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in depth review of breast cancer

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Since the 1992 adoption of the pink ribbon as the official symbol of National Breast Cancer Awareness Month, this popular icon has made breast cancer the most publically-identified cancer in the world. Yet despite the public’s recognition of the pink ribbon’s meaning, there is still a huge deficit in the public’s knowledge of the facts surrounding breast cancer. It is the most common cancer faced by women in this country. One in eight women will hear the words, “You have breast cancer,” during their lifetime. Despite huge investments of research dollars and tireless work by healthcare experts, breast cancer remains a challenging healthcare problem worldwide. The purpose of this publication is to help you become more knowledgeable about breast cancer and improve your understanding of where we stand today as we struggle to master the intricate puzzles of breast cancers.

The amount of new information regarding breast cancer generated by research in the past 20 years is overwhelming. Additionally, we continue to add to that ever-increasing volume of knowledge on literally a “daily” basis. That is why anyone seeking answers to questions about breast cancer, needs to have access to the latest, reliable information available. This publication will address many of the more universal facts about breast cancers.

Breast Cancer: the basics

Cancer is a group of diseases that cause cells (the building blocks of all body tissues) to change and grow without normal control. Normal cells grow and divide to create new cells as they are needed. When normal cells grow old or become damaged, they die, and new healthy cells take their place. Sometimes this process goes wrong: New cells grow when the body does not need them and old or damaged cells do not die and become reabsorbed by the body, as they should. This buildup of extra cells often forms a mass of tissue called a lump, growth, or tumor. Tumors in the breast can be benign (not cancer) or malignant (cancer).

What is Breast Cancer?

Breast cancer is cancer that forms in the cells of the breasts. There are numerous types of breast cancer, but cancer that begins in the milk ducts (ductal carcinoma) is the most common type. The human breast is made up of glands (lobules) that create milk when certain hormones tell them to, ducts (tiny tubes that connect theses glands to the nipple), and other fatty, connective, and lymphatic tissues.

It is important to understand that all breast cancers are not the same disease and that two breast cancers that appear to be the same, may behave differently in different people. This fact is the cornerstone of our current standards of diagnostic testing and treatment planning. The experience of each patient is very individual, so the planning of their care needs to be “individual” as well.

Who develops Breast Cancer?

After skin cancer, breast cancer is the most common cancer diagnosed in women in the United States. Breast cancer can occur in both men and women, but it's far more common in women. According to the National Cancer Institute (NCI) more than 230,000 women in the United States were diagnosed with breast cancer in 2011; 2,000 men also learned they had breast cancer in 2011. The good news is that it is, increasingly, a survivable cancer for most patients. The National Cancer Institute (NCI) estimated that there were over 2.6 million women with a history of breast cancer alive in the US in 2008. Most were cancer free, but some were still undergoing treatments.

Although the majority of the information in this document applies to male breast cancer as well as female breast cancer, the Mayo Clinic website has an excellent summary paper on male breast cancer.

IN SITU VS . INVASIVE BREAST CANCER : In situ cancers are small and most importantly they are still confined to the structure (ducts or lobules) that they were formed in. These are referred to as either DCIS (Ductal Carcinoma In Situ) or LCIS (Lobular Carcinoma In Situ). More breast cancers are being found early (In Situ) due to better public education and better access and compliance with breast cancer screening, including mammography. Statistically, 83% of the in situ breast cancers are DCIS; 11% are LCIS (2004-2008 data).5 There is some professional controversy that LCIS should not be considered a true cancer, but rather an indicator of a higher risk for further breast cancer development.

Most breast cancers are invasive (or infiltrating) when they are first diagnosed/discovered. It is important to understand that an actual analysis of the questionable breast tissue must be performed (biopsy) to determine whether or not a cancer is actually “in situ or invasive” and whether it originated as a “ductal or lobular” growth. This is the very first part of the critical diagnostic information the physicians need before they can determine what is actually happening in the breast tissue.

