Breast Cancer FAQ. How does Breast Cancer spread? Breast cancer spreads by invading into

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1 FAQ Breast Cancer What is Breast Cancer? Breast Cancer is the second leading cause of cancer deaths in women today (second to lung cancer) and is the most common cancer among women excluding non-melanoma skin cancers. The breast is composed of lobules (milk producing glands), ducts (tubes that transport milk out of the breast), and stroma (supporting tissue including fat, connective tissue, blood vessels, and lymphatic channels). Breast cancer can arise from any of these components. Usually, it is an abnormal growth of those cells that line the ducts or lobules. When these cells spread through the walls of the ducts or lobules into the surrounding stroma, infiltrating (or invasive) ductal or lobular cancer is diagnosed. How does Breast Cancer spread? Breast cancer spreads by invading into the stroma or fatty tissues outside the ducts where lymphatic channels and blood vessels live. The cancer can spread to the lymph nodes under the arm (via the lymphatic channels) or to the rest of the body via the blood stream. This is referred to as lymphovascular involvement on a patient s pathology report. It can also spread by direct invasion into surrounding tissues such as the skin, chest wall, or muscles. In order to kill cells that have spread, doctors give endocrine therapy, systemic chemotherapy, or biological therapy to target cancer cells in specific ways. Who gets Breast Cancer? In 2010, the American Cancer Society estimated that 207,090 women would develop invasive breast cancer; 54,090 women would develop preinvasive breast cancer called DCIS; and 1,970 men will develop invasive breast cancers. During 2010, the ACS estimated that 39,840 women and 390 men would die from this disease. What are a woman s chances of developing breast cancer? A woman s chances of developing breast cancer increases with age. SEER data shows that by age 30, 1 out of 2,212 women develop breast cancer; by age 40: 1 out of 235; by age 50: 1 out of 54; by age 60: 1 out of 23; by age 70: 1 out of 14; and by age 80: 1 out of 10. Most importantly, 75% of breast cancers develop after age 50. Does race play a role in incidence? Caucasian, Hawaiian, and African American women have the highest incidence of breast cancer, whereas Korean, American Indian, and Vietnamese women have the lowest risk of breast cancer in the USA. African Americans, young women (less than age 50), and older Caucasian women have the highest death rates from breast cancer.

2 What are the risk factors for developing Breast Cancer? There are many risk factors associated with the development of breast cancer. These include: carriers of the BRCA-1 and BRCA-2 genes, a family history of breast cancer, a prior history of breast cancer, history of atypical proliferation found on a prior biopsy, papillomatosis, early menses, late menopause, late first pregnancy or nulliparity, long term hormone therapy use, obesity, and prior history of radiation therapy in the breast area. Can we determine who is at risk for developing breast cancer? The NCI sponsored Gail Risk Index Assessment tool is used to determine individual risk for developing breast cancer. It takes into account the woman s age, race, biopsy history, family history, menstrual history, and child bearing history. It is a statistical model that compares women of the same race and age. There are also the Tyrer-Cuzick, BRCApro, and the Hughes risk application models available for risk assessment. Furthermore, MD Anderson has a risk stratification algorithm that can also be used to identify high risk women. Can we prevent breast cancer? In 1998, the Breast Cancer prevention trial or P1 trial showed that Tamoxifen can reduce a woman s chances of developing breast cancer anywhere from 49 to 86%. The P2 trial, comparing Tamoxifen to Raloxifene (Evista), has shown both of these estrogen receptor modulators decrease a woman s risk of developing breast cancer but only tamoxifen decreases the risk of DCIS and LCIS. How is breast cancer diagnosed? In the past, breast cancer most commonly presented as a mass on physical exam. Today, mammographic screening and public awareness has lead to the diagnosis of breast cancer at an earlier, non palpable stage. This has lead to a decrease in the death rate from breast cancer. Radiologists look for changes in a woman s mammogram such as a new density or mass, microcalcifications, or architectural distortion. Mammograms miss approximately 10% - 15% of breast cancers, which is where other imaging studies may aid in the diagnosis in this setting. Ultrasound is a simple, non invasive imaging modality that uses sound waves to identify masses or areas of distortion