Breast cancer is a very treatable cancer and over 89% of all patients are alive at five years. Once you are diagnosed, usually after a needle biopsy performed in radiology, the next step is to contact the Auerbach Breast Center at Newton-Wellesley Hospital at 617.243.5540. The nurses will perform an intake evaluation on the phone and set you up for any additional imaging that may be required, such as an MRI. Appointments will be scheduled as necessary with a surgeon, oncologist, radiation oncologist, genetic counselor and support services.
One in eight women will develop breast cancer. That means all women are born with a 12% lifetime risk of getting breast cancer if they live until the age of 90. Only 5% of those cancers are related to the breast cancer gene. The most common risk factors include multiple relatives with breast cancer in their 30s and 40s, ovarian cancer, or Ashkenazi-Jewish heritage. The genetic counselors at the Auerbach Breast Center will help determine if you should be tested.
Breast cancer is an umbrella term for a number of different cancers. In other words, not all breast cancers are the same. Treatment is varied depending on certain features that the tumor possesses. Every tumor is analyzed closely to personalize your treatment.
We have four tools in our armament with which to treat breast cancer. Not every patient will require all four stages.
Surgery is usually the first step when treating breast cancer. It not only removes the tumor but also finishes the staging of the disease by getting a true measurement of the size of the cancer and sampling the lymph nodes to detect any spread. The medical and radiation oncologists use the information from surgery to plan the other arms of breast cancer treatment.
The surgical options on the breast are essentially twofold: lumpectomy and mastectomy. Survival rates are the same for patients who undergo a mastectomy and for those who have a lumpectomy followed by radiation. The decision between the two types of surgery depends on the tumor size in relationship to the breast, the ability of a patient to have radiation and whether or not a patient carries the breast cancer gene.
Surgery and radiation treat the breast but chemotherapy treats the body. The decision on who needs their body treated is based on a number of factors that are analyzed to estimate how aggressive the breast cancer cells are. Sometimes we start a patient on chemotherapy before their surgery to start the process of treating the body right away or to a shrink a large tumor to allow a patient to have a lumpectomy instead of a mastectomy.
The decision process to recommend chemotherapy is not done in isolation. We look at a number of different characteristics such as:
Radiation is used to help control disease in the breast and the axilla. All patients under the age of 72 who undergo a lumpectomy are offered radiation therapy. Patients who have a mastectomy and have a positive lymph node are also offered radiation therapy.
There are different ways to deliver radiation and they can occur over different time periods. Standard radiation happens 5 days a week for 6 weeks. Patients usually can drive themselves and fit it in before or after work. There is a 4 week program that delivers the same amount of radiation in a shorter time period. Partial breast irradiation targets the tissue around the lumpectomy cavity and happens twice a day for 5 days.
It is important to understand that a breast can only be radiated once. Therefore if a patient who had a lumpectomy followed by radiation, develops a second cancer later in time in a different part of the breast, they will usually need a mastectomy for treatment no matter how small this new cancer is.
We frequently refer to drugs like Tamoxifen or the aromatase inhibitors as hormonal treatment. In reality it is anti-hormonal treatment. These drugs which are taken by mouth for 5-7 years block either the production of estrogen (aromatase inhibitors) or the effects of estrogen (Tamoxifen) from stimulating the cancer cells from growing in estrogen receptor positive (ER+) tumors. They are not offered to patients whose tumors do not carry the estrogen receptor. Like chemotherapy, hormonal treatment helps to treat the body and the other breast.
A lumpectomy is when the cancer is removed with a rim of normal tissue called a margin. Usually, on the morning of surgery, the radiologist will place a wire in the lumpectomy bed to help identify and center the cancer. Gold or titanium markers are placed in the cavity left behind by surgery to help the radiation oncologists aim the radiation beams at the correct area in the breast.
The benefits of a lumpectomy are that the patient keeps her breast and the recovery is quick. Most patients have only minor discomfort in the breast and are back to work in a few days. The local recurrence rate is approximately 5%. The down side is that sometimes a second surgery is necessary to obtain a better margin and the breast may end up smaller than the other one, especially after radiation.
Wires are placed pre-operatively to localize the tumor.
After the lumpectomy has been performed.
A mastectomy is when the whole breast is removed. It can be done with or without immediate reconstruction. Mastectomy is usually for larger tumors, multiple sites of cancer in the different areas of the breast, recurrent cancers or patients with a high likelihood of having a recurrence, such as BRCA positive patients. The benefits to the mastectomy are a low chance of local recurrence (1-3%) and, if the nodes are negative, a patient can forego radiation therapy. The surgery takes longer with reconstruction and recovery is delayed.
Left nipple sparing mastectomy, two weeks post-op.
Invasive cancers require that lymph nodes be sampled to complete staging and determine future therapy. If the nodes under the arm are not palpable or enlarged on imaging, a sentinel node procedure will be performed. Using one or two types of dye that are injected into the breast, the first node or nodes that drain the breast are identified. If these are found and do not have tumor in them then it is highly likely that the others don’t either and the surgery is stopped. If there is a lot of tumor in the nodes, then a section of the axillary tissue is removed to clean out the area.
Dual surgery is becoming very popular for large breasted women. It is ideal for women with small tumors and allows us to obtain larger margins while giving them the cosmetic outcome they desire. Patients will still need radiation therapy as they have essentially had a lumpectomy. Sometimes we stage this surgery over a very short period of time to ensure that we have clear margins on the lumpectomy before having the reduction.
Patients who are diagnosed with ductal carcinoma in situ or DCIS have noninvasive breast cancer (stage 0). The malignant cells are still within the ducts but have not migrated outside of the ducts into the fat. DCIS is treated with surgery, radiation and Tamoxifen (if it is ER+). Chemotherapy is not necessary. Nodes are not usually evaluated unless there is >4cm of DCIS, in case there is an invasive component.
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