INFLAMMATORY BREAST CANCER : This is a rare type of breast cancer (also invasive) which grows quickly, causing discoloration (redness, purple, pink or bruised appearance), sometimes roughness, and swelling of the breast. The area may be warmer than other skin areas, and may be very sensitive. There is usually not a ‘lump” of any sort present. Often appearing more like an infection of the skin or breast tissue, it can be difficult to diagnose, despite visual symptoms. The changes may develop in days or weeks, so a timely intervention is important. Women that notice any symptoms that cause them concern should make an appointment with their doctor for an evaluation. Other problems that may start with similar symptoms include a breast injury or infection (mastitis). There is an excellent resource on inflammatory breast cancer on the Mayo Clinic website.

Common signs and symptoms of possible Breast Cancer

Early breast cancer usually does not have any symptoms. However, as the cells increase in number the appearance and/or feeling of the breast tissues may change in the following ways:
• A lump or thickening in or near the breast or in the underarm area
• A change in the size or shape of the breast
• Dimpling or puckering in the skin of the breast
• A nipple turned inward into the breast
• Discharge (fluid) from the nipple, especially if it's bloody
• Scaly, red, or swollen skin on the breast, nipple, or areola (the dark area of skin at the center of the breast). The skin may have ridges or pitting so that it looks like the skin of an orange. (Source: National Cancer Institute, 2011)

These changes may or may not be sensitive to touch, or uncomfortable. Most often, these symptoms are not caused by cancer but it is very important to see your health care provider for such symptoms, even if you have recently had a mammogram that was normal, because it is important to have any such changes medically evaluated.

NOTE : Very early breast cancer usually does not have any noticeable symptoms. This is why following the recommended guidelines for early diagnosis, including mammograms is strongly recommended.

AMERICAN CANCER SOCIETY GUIDELINES FOR THE EARLY DETECTION OF BREAST CANCER IN AVERAGE - RISK, ASYMPTOMATIC WOMEN

Age 20 - 39
• Clinical breast examination at least every 3 years
• Breast self-examination*

Age 40 and over
• Annual mammogram
• Annual clinical breast examination (preferably prior to mammogram)
• Breast self-examination*

*All women need to become familiar with both the appearance and feel of their breasts so that they will be aware of changes and report them to their doctor. Research has shown that this approach, seems to be most effective in finding early changes and diagnosis of breast cancers.

How is Breast Cancer diagnosed?

Tests and procedures used to diagnose breast cancer may include:

BREAST EXAM: Your doctor will check both of your breasts, feeling for any lumps or other abnormalities. Your doctor will likely check your breasts in varying positions, such as with your arms above your head and at your side.

MAMMOGRAM: A mammogram is an X-ray of the breast that uses a very low amount of radiation. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend other diagnostic tests to further evaluate that abnormality.

ULTRASOUND OF BREAST: Ultrasound uses sound waves to produce images of structures deep within the body. Your doctor may recommend an ultrasound to help determine whether a breast abnormality is likely to be a fluid-filled cyst or a solid mass, which may be either benign or cancerous. Breast ultrasound is also helpful to guide radiologic biopsy to get a sample of breast tissue if a solid mass is found.

BIOPSY: Removing a sample of breast cells for testing. A biopsy to remove a sample of the suspicious breast cells helps determine whether cells are cancerous. It is not currently possible to be absolutely certain whether breast tissue is cancerous without obtaining some of the questionable cells with a biopsy. Today, this type of biopsy is most often completed as a needle biopsy, and can be completed as an outpatient in the mammography suite by the radiologist. This sample is sent to a laboratory for testing.

A biopsy sample provides multiple types of information including to whether or not the breast cells are cancerous and which type of breast tissue the cancer started in. If cancer is present, the cells are analyzed to determine how quickly the cells are growing, which is often referred to as the aggressiveness (grade) of the cancer. Also, these cells are tested in a laboratory to identify specific characteristics of the cancer cells that are very important when planning your treatment.

