All About Breast Cancer

Everything You Need To Know About Breast Cancer

Breast cancer occurs when cells in the breast tissue mutate and rapidly divide. These abnormal cells form a tumor. A tumor can become cancerous when these abnormally growing cells spread to other parts of the breast or the body. Metastasis is the process of abnormal cells dividing. Metastasis happens via the bloodstream or the lymphatic system that helps fight infections.

Breast_Cancer

What is Breast Cancer

Breast cancer occurs when cells in the breast tissue mutate and rapidly divide. These abnormal cells form a tumor. A tumor can become cancerous when these abnormally growing cells spread to other parts of the breast or the body. Metastasis is the process of abnormal cells dividing. Metastasis happens via the bloodstream or the lymphatic system that helps fight infections.

It generally begins in the milk-producing glands (lobules), or in the tube-shaped ducts that carry milk from the lobules to the nipple. Sometimes, it begins taking shape in the fatty and fibrous connective tissue of the breasts.

Both women and men are at risk of developing a tumor in the breast. But it is 100 times more common in women than in men. It is one of the leading causes of cancer-related deaths in women around the world. But the mortality rates have declined in recent years. Better awareness, regular screening, and advanced treatment options have proved useful.

tnm staging of breast cancer

What are the different types of breast cancer?

Breast cancer can be of different types and sub-types, classified according to causes, aggressiveness and possible response to treatment. It is important to know the exact type of breast cancer in order for the treatment to be streamlined towards the best possible outcome.

Breast cancer can originate in different parts of the breast area, such as the ducts, the lobules, the connecting tissue between breasts, and in some cases, in the armpit area, where lymph nodes are located.

The treatment for different types of breast cancer usually depends on the site of primary origin, the state of invasion (spread) and the dependency of tumor growth on hormones such as estrogen or progesterone.

Reference guide to understand the different types of breast cancer

  • Most breast cancers are carcinomas (carcinomas are cancers that start in the cells lining the organs or tissues)
  • In-situ breast cancers are those that have not spread to the surrounding tissue, which makes them more treatable
  • Invasive breast cancers are those that have an invaded basement membrane of epithelial lining in the ducts
  • Metastatic breast cancers are those that have spread to other organs or parts of the body, such as the lungs, bones, liver, or brain
  • Recurrent breast cancer refers to the return/relapse of breast cancer after a disease-free period in completely treated patient

Types of breast cancer

Ductal carcinoma in-situ (DCIS)

This is a highly treatable form of pre-cancer (sometimes called ‘stage 0’ breast cancer). It starts in a milk duct and is the most common type of non-invasive breast cancer. In DCIS, the cells are abnormal but have not spread to the surrounding tissue areas. If left untreated over time, or if mistreated, DCIS may progress and evolve into an invasive form of breast cancer.

Invasive ductal carcinoma (IDC)

This is the most common type of breast cancer. It accounts for up to 80% of all invasive breast cancer cases and is also known as ‘infiltrating ductal carcinoma’. Like DCIS, IDC also starts in a milk duct. It then breaks through the duct wall, and invades the surrounding breast tissue area as well as has the potential to spread to other parts of the body as well.

Invasive lobular carcinoma (ILC)

This type of breast cancer begins in lobules, or the milk-producing glands present in breasts. It is also known as ‘infiltrating lobular carcinoma’. ILC has the potential to spread beyond the lobules, into the surrounding breast tissue and it can also metastasize to other parts of the body. It accounts for nearly 10% of all invasive forms of breast cancer.

Inflammatory breast cancer (IBC)

IBC is a rare and aggressive type of breast cancer. It causes redness and swelling in one or both breasts. The affected breast starts to feel warm, heavy, and tender. For IBC patients, the skin around the breast area becomes hard and ridged. It does not show up easily in a screening mammogram, and compared to other types of breast cancer, IBC tends to strike five years earlier.

Paget disease of the breast (or the nipple)

Paget disease is another rare type of cancer that affects the skin of the nipple and the areola (the darker circle of skin surrounding the nipples).

It should be differentiated from eczema of the nipple. For people affected with Paget disease, the nipple and areola often become scaly, red, or itchy. Patients may also experience yellow or bloody discharge from the nipples. Most people with Paget disease are likely to have invasive breast cancer or DCIS in the same breast.

Metaplastic breast cancer

Metaplastic breast cancer is also an extremely rare and invasive type of breast cancer. It begins in a milk duct, and proceeds to form very large tumors. It can contain a combination of cells that are different in appearance as compared to typical breast cancers, and it is generally harder to diagnose.

Angiosarcoma of the breast

Angiosarcoma is a rare soft tissue tumor of the breast. It occurs in both a primary form without a known precursor, and a secondary form that has been associated with a history of breast tissue that has been previously exposed to radiation.

