Breast Cancer Tests

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.

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).

The NCCN publishes guidelines for followup.
http://www.nccn.com/files/cancer-guidelines/breast/index.html#/86/
Physical exam is indicated every 4-6 months initially. Annual blood work and tumor markers are often drawn. There is a trend away from routine imaging in asymptomatic patients.

The HALO test is a way to obtain fluid from the nipple which then can be analyzed to see if there are any abnormal, or atypical cells. Cellular atypia is a risk factor for the future development of breast cancer, and patients who have atypia usually are followed more closely. The HALO test is not a substitute for mammogram or other imaging as it is not meant to diagnose breast cancer - it is a way to determine if a woman might be at increased risk and therefore might need additional imaging. The HALO test is typically used in women under the age of 40, who are not yet undergoing routine screening with mammography.

When you’re given drugs that can cause cardiac damage, your heart is carefully monitored so that if damage occurs that outweighs the benefit of the drugs, your oncologist can change your treatment. I was given two drugs—Adriamycin and Herceptin—that are known to cause heart damage in some people.

In my case, the test used to monitor my heart function was the MUGA (short for Multi Gated Acquisition Scan), which provides a very accurate, real-time image of your beating heart and shows how efficiently your left ventricle is pumping blood. I was given a baseline MUGA before I began Adriamycin, and a follow-up every three months until I finished Herceptin over a year later.

The test isn’t particularly difficult or painful, but it’s time-consuming: a couple of hours from start to finish. First a small amount of your blood is drawn, mixed with a radioactive substance, and injected back into your bloodstream. Then you lie on a table under a special camera that records the movement of the radioactive blood through your beating heart. The technician measures the percentage of blood pumped through the left ventricle with each heartbeat. This figure is called the Left Ventricular Ejection Fraction or LVEF. Each time you go for a MUGA, your LVEF is compared with your previous LVEF and your baseline LVEF so that changes can be noted.

My heart function dropped slowly throughout my treatment, and I was afraid I might have to stop or delay the rest of my scheduled Herceptin infusions. But it didn’t drop so fast or so low that my oncologist felt the risk outweighed the benefit of continuing treatment.

The only disturbing thing about the MUGA was the piece of paper I was given to carry with me for 24 hours after the test in case I set off any alarms at, say, an airport. I was also instructed not to hug or hold babies during that time.

My advice: Drink enough water to be well hydrated for the blood draw. And bring a book or your knitting; there’s a fair amount of downtime between the initial blood draw and the actual scan.

During chemotherapy we hope to see an improvement in symptoms, if you are having any, within days or weeks of treatment. We expect to see changes on scans (for example, CT scans, X-rays, bone scans) within weeks of beginning treatment. Most often, we would recommend looking at scans within 6-8 weeks after starting chemotherapy. Sometimes the interval is related to how often you have the chemotherapy. For example, if your treatment is every 3 weeks then you may have scans at 6 or 9 weeks and if the chemotherapy is every 4 weeks then you may have scans in 8 or 12 week intervals. If the drug is working then we would expect to see tumors shrinking or staying the same size. If the drug is not working as well as we would like then we may see tumors getting larger or new tumors showing up on the scans.

Symptoms our often our main clue. We use a variety of imaging : plain xrays, bone scans, CT scans, PET scans. Which one is used is dependent on the problem that we are investigating. Tumor markers (from the blood) can be helpful in some cases.

I use the HALO test fairly often in my practice. It is true that approximately 50% of women will produce fluid. Those that do not produce fluid are considered to have had a normal test, and it is unlikely that they have any abnormality of their milk ducts. If fluid is produced, it is sent for cytology evaluation to see if there are abnormal cells present. Some studies have suggested that if a condition called atypia is present, it has the same significance of atypical ductal hyperplasia found on needle biopsy, which leads to an increased risk of breast cancer in the future.

As the women undergoing the HALO test are often younger than 40 and not undergoing routine mammogram screening, if a patient has atypia found on the HALO test, I would likely recommend that she begin screening, possibly with ultrasound and MRI in addition to mammogram, earlier than age 40. However as pointed out by Dr. Bone, this can open up a whole host of other issues, including radiation exposure and false positive test results.

It is important to remember that the HALO test is not meant to detect breast cancer or to be a screening test for breast cancer. It is a form of risk assessment, meant to help us sort out if a woman should undergo screening when she normally would not. I generally do not recommend that the HALO test be performed on women over age 45.

It is certainly not too late to be tested. BRCA 1 and 2 testing can be done on DNA extracted for a blood sample or from a buccal swab. NCCN guidelines for who should be offered testing were updated in April 2011. Generally if the guidelines are followed, insurance will cover the testing.

Myriad will provide testing kits to a doctor's office to facilitate the sample being sent in.

Oncotype DX is a test designed for women with an early stage breast cancer, negative lymph nodes, and estrogen receptor positive breast cancer. The purpose of Oncotype DX is to determine whether seemingly low risk women, per their diagnosis, would benefit from chemotherapy.
If a person has a more advanced stage of breast cancer, positive lymph nodes, triple negative breast cancer, or another factor that would require chemotherapy then the oncologist does not order Oncotype DX because they already know the person requires chemotherapy.
So in your case I think you do not need the Oncotype DX because you are already having chemotherapy.
You may want to read more about Oncotype DX at the Genomics website...
http://www.genomichealth.com/en-US/OncotypeDX.aspx

Thanks,
Heather

I am doing mammaprint on all patients with tumor 1cm or greater.

