Breast Cancer

1. I most likely will not die.

2. You can finish final while I have surgery, it's ok.

3. You can cut my hair before it fall out.

When a woman is diagnosed with cancer, she needs to consider her family’s history of cancer. Some cancers are inherited; however, most are spontaneous. If there is a concern with a family pattern of cancer, then a thorough family history should be taken. Sometimes this leads to formal genetic counseling with blood testing for specific gene mutations. If you have a specific gene mutation putting you at risk for breast or ovarian cancer, then surveillance testing or procedures are different from those with a spontaneous cancer. Therefore, start with telling your oncologist your family history.

I opted for a bilateral. I only had cancer on the right side, but after finding that and getting my MRI, something popped on the left. We weren't sure what it was. I could have had it tested, but at that point I just knew I wanted to have both sides removed. So I chose to not get that side tested and proceed with a bilateral mastectomy.

After surgery, pathology showed it was not cancer, but I don't regret
making that decision. It was 100% correct for me.

That said, what is right for me, may not be right for you. And it's a hard decision to make. And I wish you best of luck making it. You have to do what you think is right for you, and only you. ((hugs))

Everyone is different ... my doctors told me not to expect any noticeable side effects from herceptin, however, I do have them.
My exhaustion levels are still so high. At first the doc blamed recovery from other chemo, but at this point believes it's the herceptin causing it.
Also, for about 2-3 days after infusion I have flu-like symptoms (very achey and sore and more tired). And for about a week I get taxol-recall joint pain.
That said, my doctors have said this isn't common BUT I have reacted strongly to everything we've done so far and they theorize that my body is just hyper-sensitive. Chances are you aren't and won't deal with it, but I share on the off chance you do get side effects, you're not crazy or imagining it!

Preferably immediately after diagnosis. I feel it is very important for patients to learn about all their breast cancer treatment options, including breast reconstruction, at the very beginning of their journey. This is the only way to ensure they are truly involved in their treatment plan. It also allows those patients interested in immediate breast reconstruction to pursue it if they are candidates. For those that may not be candidates, knowing they will have the option once all their other breast cancer treatment is completed is often a huge source of strength.

Dr C
http://www.PRMA-enhance.com

Breast and ovarian cancer survivors, especially those with, hormone-sensitive cancers, may worry about using ovarian stimulating hormones either during fertility preservation prior to cancer treatment or during survivorship. For fertility preservation purposes, embryo or egg banking are options for many young women. In this process, hormones are used to induce the ovaries to produce multiple eggs in one month (normally an ovary produces a single egg per month). Clinical hormonal stimulation protocols have been modified to work for women with hormone-sensitive cancers. The one study that looked at cancer recurrence rates for breast cancer survivors who underwent this procedure, found that these women did not have an increased risk for cancer recurrence compared to those who did not have ovarian stimulation.

Survivors of hormone-sensitive cancers may also discuss using this protocol with their fertility specialist. However, they may first wish to examine their ovarian reserve, the number of immature eggs in their ovaries, as chemotherapy, radiation, and surgery for cancer treatment may have significantly reduced this number.

When the tissue sample is inspected grossly, the tumor is measured in three dimensions using a ruler and the distance to all the margins of excision are recorded. Other observation such as the presence of satellite nodules, tumor necrosis (death tissue), calcifications, relationship with the skin, nipple or deep fascia etc are recorded. The presence of other possible non-cancerous lesions are described. Ultimately, samples of the tumor, margins, other lesions etc. are taken and submitted for microscopic examination.

I see. I did not realize it was an individual plan related to autonomy. Very helpful.

Radiotherapy is a significant risk factor for lymphedema (breast as well as extremity). Selection of patients who will or will not benefit from radiotherapy. And trading off risk of lymphedema against risk of salvagable local recurrence can be discussed with the patient

The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy.

The standard recommendation is for five years of aromatase therapy based on our present knowledge and the results of numerous large clinical trials that compared aromatase inhibitors to tamoxifen. It is also an acceptable strategy to initiate therapy with tamoxifen and switch to an aromatase inhibitor after 2 to 3 years to complete a total of five years of therapy. Based on evidence from a large clinical trial, it is also acceptable to switch to tamoxifen from an aromatase inhibitor; this is an option for individuals who are experiencing difficult side effects with aromatase inhibitors.

This may vary depending on the individual and their risk for bone density loss or fracture. It is important when starting an aromatase inhibitor that you have a baseline bone mineral density study (referred to as a DEXA scan) and a clinical assessment for other potential risk factors for osteoporosis (defined as a T score < 2.5 on a DEXA scan by the World Health Organization). These risks include older age, previous fracture, low body weight, current tobacco use, and excessive alcohol consumption, among others. I encourage all women starting an aromatase inhibitor to adopt lifestyle changes that promote not only bone health but overall health as well. These include increasing physical activity (including weight bearing exercise), stopping smoking, and taking calcium and vitamin D supplements. Some individuals starting an aromatase inhibitor may be advised to take drug therapy with bisphosphonates if they have osteoporosis or a history of a fracture or osteopenia (http://www.medterms.com/script/main/art.asp?articlekey=8048)(T-score between -1 and -2.5 on a DEXA scan) with other risk factors. There is no consensus on the optimal strategy for monitoring but every two years is a common strategy.

Aromatase inhibitors lower estrogen levels in your body and this estrogen deficiency leads to increased bone turnover and bone loss. This side effect, however, does not reflect whether the medication is working for your breast cancer. Estrogen is known to stimulate hormone receptor positive breast tumor cells and aromatase inhibitors are very effective at lowering estrogen levels and thereby removing this growth signal and resulting in tumor cell death. Thus, the lowering of estrogen is a critical reason why these drugs work so well to treat hormone receptor positive breast cancer but may have, at the same time, a negative impact on bone health.