HORMONE RECEPTOR TESTS : Some breast cancers need hormones to grow. So the breast tissue is tested for the hormones estrogen and progesterone. Whether these test are positive or negative – this is very important information for the physician planning your care. If your breast cancer has positive hormone receptors, then hormone therapy will probably be part of your treatment plan. There will be more information about this type of therapy within the Treatment section of this article.

HER2/NEU TEST: Her2/neu protein is found on some types of cancer cells. If the breast cancer cells have too much HER2/neu present, then a specialized type of therapy may be included in your treatment planning. There will be more information about this targeted type of therapy within the Treatment section of this article.

MULTIGENE TEST: A test in which samples of tissue are studied to look at the activity of many genes at the same time. It may help predict whether cancer will spread to other parts of the body or recur (come back).4 This test is only needed in very specific circumstances.

» On c o t y p e DX : This test helps predict whether stage I or stage II breast cancer that is estrogen-receptor-positive and node-negative will spread to other parts of the body. If the risk of the cancer spreading is high, chemotherapy may be given to lower the risk.

Mammography – when should you start screening?

It is not hard to tell that October is Breast Cancer Awareness Month because everywhere you go, you can see pink ribbons reminding us that breast cancer is the most common cancer and the second leading cause of death for women in the United States. One in eight women will develop breast cancer during their lifetime; many times this will be a friend, teacher, neighbor or relative.

I still get asked the question regularly, when should I get my first mammogram?’ It is important to realize that most (60%) patients, who get breast cancer, have no family history. So using risk factors such as family history alone can be problematic. Mammography is still the gold standard screening test for breast cancer. Since the onset of regular screening mammography in 1990, there has been a reduction in mortality. A large study out of Sweden of more than one million women in their 40’s who received screening mammography, showed a decrease in breast cancer death by 30%. Other studies around the world have shown smaller but definite reduction in mortality.

Most of us who treat breast cancer patients realize that we should be looking at, not only decreasing the death rate, but how earlier diagnosis can prevent less aggressive treatment options by finding smaller tumors. A smaller tumor might allow a lumpectomy instead of a mastectomy which is often a great relief to the patient, especially if she is 40 years old! Sometimes finding a smaller tumor might mean that no chemotherapy is indicated and, not only is the patient happy, but it doesn’t subject them to side effects and saves thousands of health care dollars.

The recommendations for women are the following:
1) Begin self breast exams in your 20’s and report any changes to your physician. The best time to do your exam is one week after you start your period, as this is when the breast should be the least lumpy (under the least amount of hormonal influence). Women know their breasts better than anyone else and should be able to at least seek medical advice as to whether the lump is worrisome.
2) Clinical breast exam by health professional such as physician, nurse practitioner or physician’s assistant at least once a year.
3) Screening mammography beginning at age 40, unless there is a family history, and then the recommendation is for mammography to start 10 years before the youngest relative was diagnosed with breast cancer (if mother was diagnosed at age 45, then mammography should start at age 35). For women over 75 years of age, the decision to have screening mammography should be based on the health of the patient, risk factors and whether the patient would be willing to undergo treatment if a cancer was found. Yes, I have recommended mammograms in healthy 90 year olds!

All the physicians in our community who treat breast cancer agree that mammography saves lives and will continue to follow these guidelines. If you have any questions or would like more information on breast cancer screening, please contact our dedicated oncologytrained nurse navigator at 805.346.3405.

As a community, we need to work toward raising awareness, educating the public and increasing screening access in order to beat this disease!

Dr. Monica Rocco is board certified General Surgeon who has devoted her surgical practice to caring for patients with breast disease and providing diagnosis and care before, during and after surgery. As an associate of the Surgical Specialists, Inc., located in Santa Maria, Dr. Rocco also serves as a member of the Marian Medical Center’s specialized surgical staff. She is the Surgical Director of Marian Cancer Care Services. Dr. Rocco has been recognized for her work in breast preservation surgery and has expertise in genetics, and can counsel and perform gene testing for hereditary cancers including: breast, ovarian, colorectal and melanoma. She can be reached at 348.3700.