Mammaprint is a 70 gene assay that can be used determine if a breast cancer is high risk or low risk for recurrence. Additionally it allows for tumor subtyping so that we can know if the tumor is luminal, basal or her2neu over-expressing. This can be very helpful for helping patients make decisions about the potential benefit of chemotherapy as well as helping to decide which medications are most effective. This assay can only be done on fresh tumor tissue either obtained at the time of core biopsy or during surgery.

The HALO test is meant to be used as a risk assessment tool, not a cancer detection test - it primarily meant for women under the age of about 40 (in whom routine mammography is not performed). The idea is that if there are abnormal cells lining the milk ducts, they may be detected in the fluid obtained from the test. If there are abnormal cells, that generally signifies an increased risk of developing cancer, and additional testing (perhaps MRI) may be indicated.

When properly performed, as many as 50% of women will not produce fluid with the HALO test, and in young women, this is considered a "negative" result (no abnormality). However with the normal aging process, there can be atrophy of the milk ducts, so that in women over the age of 40-50, no fluid might be due to changes related to age, and not necessarily a negative result. In addition, the HALO test will probably not pick up abnormal cells even if a cancer is present if the tumor is in the outer aspects of the breast. Lobular cancer (as it is not growing initially in the milk ducts) also will not likely be picked up with the HALO test.

The HALO test is not for everyone and again it is important to stress that this test is not meant to be a screening test for breast cancer, and is not a substitute for clinical and self-examination as well as routine imaging such as mammogram (and ultrasound / MRI if indicated). However when used appropriately it can be helpful to provide some counseling to young women regarding their risk.

CA15-3 (Cancer Antigen 15-3) is a tumor marker useful in monitoring breast cancer. Elevated levels of serum Ca15-3 during the follow up suggest a relapse of the disease

Immunohistochemistry (IHC) is a way to stain for a particluar protein on or in a cell. They are a combination of an antibody to a portion of the protein hooked to a colored stain. If the protein is there, the stain will appear a certain color - typically brown and if it is not then there will be an absence of color. Immunohistochemistry is used in breast cancer to see if the cells have estrogen receptors, progesterone receptors, epidermal growth factor receptors (such as Her2/neu). IHC stains are also used to look for cancer cells in sentinel nodes (staining for cytokeratin - a protein that is on breast cancer and other types of cancer cells).

Screening mammograms check for lumps in the breast when there no signs or symptoms of breast cancer. Two X-rays are taken of each breast to determine if there have been any tissue changes compared to previous mammograms and look for tumors and microcalcifications.

Diagnostic mammograms are used to help diagnose or rule out breast cancer. Diagnostic mammograms are given after a lump or other sign or symptom of the breast cancer has been found. For diagnostic mammograms, more x-rays are taken to obtain views of the breast from several angles. Suspicious areas may be magnified to produce a detailed picture. The purpose is to locate and analyze potentially cancerous tumors or cells.

If a biopsy has been completed and the diagnosis is breast cancer, data collected from tests and surgery will help to determine the stage, treatment options, and prognosis.

One of the first steps is for the pathologist to assign a grade to the cancer based on examining a tissue sample. The grade measures the speed of growth of the cancer.
The DNA Ploidy and Ki-67 Antigen tests may also be used to measure speed of growth. The grade of the cancer helps to determine the treatment options and prognosis.

Determining the stage of the cancer also helps to determine the treatment options (staging tests are not required depending on size of cancer and symptoms):
- Tests may include:
- Diagnostic mammogram in both breasts - to get a more thorough view, pin point location, measure size, and search for other abnormal areas
- A complete blood count to determine overall health and if cancer has spread to the organs
- MRI - to help measure size of tumor and to see if cancer has spread to other parts of the body
- CT scan - to see if cancer has spread to other organs
- PET scan - to see if cancer has spread to other parts of the body
- Chest x-ray - to see if cancer has spread to the lungs
- Bone scan - to see if the cancer has spread to the bones

In order to accurately determine the stage of the cancer, many times surgery is required. During breast surgery, the following data may be collected to help determine the stage: size of the tumor(s), presence of cancer cells in the axillary lymph nodes under the arm, and the presence of cancer cells in other parts of the body.

Determining the hormone receptor status and Her2 status will determine how the cancer will respond to hormonal therapy and other targeted treatments.
- Her 2/neu - used to determine Her2 status. Helps to determine treatment options. If there are increased levels of Her2 protein, patients may respond well to the medication Herceptin.
-Estrogen Receptor/Progesterone Receptor - used to determine hormone receptor status. Helps to determine treatment options. Patients who have high percentages and intensity of estrogen and progesterone positive cells, may respond well to anti-hormone therapy.

There are also more specific tests for patients whose cancer meet specific criteria. A couple of examples are:
- Oncotype DX - for early stage, node negative, ER+ cancers to predict chemotherapy benefits and recurrence.
- MammaPrint (Agendia) - for lymph node negative breast cancer patients under 61 years of age with tumors of less than 5 cm. May assist in determining risk for possible metastasis of cancer.