This page contains information about cases in
which a biopsy has been done,
whether for a lump or other abnormality on exam,
or for an abnormal mammogram, and the biopsy
shows invasive cancer. This general information
should be helpful for patients with all
different “stages” of breast cancer, or if you
do not know what stage your cancer is. If you
already know the stage of your cancer (the stage
may be called either “clinical” or
“pathological”, or “working” stage),
refer to the links below for more specific
information.
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I had a
breast biopsy that showed invasive cancer. What
should be done now?
You will need
to be evaluated to decide on an individualized
treatment plan, based on the specific details of
your case. Several factors must be considered,
including the type of breast cancer (ductal is
the most common subtype, and lobular is the
other, but there are even subtypes of the
subtypes), your age and menopausal status, the
apparent size of the tumor, your medical
history, and any pertinent abnormalities noted
on a thorough physical exam, findings on
mammogram and possibly additional imaging
studies, and some molecular characteristics of
the cancer (you might think of these as the
“fingerprint” of the cancer), primarily the
estrogen receptor (ER) and HER2 status. For
some women, an additional assay called the
OncotypeDX Recurrence Score may be ordered
as well.
All these
elements should be considered by your surgeon.
In cases where the cancer appears small, and
there is no evidence of cancer spread to lymph
nodes or elsewhere, the next treatment step is
surgery. This will usually mean a “lumpectomy
and sentinel lymph node biopsy”. A
“lumpectomy”, which can also be referred to as a
“partial mastectomy”, removes enough tissue
around the cancer so that no cancer cells are
seen along the margins of the removed tissue. I
like to use the analogy of a hard-boiled egg.
The yellow yolk (which represents the cancer) on
the inside should have “egg white”, or normal
breast tissue, on all sides, such that that
yellow egg yolk is not seen anywhere on the
outside surfaces of the egg. Now in actuality,
cancer cells aren’t yellow like an egg yolk, and
one cannot always tell during the surgery that
the margins are clear. But fortunately in over
90% of the cases at DeKalb Surgical, the margins
are clear with just one procedure. At many
centers, as many as 40-50% of women need a second
procedure to get “clear margins”. Our
technique involves the use of a customized
surgical device that is not yet available for
general use, which helps to minimize the
likelihood that you would need a second
procedure.
The “sentinel
node biopsy” part of the operation involves a
second small incision under your arm (called the axilla), combined with an injection of dye in
your breast, usually at the nipple. The idea is
to check to see if there is any cancer spread to
the lymph nodes. The dye injection allows the
surgeon to identify the first nodes to receive
any lymph flow from the breast; if any cancer
cells have spread to the lymph nodes, they
almost certainly will be found in these first,
or sentinel, nodes. This method allows the
surgeon to leave all of the other lymph nodes
alone, unless cancer cells are seen in the
sentinel nodes.
Following
lumpectomy, radiation is almost always required
in order to minimize the possibility of
recurrence. Decades ago, when mastectomy
was the only surgical option, several national
and international studies were done to determine
if women could undergo a less radical
operation. Although these studies clearly
showed that women did just as well long term
with lumpectomy instead of mastectomy, radiation
therapy was needed to keep the local recurrence
rate to a minimum. In these studies, women who
had lumpectomy without radiation therapy
had cancer come back in the breast about 30% of
the time. And so, these days when lumpectomy is
considered the preferred surgical option, it is
almost always considered as part of a
“package deal”, with radiation therapy to
follow.
Radiation
therapy for breast cancer has traditionally been
given as several daily brief treatments to the
entire breast, usually taking about 6 weeks. It
is given this way in order to minimize the side
effects to the skin. The effect of the
radiation on the breast tissue is “cumulative”,
meaning that the total required dose can be
divided into very small daily doses, and as long
as the sum of the small doses equals the
required total dose, you will achieve the
desired outcome. If higher daily doses would be
given instead, the skin would get radiation
burns. Even with the small doses given, this
can sometimes be a problem. The radiation
therapy physician will discuss these
possibilities with you, and will monitor you for
any evidence of problems during the six weeks of
treatment.