within the breast. Although ultrasound should not be used as a screening modality, it can be very effective in evaluating dense breasts where mammography has pitfalls. MRI of the breast has emerged as a very sensitive modality to evaluate mammographically dense breasts, discordant findings, and high risk women. Minimally invasive breast biopsies using image guidance (mammogram, ultrasound, or MRI) is the standard of care for diagnosing breast cancer. What are the physical signs and symptoms of breast cancer? Breast self examination on a monthly basis is an important health habit to develop. In fact, women find most of the new onset breast lumps themselves. Other possible signs of breast cancer include: prominence of the superficial veins on the skin surface, bloody or clear nipple discharge, retraction of the nipple, dimpling of the skin, and changes in the skin texture of the breast such as discoloration and swelling. All of these findings need to be investigated by a breast health professional. What is breast ultrasound? Ultrasound is a non-ionizing radiographic technique that uses high frequency sound waves to further evaluate a mass found during a physical exam or a lesion seen on mammogram. This form of imaging helps us to determine if a lesion is solid or cystic. Furthermore, it is used in the evaluation of dense breasts where mammographic evaluation is limited. Ultrasound guided core needle biopsy is a minimally invasive and rapid diagnostic technique used today to biopsy breast abnormalities.

3 What is MRI? Magnetic resonance imaging is an imaging technique used in the evaluation of the breast. Its uses include evaluation of breast implants, determining multifocality of breast cancer, determining response of a tumor to chemotherapy, determining the extent of disease, evaluation of occult primary tumors in patients presenting with axillary lymph node metastases, as part of breast cancer screening in very high risk patients, and in further evaluation of suspicious clinical findings or imaging results after complete mammographic and sonographic evaluations have been performed. MRI guided breast biopsy has become increasingly important as more and more lesions are only seen on MRI. How is breast cancer staged? Breast cancer is staged or classified according to the size of the tumor in centimeters (T), status of the axillary lymph nodes (N), and the presence or absence of distant metastases (M). This TNM classification system gives physicians prognostic and therapeutic information that is vital in the treatment of breast cancer. Typical 5 year survival figures are as follows: stage 0-93%; stage I - 88%; stage IIA - 81%; stage IIB - 74%; stage IIIA - 67%; stage IIIB - 41%; stage IIIC - 49%; and stage IV - 15% Are there different types of breast cancer? There are multiple types of breast cancer that are defined pathologically, according to breast tissue of origin, and by clinical presentation. The most common type of invasive breast cancer is infiltrating ductal carcinoma (80%), followed by infiltrating lobular carcinoma (10-15 %). Medullary (5%), colloid (2-3%), tubular (2%), and inflammatory carcinomas (1-3%) make up the rest. Tubular and colloid carcinomas have a better prognosis whereas inflammatory carcinoma has the worst. Ductal carcinoma in situ (DCIS) represents 20% of newly diagnosed breast cancers. Are there prognostic indicators in breast cancer? The most useful clinical prognostic indicators used today that help determine treatment planning for women with breast cancer are tumor size, lymph node status, presence of lympho-vascular involvement, nuclear grade, architectural grade, mitotic index, ER/PR status, and HER2/neu status. The OncotypeDx is a 21 gene analysis of a woman s breast cancer. It has been validated in retrospective studies done on patients who participated in the NSABP B-14 and B-20 clinical trials. This genomic test can help provide an individualized assessment of the likelihood of distant recurrence and the magnitude of chemotherapy benefit for a woman with breast cancer. This test has the ability to help physicians to decide who does or does not need chemotherapy based on the individual s breast cancer genomic make up. MammaPrint is an FDAapproved study that helps identify which early stage breast cancers are more likely have distant recurrence based on a 70 gene analysis. These types of tests are used in conjunction with older prognostic indicators to determine a woman s treatment options. What are the different biopsy options? Today, breast cancer should rarely be diagnosed in an operating room. Open surgical excision or biopsy of tumors can have potential serious implications in regards to margin status assessment and lymphatic mapping of the primary tumor. It also removes the option of up-front or neoadjuvant chemotherapy. There are multiple minimally invasive techniques available that should be employed prior to open surgical excision. These include Fine Needle Aspiration, where a small needle is inserted into the tumor or mass and cells are suctioned out and then studied microscopically by a cytopathologist. Ultrasound guided biopsy is a procedure we do in the office on lesions that can be seen with ultrasound. It is a minimally