Staging Breast Cancer

Once your doctor has diagnosed your breast cancer, he or she works to establish the extent (stage) of your cancer. Complete information about your cancer's stage may not be available until after you undergo breast cancer surgery. Multiple factors are considered when staging your breast cancer. Staging your cancer on a scale of I-IV (1-4) gives your doctor important information about whether or not the breast cancer cells have traveled outside of the original area that they were formed in. This information is very important to planning the best way to treat your specific breast cancer.

Tests and procedures used to stage breast cancer may include:
• Blood tests, such as a complete blood count
• Mammogram of the other breast to look for signs of cancer
• Chest X-ray
• Breast MRI
• Bone scan
• Computerized tomography (CT) scan
• Positron emission tomography (PET) scan Not all patients will need all of these tests and pprocedures. Your doctor selects the appropriate tests based on your specific circumstances

staging

STAGE 0 - CARCINOMA IN SITU

Atypical cells have not spread outside of the ducts or lobules, the milk producing organs, into the surrounding breast tissue. Referred to as carcinoma in situ, it is classified in two types:
• Ductal Carcinoma In Situ (DCIS) – very early cancer that is highly treatable and survivable. If left untreated or undetected, it can spread into the surrounding breast tissue.
• Lobular Carcinoma In Situ (LCIS) – not a cancer but an indicator that identifies a woman as having an increased risk of developing breast cancer.

STAGE 1 - EARLY STAGE INVASIVE BREAST CANCER

The cancer is no larger than two centimeters (approximately an inch) and has not spread to surrounding lymph nodes or outside the breast

STAGE 2 (ll) - BREAST CANCER

Is divided into two categories according to the size of the tumor and whether or not it has spread to the lymph nodes:
• Stage II A Breast Cancer – the tumor is less than two centimeters (approximately an inch) and has spread to no more than three auxiliary underarm lymph nodes. Or, the tumor has grown bigger than two centimeters, but no larger than five centimeters (approximately two inches) and has not spread to surrounding lymph nodes.
• Stage II B Breast Cancer – the tumor has grown to between two and five centimeters (approximately one to two inches) and has spread to up to three auxiliary underarm lymph nodes. Or, the tumor is larger than five centimeters, but has not spread to the surrounding lymph nodes.

STAGE 3 (lll) - BREAST CANCER

Is also divided in to two categories:
• Stage III A Breast Cancer – the tumor is larger than two centimeters but smaller than five centimeters (approximately one to two inches) and has spread to up to nine auxiliary underarm lymph nodes.
• Stage III B Breast Cancer – the cancer has spread to tissues near the breast including the skin, chest wall, ribs, muscles, or lymph nodes in the chest wall or above the collarbone.

STAGE 4 (lV) - BREAST CANCER

The cancer has spread to other organs or tissues, such as the liver, lungs, brain, skeletal system, or lymph nodes near the collarbone.

Choosing a Treatment for Breast Cancer

Understanding a specific diagnosis and treatment options can be difficult and stressful for anyone. It is usually recommended that you bring someone with you to your appointments so that you have an additional set of ears to hear the information that is shared. If you are unable to bring anyone to the appointment, you may want to bring a small tape recorder and ask the doctor if it is okay if you tape your discussion that day. It is very helpful to be able to hear the information more than once.

Also, it is very beneficial to write down your questions for the doctor at each appointment and prioritize the questions that are most important to you, to make sure there is enough time to answer them. Some of the questions that any breast cancer patient should ask her doctor are provided in the NCI’s guide, What You Need to Know About Breast Cancer.

