INVASIVE BREAST CANCER

If you already know the stage of your cancer, click here.

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”.

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. This portion of the treatment (called neoadjuvant therapy) is managed by an medical oncologist, and not the surgeon.  Modern treatment of breast cancer involves a team of specialists to customize your care, based on the unique characteristics of each individual case.  This team includes the surgeon, the oncologist, radiation therapist, and often others, such as the plastic surgeon, physical therapist, geneticist, nutritionist, clinical trials specialists, as well as others, depending on your specific needs.

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@www.dekalbsurgical.com or drchampney@www.dekalbsurgical.com.

For some information on survival rates for breast cancer, you can see our results on our Outcomes page.

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