What are the signs and symptoms of breast cancer?

Early detection plays a vital role in the timely treatment of breast cancer. In the early stages, the disease is at lesser progression; the tumors are small and usually have not spread to nearby organs. In such situations, the right treatment will lead to better outcomes.

Common breast cancer signs and symptoms:

  • A painless breast lump
  • Bloody discharge from the nipples
  • Redness of breast in non-lactating women
  • Nipple retraction (nipple turning inward)
  • Skin irritation or ‘dimpling’
  • Unilateral scaliness, redness, or thickening of the nipple or the skin on breasts
  • A lump in the underarm area

Breast Cancer Signs and SymptomsIn most of patients, a lump in the breast is the first sign of a cancer risk. A lump that is painless, hard, and has uneven edges, has a higher chance of being cancerous. In some cases, however – cancerous lumps may also present as tender, soft and rounded. Hence, it is essential that any unusual changes, if noticed, are pointed out to a doctor and checked at the earliest.

What are the causes of breast cancer?

The causes of breast cancer may be sporadic, familial, or hereditary. Sporadic breast cancer means breast cancer that is not due to an inherited gene mutation. There are multiple risk factors responsible for sporadic breast cancer: hormonal, dietary, lifestyle-induced, benign breast diseases, and environmental factors are significant causes of breast cancer.

The majority of occurences are sporadic (approximately 70%), while 20-25% causes of breast cancer are familial, and only 5-10% are hereditary. Hereditary causes of breast cancer have mutated genes like BRCA. Familial causes of breast cancer have no apparent mutations in genes, but other family members are at higher risk of developing breast or other cancers. Some can be modified, and their presence indicates a necessity for regular screening or active surveillance.

Non-modifiable risk factors: Genetic causes of breast cancer

Being a woman

Being a woman is the most significant risk factor for breast cancer. Women have a 100 times higher risk than men do. Male breast cancer contribution is less than 1% of the total breast cancer burden.

Being an older woman

Women aged above 50 are at more risk to develop breast cancer than younger women. This risk is considered to be the highest for women in their 70s. In the last decade, because of the change in lifestyle and environment, the number of young breast cancers is increasing.

Family history

Breast cancer (and the genetic mutations responsible for the disease) can be passed on within a family. Having a close blood relative with confirmed breast cancer increases the risk of developing the disease, especially in later years. A woman is considered to be at 2X risk of developing breast cancer if a direct female blood relative such as her mother, sister (or even daughter) is diagnosed positive. If a woman has two or more first-degree relatives with breast cancer, her risk of developing the disease increases threefold. Up to 10% of all cases of breast cancer are hereditary.

Personal history of having breast cancer

Patients with a prior history of breast cancer are at a higher risk of developing contralateral breast cancer (in the opposite breast), or in the different quadrant of the same breast if the patient had undergone breast conservative surgery.

Genetic abnormalities

Hereditary breast cancer constitutes 5-10% of all breast cancer. The most common genetic mutations occur in the BRCA1 and BRCA2 genes. Women with a mutated BRCA1 gene have a 60-85% lifetime risk of developing breast cancer while BRCA2 mutated patients have a 40-60 % lifetime risk. BRCA mutated patients also have a 20-30% lifetime risk of ovarian cancer. There are other genes like p53, PTEN, ATM, which can lead to hereditary breast cancer.

Race and ethnicity

There is a direct link between breast cancer and a patient’s race. For example, white Caucasian women are at a higher risk of developing breast cancer as compared to Asian, African-American, or Hispanic women. Survival outcomes also vary with race. For example, the probability of breast cancer-related death is higher in African American women and Hispanic women than in Caucasian women. Also, African-American women are most likely to develop an aggressive form of breast cancer at a much younger age than women of other races and ethnicities.

History of menstrual activity

Early menarche and late menopause are important risk factors for breast cancer that is women who attained puberty before the age of 12 (with early menstrual activity), and women who attain menopause after the age of 55 are at a higher risk of developing breast cancer in their lifetime. More prolonged exposure towards estrogen stimulates the growth of cells within breast tissues. Similarly, exposure to hormone replacement therapies (HRT) after menopause can also boost a woman’s breast cancer risk.

Dense breasts

Breast density is a significant risk factor. Patients with high breast density are at 2-4 times higher risk of developing breast cancer. Having dense breasts also makes it harder for mammograms to make early detection of a cancerous lesion in the breast tissues.