The role of hormonal therapy for risk reduction should be carefully considered and discussed with experts in breast cancer risk assessment and management in a shared decision-making environment. Guidelines from expert groups recommend that the risks and benefits of breast cancer prevention be discussed with premenopausal and postmenopausal women who are at high risk for the disease.

Women at high risk may include some women over the age of 60; women with certain high-risk conditions found on breast biopsy, such as lobular carcinoma in situ (LCIS) or atypical ductal or lobular hyperplasia; women between the ages of 35 and 59 years who have a calculated five-year risk of developing breast cancer of 1.7 percent or higher, according to a system called the Gail model. The Gail model uses a woman's current age, age at first menstrual period, age at first live birth, the number of first-degree relatives with breast cancer, and the number and pathologic findings of any breast biopsies to estimate the probability of breast cancer over time. This model, and others, is used by health professionals to calculate an individual’s risk and the results should be interpreted with an expert in breast cancer risk assessment. It is also important to remember that the presence of breast cancer risk factors does not mean that cancer is inevitable as many women with risk factors never develop breast cancer.

Another very important issue is that the Gail model does not consider the risk of cancer associated with inherited breast cancer-predisposing genes such as BRCA1 and BRCA2. If an individual has a strong family history that suggests the possibility of an inherited predisposition to breast cancer, then that individual should be referred for genetic counseling. Other components of a risk/benefit assessment and counseling include a careful discussion of the side effects of hormonal therapy, options for participation in clinical research and healthy lifestyle changes.

There are multiple parameters used to determine the tumor aggressiveness. Some are histological, some molecular some clinical.

The histologic indicators are: tumor size, tumor histology, tumor differentiation, lymphovascular invasion, multi-focality, and number of mitosis.

Molecular parameters include expression of estrogen and progesterone hormonal receptors; expression of HER2-neu; proliferative activity of the tumor (Ki67, mitosis) and other genetic profiles of the tumor cells as determine by molecular analysis of the cells via RNA or DNA studies such as Oncotype, Mamotomme etc. that provide a “genetic signature” of the tumor cells able to predict the aggressiveness of the tumor and guide to a certain extent the therapeutic approach.

Clinical parameters relate to the clinical and imaging findings such as palpable lymph nodes, positive scans for probable metastasis, etc.

Smaller and single size (<2 cm) tumors with pure mucinous or tubular type of histology or other histology that is well differentiated (grade 1), with no vascular/lymphatic invasion, and ER/PR positive with no overexpression of Her2 neu would be the least aggressive tumors. However, the histologic/molecular parameters are secondary to the stage of the tumor as given by the TNM staging.

Cancer staging system is routinely used to summarize some histologic/clinical characteristics of the tumors. The staging includes three letters: T is for Tumor size; N is for lymph Node metastasis and M is for distant organ Metastasis. Of the four possible stages, Stage 1 will have the best prognosis since the tumors in this group are small and there is no nodal or distant organ metastasis. It is only within the same stage that the histologic and molecular indicator acquire larger relevance.

The HALO Breast Pap Test is a non-invasive way of retrieving breast duct cells for pathologic examination. It is NOT a diagnositc test (meaning it will not find a cancer int he breast) but is only used as another way to assess a woman's risk of developing breast cancer in the future. Suction cups are applied to the breast (similar to a breast milk pump) and fluid is obtained from the ducts at the nipple. Approximately 2/3 of the women will have fluid obtained (so 1 in 3 women will not have fluid for examination) and the cells can look normal, hyperplastic, atypical and very rarely frankly cancerous. Hyperplastic cells raises a woman's risk by ~1.5-2x above her known risk (as assessed by the Gail or Tyrer-Cusick models) and atypical cells raise her risk by 4-5x. If cancerous cells are found, advanced imaging must be done to determine where the cells originated. The HALO Breast Pap can be done on any woman over 30-35 years of age and is typically done yearly (just as the cervical Pap test is done).

Americans get risk screening all the time but we generally don't think of these tests in those terms. Assessment of cholesterol levels in the blood and blood pressure are risk assessments for heart disease and stroke. These are offered to essentially everyone and help to direct additional testing (advanced cardiac/vascular examinations) and treatment (cholesterol and blood pressure lowering medicines). There is no downside to risk assessment in all women and can help direct advanced breast imaging and closer follow ups as well as alleviating fear in some women who overestimate their risk of developing breast cancer. The risk assessment requires no blood draws and can be done in less than 5 minutes by a trained medical assistant.

Basic starting points would be listening to the patient, breast examination and appropriate imaging. It is recommended that an image-guided biopsy be done (either stereotactic or ultrasound-guided), rather than an excisional biopsy operation. Fine needle aspiration can be performed as an alternative, but the core biopsy yields more information.

The first visit post-diagnosis will be a discussion of the biopsy results, type of cancer, and treatment options. Additional tests will be mentioned. This will take in the order of 45 minutes to an hour. There should be ample time for questions. Families are encouraged to take notes. Literature may be provided to the patient and family. There may be referrals to other team members such as radiation oncology, medical oncology, plastic surgery, social work or counseling.

Obesity is a risk factor. In terms of the surgery itself, lymphedema rates are reduced with sentinel node biopsy (2-5%) compared to full axillary dissection (20-35%). Radiation to the axilla and supraclavicular nodes increases lymphedema risk.