YOU MAY WANT TO AKS YOUR DOCTORS THESE QUESTIONS BEFORE CHOOSING YOUR TREATMENT

• What did the hormone receptor tests show? What did other lab tests show? Would genetic testing be helpful to me or my family?
• Do any lymph nodes show signs of cancer?
• What is the stage of the disease? Has the cancer spread?
• What are my treatment choices? Which do you recommend for me? Why?
• What are the expected benefits of each kind of treatment?
• What can I do to prepare for treatment?
• Will I need to stay in the hospital? If so, for how long?
• What are the risks and possible side effects of each treatment? How can side effects be managed?
• What is the treatment likely to cost? Will my insurance cover it?
• How will treatment affect my normal activities?
• Would a research study (clinical trial) be appropriate for me?
• Can you recommend other doctors who could give me a second opinion about my treatment options?
• How often should I have checkups?

Once your breast cancer has been (1) confirmed by a biopsy and (2) staged, it is often wise to take some time to insure you have been able to obtain all the relevant information regarding your situation and treatment options. The only type of breast cancer in which immediate treatment is truly a priority is Inflammatory Breast Cancer (see notes above). In all other instances, taking time to process and understand everything makes very good sense.

Specific recommendations prior to making this decision might include:
• To obtain medical opinions from each of four specialties that routinely treat patients with breast cancer: (1) General Surgeon, (2) Radiation Oncologist, and (3) Medical Oncologist and possibly (4) Plastic Surgeon, if reconstruction surgery may ever be desired.
• To attend one or more support groups, preferably one that focuses on women with breast cancer. Talking openly with other cancer patients and sharing their experiences as they weighed different treatment options (including possible reconstruction surgery) can be extremely valuable to many patients.
• To determine whether participation in a clinical trial may be appropriate for your situation.
• To consider your personal feelings, fears, and lifestyle as these is a very important factor when making treatment choices.

It is always possible to make an appointment to see or call a Breast Care Nurse Navigator at Marian Cancer Care (739-3780) for assistance in connecting with resources as you sort out your options. Basic information on the most common breast cancer treatments is summarized below for your review.

BREAST CANCER TREATMENT OPTIONS: There are multiple categories and types of treatment utilized for breast cancer. Most patients end up choosing a combination of categories and types of treatment. The most common categories of treatment recommended include:
• Surgery
• Radiation Therapy
• Chemotherapy
• Hormone Therapy
• Targeted Therapy
• Other Categories of Drug Therapy
• Complementary Therapy
• Supportive Therapy
• Clinical Trials – many include any/all of the above treatment categories

SURGERY

Operations used to treat breast cancer include:

LUMPECTOMY: Removing Breast Cancer.
During lumpectomy, which may be referred to as breast-sparing surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue. Lumpectomy is typically reserved for smaller tumors that are easily separated from the surrounding tissue.

MASTECTOMY: Removing the entire breast .
Mastectomy is surgery to remove all of your breast tissue. Mastectomy can be simple, meaning the surgeon removes all of the breast tissue – the lobules, ducts, fatty tissue and some skin, including the nipple and areola. Or mastectomy can be radical, meaning the underlying muscle of the chest wall is removed along with breast tissue and surrounding lymph nodes in the armpit. Radical mastectomies are less commonly done today. Some women may be able to undergo a skin-sparing mastectomy, which leaves the skin overlying the breast intact and may help with reconstruction options.

SENTINAL NODE BIOPSY: Removing one lymph node.
Breast cancer that spreads to the lymph nodes may spread to other areas of the body. Your surgeon determines which lymph node near your breast tumor receives the lymph drainage from your cancer. This lymph node is removed using a procedure called sentinel node biopsy and tested for breast cancer cells. If no cancer is found, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.

AXILLARY LYMPH NODE DISSECTION: Removing several lymph nodes.
If cancer is found in the sentinel node, your surgeon may remove additional lymph nodes in your armpit. However, there is now good evidence that removal of additional affected lymph nodes does not improve survival in cases of early breast cancer following a lumpectomy, chemotherapy and whole-breast irradiation for tumors less than 2 inches (5 centimeters) in size, and where the cancer has spread to just a few lymph nodes in the armpit. In such cases, chemotherapy and radiation treatment after the lumpectomy have proved to be equally effective. This avoids the serious side effects, including chronic swelling of the arm (lymphedema), that often occur after lymph node removal.