Previous breast changes/breast abnormalities

If any of the following conditions is present, a woman is considered to be at higher risk of developing breast cancer are a personal history of:

  • benign breast lumps
  • breast lumps
  • breast cancer
  • benign breast disease

Modifiable risk factors: Environmental and lifestyle causes of breast cancer

Lack of physical activity

People with low or no physical activity are at an increased risk of developing breast cancer. Research has shown that 4 to 7 hours of moderate-to-intense exercise every week can significantly reduce breast cancer risk.

Being overweight/obese

Women who continue to remain overweight/obese after menopause are more likely to develop breast cancer. This risk is commonly attributed to estrogen secretion by fat cells after the age of menopause. Also, being overweight increases the levels of insulin present in the blood, which in turn boosts a woman’s breast cancer risk. Women who have completed breast cancer treatment are also at a higher risk of recurrence if they continue to remain overweight.

Alcohol consumption

Studies have shown that women who consume two or more alcoholic beverages in a day are at a 1.5 times higher risk of developing breast cancer as compared to women who do not consume alcohol. This risk is seen to increase with more significant proportions of daily alcohol intake.

Smoking

Young and pre-menopausal women who smoke are at a higher risk of developing breast cancer. Research has also demonstrated the links between massive second-hand smoke exposure and breast cancer risk in postmenopausal women.

Exposure to radiation (before the age of 30)

Women exposed to prolonged chest radiation at an early age are at an increased risk of developing breast cancer later in their lives. Women who have received radiation to the chest to treat any type of cancer other than breast cancer (such as Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, chest wall sarcoma) are also at a higher risk of developing breast cancer than those who have not received radiation therapy.

Pregnancy timelines

Women who do not get pregnant at all (nulliparous), or get pregnant after the age of 30, or did not complete a full-time pregnancy are also at a higher risk of developing breast cancer.

Breastfeeding history

Women who have breastfed their babies for one year or more are at a lower risk of developing breast cancer as compared to those who have not.

History of Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) refers to the treatment used to relieve women from symptoms of menopause. HRT replaces hormones that are at a lower level, as women approach menopause. Women who are currently receiving HRT or have received it in the near past, have a higher risk of developing breast cancer.

Emerging causes of breast cancer

Vitamin D deficiency

Women with low levels of vitamin D are at an increased risk of developing aggressive/invasive forms of breast cancer. Vitamin D plays a vital role in controlling the regular growth rate of breast cells and may be able to stop breast cancer cells from growing.

Exposure to artificial light at night

Survey results have shown that women who work in night shifts, including doctors, nurses, and police officers, are at a higher risk of developing breast cancer compared to women who work during daylight. Increased exposure to artificial light at night causes this. Women who live in areas with high levels of artificial external light during the night (e.g., street light) also face a higher breast cancer risk.

Eating junk/unhealthy food

Unhealthy dietary habits are partly responsible for breast cancer. Whole foods and foods rich in antioxidants can boost human immune activity, and reduce the risk of breast cancer.

Eating processed foods/chemically preserved foods

Chemical food preservatives and enhancers include pesticides, antibiotics, and hormones used on both crops and livestock. Research shows that these can contribute to an increase in breast cancer risk. The risk extends to mercury found in seafood and industrial chemicals used in the food and food packaging.

Eating grilled meat

Research shows that women who eat a lot of grilled, barbecued, or smoked meats are at a higher risk of breast cancer compared to those who have a diet of fruits and vegetables.

Heavy use of cosmetics

Recent research suggests that exposure to certain chemicals found in cosmetics can contribute to the growth of breast tumors.

Excessive use of sunscreen

The use of sunscreen is intended to protect us against UV rays. However, recent research suggests that excessive levels of exposure to some of the chemicals that are part of sunscreens can lead to breast cancer.

High exposure to plastic

Research has it that at certain exposure levels, some of the chemicals used in manufacturing plastic products, such as bisphenol A (BPA), may act as carcinogens and boost breast cancer risk.

Exposure to chemicals in gardening products

Research-backed evidence supports the theory that chemicals used in lawn and garden products may boost cancer risk. Also, it is difficult to establish definitive cause and effect for any specific chemical. Exposure to such substances are dangerous.

Drinking contaminated water

More than 206 drinking water contaminants are identified to date. There is no conclusive evidence relating these pollutants directly with breast cancer; government bodies regulate some of these contaminants (such as chlorine and fluoride).

How is Breast Cancer Diagnosed?

Diagnosis of breast cancer is different from breast cancer screening. Screening is performed to detect breast abnormality (breast cancer) in its pre symptomatic phase , whereas diagnosis is performed to confirm whether an abnormality that has already been detected, is cancerous or not. Contrary to popular opinion, an abnormal finding on a screening mammogram or the self-discovery of a lump or other breast changes does not necessarily confirm that someone has breast cancer.

There is only one way to confirm if an abnormal finding is cancerous – by performing a breast biopsy and its histopathological examination.

