer is responding to the chemo drugs. Neoadjuvant chemotherapy can lower the risk of the breast cancer from coming back.

Chemotherapy given after surgery is known as adjuvant chemotherapy. Adjuvant chemotherapy is given to kill any cancer cells that might have been left behind after surgery. If any cancer cells were allowed to be left behind, they could grow and form new tumors in other areas of the body.

Please keep in mind that 80% of all breast cancers are ER-positive and 65% are PR positive so the majority of patient’s breast cancer can be treated with hormone therapy. Hormone therapy is given after surgery, chemotherapy, and radiation therapy.

Hormone therapy in the form of Tamoxifen or Aromatase Inhibitors (AI’s) is given to help prevent breast cancer from coming back. Chemotherapy side effects include:

  • Hair Loss
  • Nail Changes
  • Mouth Sores
  • Loss of appetite or weight changes
  • Nausea and vomiting
  • Diarrhea
  • Increased chance of infection due to a compromised immune system
  • Easy bruising or bleeding
  • Fatigue

Treatment (Radiation Therapy)

Radiation Therapy, also known as radiotherapy, is a targeted treatment which is a highly effective way to kill cancer cells.

Despite what many people have heard, radiotherapy is relatively tolerable and any side effects are limited to the treatment area. Radiotherapy kills cancer cells while the high energy X-rays kill normal cells too, and radiotherapy affects cancer cells more than normal cells.

In fact, because cancer cells are busy growing and multiplying and are less organized than normal cells, it is more difficult for the cancer cells to repair themselves. Radiation is delivered with a machine called a linear accelerator.

Radiation can also be delivered directly to the cavity left behind after surgery with a catheter which is inserted by a radiologist or surgeon.

There are times when radiotherapy is not necessary for the treatment of breast cancer so check with your radiation oncologists for the best treatment for you. Key points about radiation therapy as described by the ACS are:

  • Radiation is a local and targeted therapy designed to kill cancer cells
  • Delivery of radiation treatment is painless
  • Radiation treatment does not make you radioactive
  • Treatment is usually given five days a week for up to seven weeks
  • Radiation will not make you lose your hair
  • Your skin can turn pink, red, or tan and may be sensitive
  • You may feel tired during treatment
  • Many Radiotherapy side effects are temporary
  • Radiotherapy can significantly decrease the risk of breast cancer from coming back

What to Do After Your Breast Cancer Diagnosis and Treatment?

When you are diagnosed with breast cancer, don’t waste time and see a healthcare provider as soon as possible. Remember the earlier your breast cancer is identified, the better chance you have of a successful treatment and longer survival.

Know your comfort level and make sure you get all the answers to your questions. Don’t let your health provider get away with not answering all of your questions. After treatment is complete, low impact exercise such as yoga will help your body recover.

It is also important for you or your family members to know if they are genetically predisposed to breast cancer. Have you and your loved ones tested for genes that cause cancer and encourage all of your friends and family to perform self-breast exams and get their annual screening mammograms.

Later stage cancers can be prevented if we educated ourselves about it. Early identification and intervention are crucial.

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Sources:
https://www.national breastcancer.org/breast-cancer-biopsy
https://www.cancer.org/cancer/breast-cancer.html
https://www.cancer.gov/types/breast
https://cancerstaging.org/references-tools/quickreferences/Documents/BreastMedium.pdf
https://www.webmd.com/breast-cancer/guide/breast-cancer-types-er-positive-her2-positive#1
https://www.breastsurgeons.org/statements/guidelines/PerformancePracticeGuidelines_ExcisionalBreastBiopsy.pdf