4 invasive procedure that allows us to make a diagnosis of breast cancer at the time of the initial office visit through a 3 millimeter incision. Stereotactic core needle biopsy is a minimally invasive procedure we perform at our women s imaging centers that use mammography and vacuum assisted sampling devices to biopsy abnormalities seen on mammogram. We were the third program in the state of South Carolina to perform this biopsy technique in 1996 and have done over 2,000 stereotactic procedure to date. MRI guided biopsies use MRI images and vacuum assisted sampling devices to biopsy abnormalities seen on MRI. Last year, 400,000 out of the 1.6 million breast biopsies done in the USA were performed in an operating room. With these new minimally invasive techniques available, the open breast biopsy rate should continue to decrease in our country. It should be noted that there have been consensus panels recommendations for minimally invasive breast biopsies since What Is Ductal Carcinoma in Situ? DCIS is the most common form of preinvasive breast cancer accounting for 60,000 cases in It is the earliest form of breast cancer and is confined to the milk ducts. Because it is confined to the inside of these ducts, it cannot spread through out the body. If left untreated, it can develop into invasive breast cancer over a period of years. It is usually treated with surgical excision or lumpectomy alone, lumpectomy followed by whole or partial breast irradiation, and in some cases total mastectomy. It has a 15 year survival rate of %. What is Lobular Carcinoma is Situ? LCIS, also called lobular neoplasia, begins within the lobules of the breast. Unlike DCIS, it does not develop into invasive breast cancer if left untreated. It does, however, convey a higher risk in that individual of developing future cancers in either breast. Many of these patients are treated with Tamoxifen in order to reduce their future risk of developing breast cancer. This is called chemoprevention. What is Atypical Hyperplasia? The functional parts of the breast are the milk ducts (tubes for transporting milk) and the lobules (milk producing glands). If the cells that make up the lining of these structures start to grow or proliferate and take on an atypical appearance microscopically, then you can have either Atypical Ductal Hyperplasia and Atypical Lobular Hyperplasia. These are considered risk factors for the future development of breast cancer. If found on a core needle biopsy, then this area is usually surgically excised in order to make sure that there is not a higher grade lesion associated with this segment in a woman s breast. What are Estrogen and Progesterone receptors? Receptors are molecules on the surface of our cells that drugs or hormones can bind to and stimulate. Breast cancer cells express estrogen and progesterone receptors on their cell surfaces about 65% of the time. These hormones are naturally occurring in a woman s body and may promote growth of the cancer. Tumors such as these are called ER/ PR positive cancers and benefit from hormone manipulation or blockade. Tamoxifen has been used and studied extensively as a hormone receptor blocker. The Aromatase Inhibitors block the production of these hormones by inhibiting the aromatase enzyme. Either way, the tumor is suppressed by the inability of estrogen or progesterone to stimulate its growth. It is thought that ER/PR positive tumors have a better prognosis. What is the HER-2/neu test? Women with invasive breast cancer should also be checked for this receptor. Breast cancer cells that over-express the HER-2/neu receptor tend to be more aggressive and faster growing. They do however respond well to combination chemotherapy (when multiple drugs are used) such as the Adriamycin, Cytoxan, and Taxol regimens used in node positive patients. Herceptin (Trastuzumab) is a drug that directly attacks HER-2/