However, axillary lymph node dissection may still be performed if the sentinel lymph node contains cancer following a mastectomy, in the case of larger breast tumors or when a lymph node is large enough to be felt on physical exam. It may also be performed in situations when a woman elects to receive partial breast irradiation.

BREAST RECONSTRUCTION SURGERY:
Some women choose to have breast reconstruction during or after the primary surgery. Discuss your options and preferences with your surgeon. You may want to request a referral to a plastic surgeon before your primary breast cancer surgery. Your options may include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date. Complications of breast cancer surgery depend on the procedures you choose. All surgeries carry some risk of bleeding and infection. These concerns must always be discussed with your surgeons before any surgery.

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-powered beams of energy to kill cancer cells. It only affects cells in the area of the body that is treated. Doctors may use two types of radiation therapy to treat breast cancer. Some women receive both types:

EXTERNAL RADIATION THERAPY: The radiation comes from a large machine outside the body. You will go to a hospital or clinic for daily treatment. Treatments are usually 5 days a week for 4 to 6 weeks. External radiation is the most common type used for breast cancer.

INTERNAL RADIATION THERAPY (Implant Radiation Therapy or Brachytherapy) : The doctor places one or more thin tubes inside the breast through a tiny incision. A radioactive substance is loaded into the tube. The treatment session may last for a few minutes, and the substance is then removed. When it's removed, no radioactivity remains in your body. Internal radiation therapy may be repeated every day for a week.

Side effects of radiation therapy depend primarily on the dose and type of radiation. The skin in the treatment area may become red, dry, tender, or itchy. Skin care becomes very important. You should check with your doctor before using any deodorants, lotions, or creams on the treated area. Bras and tight-fitting clothes may rub the skin and become very uncomfortable. Loose-fitted, cotton clothing is usually the most comfortable. Toward the end of treatment, your skin may become moist, wet or dewy. Exposing this area to air as much as possible can help the skin heal. After treatment is over, the skin will gradually heal.

Fatigue is often a problem during and after radiation therapy, especially in the later weeks of treatment. Being able to get adequate rest becomes important but staying somewhat active (mild exercise like short walks) is also very beneficial.

You may wish to discuss with your doctor the possible long-term effects of radiation therapy. For example, radiation therapy to the chest may harm the lung or heart tissues. Also, it can change the size of your breast and the way it looks, as there may be a lasting change in the color and texture of your skin.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells.

• If your cancer has a high chance of returning or spreading to another part of your body, your doctor may recommend chemotherapy to decrease the chance that the cancer will recur. This is known as adjuvant systemic chemotherapy.

• Chemotherapy is sometimes given before surgery in women with larger breast tumors. Doctors call this neoadjuvant chemotherapy. The goal is to shrink the tumor to a size that makes it easier to remove with surgery. This may also increase the chance of a cure.

• Chemotherapy is also used in women whose cancer has already spread to other parts of the body. This systemic chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.

Side effects from chemotherapy depend on the specific drugs you receive. Most often more than one type of drug is utilized. Side effects may include temporary hair loss, fatigue, nausea/ vomiting (usually controlled with medications), numbness/tingling in your hands/feet, and a small increased risk of developing infection.

HORMONE THERAPY: Perhaps more properly termed hormone-blocking therapy, this treatment is often used to treat breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers. Hormone therapy can be used after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it. Treatments that can be used in hormone therapy include:

» Medications that block hormone from attaching to cancer cells.
Tamoxifen is the most commonly used selective estrogen receptor modulator (SERM). SERMs act by blocking estrogen from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. Tamoxifen can be used in both preand postmenopausal women. Possible side effects include fatigue, hot flashes, night sweats and vaginal dryness. More significant risks may include cataracts, blood clots, stroke and uterine cancer.