What are the steps involved in the diagnosis of breast cancer?

In our knowledge article on breast cancer screening, we have examined the following types of imaging tests that help doctors detect an early abnormality in the absence of symptoms:

Clinical breast examination:

A doctor will check both of your breasts and lymph nodes in your underarm area, to feel any lumps or other abnormalities.

Screening mammogram:

A mammogram is an X-ray picture of the breast. They are commonly used in breast cancer screening. If an abnormality is seen during a screening mammogram, doctors generally recommend a diagnostic mammogram to further inspect the problem.

Breast MRI:

MRI scan of breast is usually recommended for patients who exhibit doubtful lesions or multiple small lesions seen on breast mammograms, and women with high risk genes (BRCA 1/2).

After the detection of abnormalities, either during routine screening or during a doctor-advised checkup, the following tests are usually performed to further diagnose and confirm breast cancer. Please note that the diagnosis remains incomplete without a breast biopsy.

Further diagnostic testing:

Diagnostic mammogram

This is an advanced form of a mammogram. To generate this image, the patient’s breasts are put, one at a time, between two special plates and compressed (pressed down) between these plates by an X-ray machine momentarily, while the X-rays are taken. A minimum of two views of each breast are taken.

Both the mammography and the compression are performed by a specially trained radiographer (medical imaging technologist). While the compression might be uncomfortable for some women and sometimes painful, it lasts only for a few seconds. Without compression, the diagnostic mammogram X-rays can become blurry, which makes it hard to confirm the nature of any abnormality. The act of compression also reduces the total amount of radiation needed for a diagnostic mammogram.

Breast ultrasonography (USG)

This process uses sound waves to render images of structures deep within the breast area. Ultrasound technology can be used to confirm whether a new breast lump is actually a solid mass (potentially cancerous) or just a fluid-filled cyst. Breast USG is helpful in young females with dense breasts.

Breast biopsy

This is the gold standard test for confirming breast cancer. After all abnormalities found through either self exams or screening are inspected using various scans, if a doctor suspects the presence of cancer, a biopsy is advised. During a breast biopsy, doctors use a special needle to extract a piece of tissue from the area of concern. Sometimes during a breast biopsy, a small metal marker is left at the site of suspicion within the breast, so that the area can be easily identified later for future imaging investigations.

Biopsy samples (tissue samples extracted during a biopsy) are then sent to a laboratory for a thorough analysis, where experts determine whether the cells in that tissue sample are cancerous. A biopsy sample can also help in ascertaining the aggressiveness of breast cancer, and to understand whether hormone receptors are present in a specific patient.

A biopsy is also the first step towards establishing the overall disease prognosis. This information will help any oncologist (medical, radiation and surgical oncology experts) to determine the best course of treatment.

Breast Cancer Screening And Self Examination

How to self-examine for breast cancer?

Breast cancer screening refers to the process of looking for breast cancer before a woman presents with symptoms. This facilitates early detection and timely treatment. If abnormal tissue or cancerous growth are detected early, it can become easier to treat. The disadvantage of not screening is that by the time symptoms are usually seen or felt, the cancer may have already progressed to an advanced stage/spread to nearby areas.

Breast cancer screening methods have begun to evolve, as scientists are trying to develop a better understanding of the genetic profile of women who are more susceptible to present with symptoms at a later stage than early. Researchers are also in the process of studying different consumption and lifestyle behaviors to figure out if these contribute to cancer risk, and if a certain risk category of women should be screened earlier, or to establish screening frequencies best suited for different women.

What is the difference between breast cancer screening and breast cancer diagnosis?

Please note, that when a doctor recommends you to get screened, they do not necessarily think that you have breast cancer. Screening tests (including routine screening mammograms) are generally administered in the absence of symptoms and after a particular age.

When screening tests yield abnormal results, further testing becomes necessary in order to probe better and confirm the presence of cancer – those are called diagnostic tests (biopsies, other imaging modalities etc).

How is breast cancer screened?

There are two established scientific methods of breast cancer screening – mammography and breast MRIs.

What is mammography?

Mammography refers to the process of creating a mammogram, or an X-ray image of the breasts. It can be used to check for breast cancer in women who have no signs or symptoms of the disease. It can also be used if someone presents with a lump or any other sign of breast cancer. Mammography is recommended for women at both standard and high risk for breast cancer.

What is a breast MRI?

Magnetic resonance imaging (MRI) of the breast uses a powerful magnetic field, radio waves, and a computer that can produce detailed pictures of the internal structures within the breast. It is used as a supplemental breast screening tool along with mammography. It can be used to screen women who are considered to be at high risk for breast cancer, or in dense breast, or to further examine abnormalities observed during routine mammography.