5 neu positive cells as a monoclonal antibody. Herceptin has been shown to reduce the recurrence rate in HER2/ neu expressing cancers by at least 40%. It is referred to as biological therapy when describing breast cancer treatment options. Other monoclonal, targeting antibodies such as Lapitinib and Bevacizumab are currently being studied in the metastatic setting. What is Lumpectomy? This procedure is the mainstay in breast cancer surgery. It is the surgical excision of an area in the breast with clear on uninvolved surgical margins. In treating breast cancer, the excised specimen should be oriented and the margins clearly marked for the pathologic orientation. There is great debate about how thick a margin should be, but 2-5 millimeters is usually acceptable and will decrease a woman s risk of In Breast Tumor Recurrence (IBTR). Margin status is considered to be the number one risk factor for developing a local recurrence. What is Sentinel Lymph Node Biopsy? The status of the axillary lymph nodes is considered to be the most important prognostic indicator in women with breast cancer. The only way to know for sure of their involvement is to study them under the microscope. In the past, a complete lymph node dissection was used because of this significance. However, a full lymph node dissection is associated with significant complications including numbness, decreased range of motion, fluid collections, and infections. Today over 60% of women are lymph node negative at the time of their presentation, so a full dissection actually yields little clinical information and no survival advantage. The sentinel lymph nodes represent the first set of lymph nodes a tumor is going to drain to, and if found to be uninvolved allows us to leave the remaining lymph nodes in place. This procedure, which requires special training and experience, is associated with a much lower complication rate and actually increases the accuracy of axillary staging. It is considered the standard of care in axillary staging today and has also been successfully used following neoadjuvant or up-front chemotherapy. What is Breast Conservation? In 1973 the National Surgical Adjunctive Breast Project instituted a clinical trial, the B-06 that compared mastectomy (the surgical removal of the breast, nipple, and axillary lymph nodes) to lumpectomy with whole breast irradiation for stage I and II breast cancers. After 25 years of follow up, it was shown that there was no difference in overall or disease free survivals in this subset of patients. Furthermore, the NSABP B-18 and B-27 trials showed that we could even convert women who had large tumors who would need a mastectomy to breast preservation by giving them up-front or preoperative chemotherapy. In 1992, the NIH released a consensus statement saying that breast preservation was preferable to mastectomy as it allows a woman to keep her breast while offering her an equivalent survival. What is Mastectomy? Mastectomy is the surgical removal of the breast and nipple areola complex along with the axillary lymph nodes. Today it is done in conjunction with sentinel lymph node biopsy. This is the procedure that all others have been compared to in dealing with local control of disease within the breast. Indications for this procedure include multifocal tumors, large tumors, cases where breast conservation will not allow a satisfactory cosmetic outcome, in patients who have had prior radiation therapy to the breast, and for local recurrences after breast conservation therapy. It can usually be combined with reconstruction at the time of surgery. What is Whole Breast Irradiation? This procedure is used in combination with surgical lumpectomy in order to achieve local control within the breast. It is done with external (outside) beam irradiation that is delivered daily to

6 the breast over a period of 6 weeks. The NSABP B-06 trial showed that it reduced breast tumor recurrence by 75%. It is also used to treat the chest wall and axilla in mastectomy patients who have tumors greater than 5 centimeters in size, in patients who have more than 1 positive lymph node, and in women who have chest wall invasion or recurrence. The kind of radiation therapy we use at our radiation center is called IMRT (Intensity Modulated Radiotherapy). This form of therapy is unique in that it delivers radiation therapy in a more precise fashion and spares healthy and uninvolved tissue and organs. What is Partial Breast Irradiation? PBI (or APBI) is a new form of radiation therapy that delivers radiation from within the breast through an implanted catheter. This form of therapy delivers an intense dose of radiation to the area in the breast where recurrence is most likely to occur. It is done twice a day for 5 days on an outpatient basis. The catheter is placed 7 to 10 days after a lumpectomy and is removed after the final treatment. It is currently being offered to women over age 50 with lymph node negative tumors that are less than 2 centimeters in size. There are multiple catheters available as delivery devices. We have the most experience in South Carolina with this technique. The American Society of Breast Surgeons Mammosite Registry trial has over 1450 