There is a new way to give the radiation therapy
after lumpectomy, which is an option for some
women, called partial breast irradiation
therapy. This method can be completed
with in just 5 days, with two daily
treatments each day. The radiation is given by
placing a tiny “radioactive seed” inside the
breast briefly for each treatment. This method
almost completely eliminates the risk of skin
damage, and this is why the treatment can be
completed so much faster. This technique has
been used at DeKalb Surgical since 2006 for
selected women, so we have lots of experience
with it. You can read more about this treatment
option on our MammoSite
page.
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For cancers
that are larger, and for cancers that have
already spread to lymph nodes or elsewhere in
the body, surgery sometimes is delayed until
after completion of some chemotherapy. The
portion of the treatment is managed by an
medical oncologist, and not the surgeon. At
DeKalb Surgical, for these slightly larger, or
more advanced cancers, many patients are offered
a Roundtable Consultation as soon as the
diagnosis of cancer is made. At this unique
meeting, a multidisciplinary team of doctors and
our nurse navigator will all meet together with
you simultaneously, in order to come to a
unified treatment plan, customized to your
specific situation, to offer you the greatest
likelihood of a cure. Since we have developed a
variety of effective weapons for breast cancer,
including surgery, radiation therapy, hormonal
treatments, and chemotherapy, we want the
doctors who specialize in each of the treatment
modalities to meet and work together to
recommend the best sequence of treatments.
We don’t have to use all of these modalities in
every case, but it is best to decide up front,
what the best plan would be, and in which order,
with input from the entire team, including you,
the patient.
In some cases,
it may be best to undergo chemotherapy first, to
shrink down the tumor,
and then follow with the surgery to remove any
remaining cancer cells. An advantage of this
sequence is that we can see that in your
specific case, the selected chemotherapy is
effective, since we will be able to see that the
cancer, if it’s palpable, actually shrinks
during treatment. In some cases, we even may
see that the chemotherapy is so effective, that
when the surgery is done, ALL the remaining
cancer has disappeared. These patients have
a particularly good prognosis.
At DeKalb
Surgical, we have available many clinical trials
for patients with breast cancer. Clinical
trials allow us to offer tomorrow’s breast
cancer treatments today. These trials often
include newly approved drugs, which have shown
benefit in more advanced breast cancers, and now
are being tested in women with breast cancers
that are more contained (ie, a lower stage). Or
they may be testing a less radical method of
giving the usual radiation therapy to the breast
after surgery. Other trials are intended to
show that hormonal treatment (which is much
easier to tolerate compared to chemotherapy) is
effective in shrinking tumors before surgery.
Not all women are candidates for clinical
trials, but studies have shown that women who
participate in clinical trials tend to have
better outcomes than those who don’t go on a
trial.
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If you already
have been told what stage your cancer is, click
on the appropriate stage below for more
information.
We categorize breast cancer based on a number of
different characteristics, but some
characteristics have more significance than
others. Three of the most important
characteristics are the size of the cancer in
the breast (referred to as “T” for tumor),
whether there is any cancer spread into the
nearby lymph nodes (referred to as “N” for
nodes), and whether there is any spread to other
parts of the body (referred to as “M” for
metastasis). The stage of your cancer is
derived by considering only these three
characteristics. Although the stage of the
cancer is very important, the recent advances in
breast cancer treatment have made other
characteristics equally important, including
estrogen receptor status (ER), HER2 status, and
for some cancers, OncotypeDX Recurrence Score.
These are not considered in determining the
stage, but are extremely important in deciding
on the best treatment.
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If you want
more information on
staging breast
cancer, click here.
Click on the
appropriate link for more specific information
for the different stages:
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
I don’t know what stage my
cancer is.
If you
have had a biopsy and already know that it’s
cancer, but don’t know the stage, you can ask
your doctor. Most cancers when diagnosed are in
the Stage 0, 1, or 2 categories. Each stage has
certain specific treatment options appropriate
for that category of cancers, as you will see in
the paragraphs above. If you want to learn more
about how your cancer can be staged, follow
this link.
If your
doctor seems unable to tell you what stage your
cancer is, you may want to consider seeing us
for a second opinion. Making an assessment of
the stage of your cancer is critical in deciding
on appropriate treatment. If you want to
schedule an appointment, you may call our office
at 404-508-4320. Or if you have other
non-urgent questions, feel free to email us at
drkennedy@dekalbsurgical.com or
drchampney@dekalbsurgical.com.
For some
information on survival rates for breast cancer,
you can see our results on our
Outcomes page.
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