How frequently should one get screened for breast cancer?

Most medical organizations, government advisory panels, breast cancer advocacy groups and cancer research organizations such as the National Cancer Institute, American Cancer Society, Breast Cancer Foundation, NHS (United Kingdom), and American Institute of Cancer Research urge older women to undergo regular (annual or biannual) screening to detect breast cancer early.

According to the NCCN (National Comprehensive Cancer Network), which is an alliance of the most advanced cancer care centers, all women above the age of 40 should go for annual screenings (mammograms).

After a woman has attained the age of 55, they should either continue annual mammograms, or switch to one mammography test every two years. Women aged above 75 have the option of discontinuing annual/biannual mammograms at their own discretion.

It is also recommended that women who have been identified to be at higher risk for breast cancer, owing to either genetic predisposition or sporadic factors, should start screening as early as the age of 30. This includes women with a known breast cancer gene mutation, or those with a first degree relative who has inherited a breast cancer gene mutation.

TNM Staging – Understanding Breast Cancer Stages

What are the stages of breast cancer?

Depending on the tumor size, nodal status and the status of distant spread of the disease, breast cancer is classified into different stages – from stage 0 to 4. At the time of diagnosis, the disease is staged with the help of clinical examination and radiological imaging. Staging helps doctors making the treatment plan according to optimum outcome possibilities.

Broadly speaking, breast cancer is classified as either early, locally advanced, metastatic or recurrent. In medical terms, breast cancer is staged based on the size of tumors, degree of invasion, status of lymph node involvement, growth rate of the tumor(s), and the status of spreading (metastasis) to other parts of the body. Oncologists have developed several strategies to determine the stage of breast cancer in each patient, such as physical exams, biopsies, x-rays, bone imaging tests and blood tests.

Stages of breast cancer – What information do they provide?

An accurate breast cancer stage provides data about the following:

  1. The size of the tumor
  2. Identification of whether the tumor is invasive
  3. Identification of whether the tumor has reached lymph nodes
  4. Identification of whether the tumor has spread (metastasized) to other parts of the body
  5. Identification of whether this is a recurrent (relapsed) version of cancer

Broadly, breast cancer can be classified as early breast cancer (EBC), locally advanced breast cancer (LABC), metastatic breast cancer (MBC) or recurrent breast cancer (RBC). The treatment protocols for different stages are distinct. However, for more detailed staging, a numeric format has also been developed and is widely accepted. This includes:

Types of early breast cancer:

Stage 0 breast cancer: This is also known as pre-cancer, and includes early and non-invasive types of breast cancer

Stage 1A breast cancer: This is a form of early, mostly invasive type of breast cancer, which has not progressed extensively to the lymph nodes

Stage 1B breast cancer: This is a form of early, mostly invasive type of breast cancer, which has mildly progressed to the lymph nodes

Types of locally advanced breast cancer:

[Also see: Treatment for locally advanced breast cancer]

Stage 2A breast cancer: This is a form of localized invasive breast cancer, which has progressed to the lymph nodes

Stage 2B breast cancer: This is a form of localized invasive breast cancer with significant lymph node involvement

Stage 3A breast cancer: This is a form of locally advanced, invasive breast cancer with significant lymph node involvement and a medium-to-large tumor at the original site

Stage 3B breast cancer: This is a mildly aggressive form of locally advanced and invasive breast cancer, with involvement of skin or chest wall and extensive lymph node involvement

Stage 3C breast cancer: This is an aggressive form of locally advanced and invasive breast cancer, with a significantly large tumor, extensive lymph node involvement, and nearby spread to tissues and organs near the breast area

Types of metastatic breast cancer:

[Also see: Treatment for metastatic breast cancer]

Stage 4 breast cancer: This is the stage at which cancer has spread from the breast tissue area, the lymph nodes, and has extended to organs such as the lungs, liver, bone and/or brain. This is generally considered harder to treat as compared to early and locally advanced stages of breast cancer.

Recurrent breast cancer: This is not a progressive stage. It refers to a condition where the cancer has relapsed after the completion of treatment for an existing breast cancer patient.

Breast Cancer Treatment Options

How is breast cancer treated?

The overall treatment plan and standard of care for breast cancer varies, depending on the following factors:

  • The type of breast cancer
  • The subtype of breast cancer (according to applicable hormone receptor status (ER/PR) and HER2 status)
  • The patient’s BRCA1/BRCA2 status
  • The stage of the disease
  • Genetic markers
  • The patient’s age
  • The patient’s general state of health
  • The patient’s menopausal status

Breast cancer treatment formats

breast cancer treatment can vary (as explained above), depending on the patient’s unique medical conditions. However, at a broad level, the following treatment formats are available to treat a variety of breast cancer types, subtypes and stages:

Surgery:

Either in the form of mastectomy (complete breast removal) or lumpectomy (removal of tumor with margins). In mastectomy, the entire breast tissue is removed, followed by reconstruction. In lumpectomy, the tumor is removed along with a part of healthy tissue around it, to obtain a clear margin. It is also called breast conservation therapy (BCT).