» Medications that stop the body from making estrogen after menopause.
One group of drugs called aromatase inhibitors blocks the action of an enzyme that converts androgens in the body into estrogen. These drugs are effective only in postmenopausal women. Aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin). Side effects of aromatase inhibitors include joint and muscle pain, as well as an increased risk of bone thinning (osteoporosis). Another drug, fulvestrant (Faslodex), directly blocks estrogen, which keeps tumors from getting the estrogen they need to survive. Fulvestrant is generally used in postmenopausal women for whom other hormone-blocking therapy is not effective or who can't take tamoxifen. Side effects that may occur include fatigue, nausea and hot flashes. Fulvestrant is given by injection once a month.
» Surgery to stop hormone production in the ovaries.
In premenopausal women, surgery to remove the ovaries can be an effective hormonal treatment. This type of surgery is known as prophylactic oophorectomy and may be called surgical menopause.

TARGETED DRUGS: Targeted drug treatments attack specific abnormalities within cancer cells. They may be recommended if your breast cancer or tumor location has the specific characteristic that the targeted drug was developed to treat. Targeted drugs approved to treat breast cancer include:

» Trastuzumab (Herceptin): Some breast cancers make excessive amounts of a protein called human growth factor receptor 2 (HER2). Trastuzumab targets this protein that helps breast cancer cells grow and survive. If your breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die. Side effects may include heart damage, headaches and skin rashes.

»Lapatinib (Tykerb) : Lapatinib targets the HER2 protein and is approved for use in advanced metastatic breast cancer. Lapatinib is reserved for women who have already tried trastuzumab and their cancer has progressed. Potential side effects include nausea, vomiting, diarrhea, fatigue, mouth sores, skin rashes, and painful hands and feet.

OTHER CATEGORIES OF DRUG THERAPY:

» Biophosphate Medications (Zometa) : Previous research indicates that this group of medications may provide some long-term advantages to certain women diagnosed with breast cancer. The beneficial effects may include a lower risk of breast cancer recurrence and decreased risk of bone loss related to several breast cancer treatments. Anyone starting this type of therapy needs to have a thorough dental exam/treatment before starting the intravenous biophosphate treatments, as some types of dental treatment may be limited after receiving this drug. Possible side effects include flu like symptoms and although the literature includes information on the risk of osteonecrosis of the jaw, this is a very rare complication.

» Bevacizumab (Avastin) : Bevacizumab is a drug designed to stop the signals cancer cells use to attract new blood vessels. Without new blood vessels to bring oxygen and nutrients to the tumor, the cancer cells die. Possible side effects include fatigue, high blood pressure, mouth sores, headaches, slow wound healing, blood clots, heart damage, kidney damage, high blood pressure and congestive heart failure. Research suggests that although this medication may help slow the growth of breast cancer, it doesn't appear to increase survival times. For this reason, bevacizumab isn't approved by the Food and Drug Administration to treat breast cancer. But doctors may prescribe it for what's known as off-label use. Use of bevacizumab in breast cancer is controversial.

Alternative/Complimentary Therapy

There are no alternative medicine treatments that have been found to cure breast cancer. Some alternative treatments may actually conflict with standard treatments, causing adverse reactions or blocking the benefits of standard therapy. Thus, it is very important to discuss any alternative therapies you are interested in with your treating physician, so that you are both aware of the potential impact on your treatment. Complimentary treatment includes a very broad spectrum of therapies that are used with (in addition to) standard therapy and when utilized appropriately, do not have an adverse effect on a patient’s health. These complimentary therapies provide physical, psychological, and emotional support to cancer patients, resulting in better tolerance of treatments, decreased side effects, and improved overall health. Your team of cancer professionals is very knowledgeable about many alternative and complimentary therapies and can direct you to reliable resources to help you explore this area of healthcare. Some of the complimentary therapies utilized through Marian Cancer Care, at no charge, include:
• Gentle exercise – tailored to abilities & fatigue level
• Nutritional therapy
• Stress management
• Relaxation strategies