patients in it. It has recently released 5 year data shows equivalent outcomes to whole breast radiation therapy when compared to recurrence rates and cosmetic outcomes. It is available at our Radiation Oncology Center in Georgetown. What are the reconstruction options? There are several techniques used to reconstruct the breast after mastectomy. At the time of mastectomy, a tissue expander can be placed under the chest wall muscle. The expander is then injected with saline every two weeks until the desired size is achieved. The expander is then removed and a permanent implant is placed. Occasionally the plastic surgeon will operate on the other breast in order to achieve symmetry. Other options include the TRAM flap, DIEP flap, or Gluteal flap. These procedures are called autologous tissue transfer flaps and are considerably more involved operations in which the skin, subcutaneous fat, and muscle of the abdominal wall or buttocks is used to reconstruct the breast. Any of these options can be performed at the time of mastectomy or months later. Why do we give chemotherapy? The treatment of breast cancer centers on control of the disease found in the breast as well as disease that may have spread throughout the body. Surgery and radiation primarily deal with local control of disease within the breast, whereas medical oncology and chemotherapy deal with systemic control throughout the body. The medications that we give kill cells that may have spread to the brain, bones, lungs, or liver. We determine who gets this treatment based on the prognostic factors, tests mentioned earlier, and on the likelihood of distant failure or recurrences. Occasionally we will give chemotherapy up-front or prior to surgery in order to shrink the tumor so it can be safely removed or to allow a patient who initially would need mastectomy to potentially have breast conservation. These drugs are usually given in combination with other agents and can be given by oral or intravenous routes. What is Tamoxifen? Tamoxifen is in a class of drugs called selective estrogen receptor modulators. Approximately 65% of breast cancers are estrogen positive. Tamoxifen binds to the estrogen receptors on the cancer cells walls, preventing estrogen from stimulating the cancer cells to grow. It has also been shown to reduce the likelihood of cancer in high risk patients. It has significant side effects including blood clots, stroke, endometrial cancer, and cataracts, so a risk benefit discussion is important between the physician and patient prior to implementing its use.

7 Coastal Carolina Breast Center is the area s only surgical practice dedicated solely to breast health and is one of only eight centers in South Carolina to be accredited by NAPBC. Recognized as a Center of Excellence, Coastal Carolina Breast Center demonstrates a commitment to patient education, advocacy, and awareness of advanced breast cancer treatments. In the last fifteen years, they have treated an estimated 25,000 patients. Breast Cancer is the second leading cause of cancer deaths in women today (second to lung cancer) and is the most common cancer among women excluding non-melanoma skin cancers. What are the Aromatase Inhibitors? This is a newer class of drugs that have shown extraordinary potential in the treatment of breast cancer. These drugs stop the formation of estrogen, such that in estrogen receptor positive patients, there is no estrogen formed that can stimulate the cancer cells to grow. The ATAC trial showed after 8 years that Arimidex was superior to Tamoxifen in preventing recurrences. However, there was no survival benefit during this period of time. Currently it is only recommended in post menopausal women who have ER/PR positive tumors. There will be more to come with this class of drugs. Turn to the professionals that women know and trust. N. Craig Brackett, III, MD, FACS Angela M. Mislowsky, MD (843) CoastalBreastCenter.com Offices in Murrells Inlet and Georgetown, SC

8 Coastal Carolina Breast Center is the area s only surgical practice dedicated solely to breast health and is now one of only eight centers in South Carolina to be accredited by the National Accreditation Program for Breast Centers, NAPBC. What this Accreditation means: We are fully qualified to offer the full spectrum of interdisciplinary care to patients with breast disease. Our patients are afforded the most currently available forms of evaluation, treatment, and follow-up care. We have passed a rigorous evaluation by independent clinical surveyors, who have awarded us their nationally recognized seal of approval. N. Craig Brackett, III, MD, FACS Angela M. Mislowsky, MD (843) CoastalBreastCenter.com Offices in Murrells Inlet and Georgetown, SC Turn to the professionals that women know and trust.