[See more about breast cancer surgery and operation here]

Chemotherapy Treatment for Breast Cancer:

It is the intravenous administration of medicines that can find and kill cancer cells. Chemotherapy medicines identify cancerous cells by virtue of rapid divisiveness, which means that they sometimes also attack and kill healthy cells that divide normally. Chemotherapy can sometimes be given before surgery in order to decrease the size of tumors, so that surgical intervention is minimal. Chemotherapy can also be administered after surgery to prevent any recurrences.

[See more about breast cancer chemotherapy treatment here]

Radiotherapy or Radiation Therapy Treatment for Breast Cancer:

This uses exposure to high-intensity radiation to kill cancerous cells. The intent of radiation therapy is to remove any residual disease and to minimize the chances of local recurrence. Radiotherapy is used as a component of BCT, where as radiation is advised after mastectomy, depending on the post-surgical pathological findings.

[See more about breast cancer chemotherapy treatment here]

Hormonal Therapy Treatment for Breast Cancer:

This type of treatment is specific to patients who have been identified as hormone receptor positive, i.e. ER/PR positive. The choice of hormonal agent depends on menopausal status of the patient. For premenopausal women, adjuvant Tamoxifen is used at a dose of 20 mg, to be taken once daily , for a duration of five years after the completion of chemotherapy and radiotherapy. For postmenopausal women, the preferred drug is Anastrozole (a type of aromatase inhibitor), delivered at a single dose of 1mg every day, for a duration of five years.

[See more about hormone therapy for breast cancer here]

Targeted Therapy Treatment for Breast Cancer:

This type of treatment either targets specific genes or proteins found inside cancerous cells making up a tumor, or the tissue environment that enables the growth and survival of cancerous tissue. Targeted therapies are extremely focused, and work differently as compared to chemotherapy. Targeted therapies can control the growth and spread of cancer cells, without damaging healthy cells that is they have minimal side effects.

[See more about breast cancer targeted therapy here]

Treatment of recurrent breast cancer (cases of breast cancer relapse)

For cases of recurrent breast cancer, the treatment depends on the history of initial treatment (treatment that was given when the cancer first appeared), and other characteristics of the cancer – such as the size of the relapsed tumor, location of relapse site (this can be anywhere in the breast tissue, not necessarily the same location as the original site of the tumor), extent of spread into lymph nodes and/or other organs in the body, the status of hormone receptors (ER/PR/HER2), and the originally diagnosed status of BRCA1/BRCA2.

Extraction and analysis of lymph node tissue

In cases of some locally advanced or invasive cancers, cancerous cells are usually present in the axillary lymph nodes. Therefore, it becomes important to extract a lymph node tissue sample, in order to determine the right treatment plan and prognosis.

Sentinel lymph node biopsy

In a sentinel lymph node biopsy, surgical oncologists extract a few lymph nodes from under the armpits. These are usually taken from regions that have been affected first with lymph drainage from the breast(s). By doing a sentinel lymph node biopsy, surgeons are able to avoid removing multiple lymph nodes dissection – most of which will be free from cancer. There are possible long-term side effects to lymph node extraction procedures, such as lymphedema (swelling of the arm), numbness, risk of restricted arm movement and motion-range restriction, which can be avoided by performing smaller lymph node procedures.

Examination of lymph node tissue sample after a sentinel lymph node biopsy

The extracted lymph node tissue sample is examined under a microscope by a pathologist to look for the presence of rapidly dividing (malignant) cells, which are indicative of cancer. To identify the sentinel lymph node, surgeons inject a tracer (either an inert dye or a radioactive marker) behind the nipple or in the area surrounding the nipple. This injection may cause some mild discomfort for 10 to 15 seconds. This dye makes its way to the sentinel lymph node by traveling across the lymph node tissue. Surgeons are able to find the sentinel node when the dye color is seen, or in the case of a radioactive tracer, when the dye shows signs of radiation.

If the sentinel lymph node is found to be free of cancer, it is mostly seen that the remaining lymph nodes are also free of cancer, and indicates that lymph nodes do not need to be surgically removed. If lymph nodes are found to contain cancer cells, then axillary dissection must be recommended.