Supportive Therapy

Like complimentary therapies, supportive therapies are designed to augment everything else your treatment team is trying to achieve for you. Everyone has their own unique support resources that are functioning for them before a cancer is diagnosed. A cancer diagnosis and subsequent treatments nearly always bring new challenges to both patients and their families. Your cancer treatment team works with you to identify your changing needs and offers a variety of supportive therapies that have proven beneficial to others on a similar journey. Each patient is encouraged to explore and consider new coping skills/behaviors to meet new needs brought on by their cancer or their treatments. Supportive therapies may include:
• Education, group and individual
• Talking with others that may have similar challenges (support groups, chat rooms etc.) • Art/Music Therapy
• Counseling:
    • One on one with social worker or psychologist
    • Individual or family
    • Financial Assistance
    • Spiritual
• Surrounding yourself with positive friends and family members (including pets)
• Maintaining intimacy with your partner. Share insecurities and talk about fears and perceived changes in feelings of attractiveness, femininity, and sexuality.

CLINICAL TRIALS
Choosing to participate in a clinical trial, means that you will be adding to the scientific data base that guides all cancer specialists in their recommendations. Most clinical trials do not involve treatments that are completely experimental, rather they compare various combinations of proven therapies or look at the impact of adding additional therapy to make established therapies more effective or better tolerated. For more information on Clinical Trials please utilize the patient information available at the NCI’s website


Survival expectations

No one can predict precise survival statistics for any one patient. However, that is often the very first question that patients and family members want answered from their doctors.

Cancer specialists will usually emphasize that it is impossible to fully predict a patient’s future, but they will usually provide some information about how the majority breast cancer patients with a similar starting point (similar type and stage of breast cancer/risk factors) are expected to do with today’s therapies. It is also important to remember that the statistics quoted by the doctor are based on data from many years prior to your diagnosis, as it takes time to see how patients do (especially long-term) with new therapies. This is also one reason why your doctor may suggest you participate in some sort of a clinical trial, to help the scientific community track and evaluate your individual journey.

It is also important to remember that even with all that science can tell us, there will always be factors that are very individual and are impossible to accurately measure that impact each patient’s survival.

SURVIVING BREAST CANCER: The American public is much more aware and compliant with screening for breast cancer than 30 years ago. Coupled with the significant advances treatment in the past decades we have a tremendous number of women living beyond the cancer diagnosis. On January 1, 2008, there were over 2,632,005 women alive who had a prior history of cancer of the breast6 in this country. Most people are aware that early diagnosis (diagnosis at the earliest stages of breast cancer) leads to the best survival numbers as referenced in the chart below:

breast cancer survival rates

Life after Breast Cancer

After your primary treatments are completed and you enter “remission” (no further evidence of any cancer tissue present), you start seeking your “new normal.” This term was first popularized by the National Coalition for Cancer Survivorship (NCCS) as their members realized that in some ways, life after a cancer diagnosis is always a little different than life before a cancer diagnosis. This is an area of the cancer experience that is being explored and studied more aggressively, due to the fact that we have so very many cancer survivors in this country (over 12 million11). The NCCS is a wonderful resource for all cancer patients and detail information is available at their website: www.canceradvocacy.org.

Increased national recognition of the needs of cancer survivors has resulted in emphasis on developing individual Survivorship Plans. These review each patient’s history with a focus on their treatments, noting what special needs they may face in later years. An example of this for breast cancer patients would be the need to have bone density screening and possibly medications to prevent bone loss from the use of hormone therapy to control breast cancer. Patients in the greater Santa Maria area may make an appointment with a nurse navigator to create a personalized survivorship record and plan (for all your current and future health care providers) by contacting Marian Cancer Care at 805.219.HOPE (4673).