Axillary lymph node dissection

For this process, surgical oncologists remove multiple lymph nodes from the armpit area, and these are sent for a pathological examination. The number of lymph nodes needed to be removed, is different for each patient. Patients with small tumor sizes and less than 2 cancerous sentinel lymph nodes may also avoid this process. As explained above, having a smaller amount of lymph node tissue removed can reduce the risk of possible side effects, without affecting post-treatment survival rates.

Both sentinel lymph node biopsy and axillary lymph node dissection become optional if the patient is aged more than 65. The requirement to perform either of these procedures, also depends on the general health of the patient and how much they are likely to be affected by the surgical outcomes. For patients of invasive breast cancers who are scheduled to undergo a complete mastectomy, a sentinel lymph node biopsy, or a partial or full axillary lymph node dissection is usually advised before the main surgery. This is done because it is difficult to find sentinel lymph nodes after a mastectomy (because there is nowhere left to inject the dye).

Reconstruction of breasts after breast cancer surgery

Women who undergo a complete mastectomy might want to get a breast reconstruction (re-creation) process done to maintain their natural appearance. Reconstructive surgery uses either synthetic breast implants or tissue which is extracted from a different part of the body. This is usually performed by a plastic surgeon and is traditionally outside the purview of oncology once breast cancer treatment is complete.

Breast reconstruction can be scheduled either immediately after surgery, or it can be delayed, as advised by the treating surgical oncologist – as the feasibility of this depends on the recovery timelines for each individual patient.

Oncoplastic surgery

Oncoplastic surgery refers to the process of simultaneous lumpectomy and reconstruction. Many breast cancer surgeons are equipped to perform this type of surgery without the assistance of a plastic surgeon. This is done depending on how healthy the other breast or the remaining breast tissue is, and it helps in matching the natural appearance of both breasts.

Glossary of definitions used in this section:

Standard of care: Refers to the best treatments known for early breast cancer and locally advanced breast cancer

Clinical trial: Refers to a study or research process that tests a new medicine/new method of treatment which is not used in mass effect

Treatment plan: This contains a clinical summary of your breast cancer diagnosis, and a layout/schedule for the treatment that your attending oncologists have planned. A treatment plan is meant to provide basic information about your medical history/ongoing treatment history to any doctor who might want to review or get involved in your treatment journey at a later stage.

Multidisciplinary panel: In cancer treatment, doctors from multiple oncology disciplines such as surgical, radiation and medical oncology work together to develop the right treatment plan. Such a team is called a multidisciplinary panel. Sometimes, at treatment delivery centres, these teams can extend to include a variety of healthcare professionals, such as assistant physicians, nurses, pharmacists, counsellors, nutritionists, and even social workers. For patients who are senior citizens (aged 65 and above), a geriatric oncologist may also be involved.

  • Standard of care – Refers to the best treatments known for early breast cancer and locally advanced breast cancer
  • Clinical trial – Refers to a study or research process that tests a new medicine/new method of treatment which is not used in mass effect
  • Treatment plan – This contains a clinical summary of your breast cancer diagnosis, and a layout/schedule for the treatment that your attending oncologists have planned. A treatment plan is meant to provide basic information about your medical history/ongoing treatment history to any doctor who might want to review, or get involved in your treatment journey at a later stage.
  • Multidisciplinary panel – In cancer treatment, doctors from multiple oncology disciplines such as surgical, radiation and medical oncology work together to develop the right treatment plan. Such a team, is called a multidisciplinary panel. Sometimes, at treatment delivery centers, these teams can extend to include a variety of healthcare professionals, such as assistant physicians, nurses, pharmacists, counselors, nutritionists, and even social workers. For patients who are senior citizens (aged 65 and above), a geriatric oncologist may also be involved.

Drugs Used To Treat Breast Cancer

What are the most commonly used medicines used in the treatment of breast cancer?

The most commonly used drugs used (either as oral prescriptions or as intravenous chemotherapy) in the systemic, adjuvant and neoadjuvant treatment of breast cancer include:

  • Docetaxel (Trade name: Taxotere)
  • Paclitaxel (Trade name: Taxol)
  • Adriamycin
  • Cyclophosphamide
  • 5-Fluorouracil
  • Trastuzumab (Trade name: Herceptin)
  • Pertuzumab (Trade name: Perjeta)
  • Lapatinib (Trade names: Tykerb, Tyverb)

Docetaxel (Taxotere)

Docetaxel is a cytotoxic chemotherapy drug and an anti-microtubule agent, used in the treatment of early, locally advanced and metastatic breast cancer. [See more]

Paclitaxel (Taxol)

Paclitaxel is one of the most popular chemotherapy drugs used in the treatment of early, locally advanced and metastatic breast cancer. [See more]

Trastuzumab (Herceptin)

Trastuzumab is a MaB (monoclonal antibody) that is approved for the treatment of HER2-positive breast cancer in early, locally advanced and metastatic stages. [See more]

Pertuzumab (Perjeta)

Pertuzumab is an anti-HER2 antibody, which is approved for the treatment of HER2-positive breast cancer. It is used in a combination with both Trastuzumab and other taxanes [See more]

Lapatinib (Tyverb, Tykerb)

Lapatinib is a single transduction inhibitor, approved for use in the treatment of advanced or metastatic breast cancer, where the tumor has a HER2 expression. It is used in combination with standard chemotherapy. [See more]

Other drugs approved for, and in use for the treatment of breast cancer in different stages

The following is a complete list of all approved drugs that are used in the treatment of breast cancer.

  • Abemaciclib
  • Abraxane (Paclitaxel Albumin-stabilized Nanoparticle Formulation)
  • Ado-Trastuzumab Emtansine
  • Afinitor (Everolimus)
  • Anastrozole
  • Aredia (Pamidronate Disodium)
  • Arimidex (Anastrozole)
  • Aromasin (Exemestane)
  • Capecitabine
  • Cyclophosphamide
  • Docetaxel
  • Doxorubicin Hydrochloride
  • Ellence (Epirubicin Hydrochloride)
  • Epirubicin Hydrochloride
  • Eribulin Mesylate
  • Everolimus
  • Exemestane
  • 5-FU (Fluorouracil Injection)
  • Fareston (Toremifene)
  • Faslodex (Fulvestrant)
  • Femara (Letrozole)
  • Fluorouracil Injection
  • Fulvestrant
  • Gemcitabine Hydrochloride
  • Gemcitabine Hydrochloride
  • Goserelin Acetate
  • Eribulin Mesylate
  • Palbociclib
  • Ixabepilone
  • Ixabepilone
  • Ado-Trastuzumab Emtansine
  • Ribociclib
  • Lapatinib Ditosylate
  • Letrozole
  • Lynparza (Olaparib)
  • Megestrol Acetate
  • Methotrexate
  • Neratinib Maleate
  • Nerlynx (Neratinib Maleate)
  • Olaparib
  • Paclitaxel
  • Paclitaxel Albumin-stabilized Nanoparticle Formulation
  • Palbociclib
  • Pamidronate Disodium
  • Perjeta (Pertuzumab)
  • Pertuzumab
  • Ribociclib
  • Tamoxifen Citrate
  • Taxol (Paclitaxel)
  • Taxotere (Docetaxel)
  • Thiotepa
  • Toremifene
  • Trastuzumab
  • Trexall (Methotrexate)
  • Tykerb (Lapatinib Ditosylate)
  • Verzenio (Abemaciclib)
  • Vinblastine Sulfate
  • Xeloda (Capecitabine)
  • Zoladex (Goserelin Acetate)

Breast Cancer Survival Rate

What are survival rates for breast cancer?

Survival rates for different cancer types depend on the percentage of people who are alive and healthy after treatment for the same stage and type of cancer, over a period, like 5 or 10 years. Besides, the available survival rate data cannot serve as an accurate indicator of how long each patient lives with their disease. However, it gives a clearer understanding of the chances of success of a patient’s treatment, depending on the stage and type of diagnosis.

What is a five-year survival rate?

Five-year survival rates for cancer depend on the percentage of people who live for at least 5 years after cancer diagnosis (irrespective of whether they received treatment or not). For instance, if the 5-year survival rate for a particular cancer type is 90%, it means that 90 out of 100 people who had that type of cancer, are still alive after 5 years from their initial diagnosis.

What are relative survival rates for breast cancer?

Furthermore, relative survival rates are a more accurate method to study and estimate the real effect of cancer on survival. These relative survival rates compare the longevity of women with breast cancer across the general population. If the five-year relative survival rate for a type of breast cancer is 90%, it means that patients are almost 90% likely to live for five years on an average.

Consequently, it is essential to understand and remember that all five-year relative survival rates are just estimates. The individual prognosis for each patient depends on several factors, the least of which is an average statistic.

What are the survival rates for breast cancer patients diagnosed at different stages?

As per reports, the prognosis of different patients is different. This depends on the stage at which cancer diagnosis happens. Generally, survival rates are seen to be better for women with an early breast cancer diagnosis. Locally advanced and stage 2 or stage 3 breast cancer patients, too, have successful treatment. However, breast cancers that have spread to other body parts are harder to treat and have a poorer prognosis. The general trend for breast cancer in the USA indicates that:

  • For women with stage 0 or stage 1 breast cancer, is 99%
  • Stage 2 breast cancer is about 93%
  • For women with stage 3 breast cancers is about 72%
  • Metastatic breast cancer (or stage 4 breast cancer) is about 27%
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