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If your cancer is a (clinical) Stage 1, it means that the tumor in your breast is small (less than 2 cm, which is about ¾”), and that there is no evidence of spread into the lymph nodes under your arm (axilla), or anywhere in your body. Using the TNM staging, the possible combinations within stage 1 are

  • Stage IA: T1, N0, M0
  • Stage IB: T0 or T1, N1mi, M0

Your doctors use their best estimate about the tumor size and the presence of cancer in lymph nodes or elsewhere to come up with the “clinical” stage, in order to make appropriate treatment plans prior to the surgery. Once the surgery has been done, these estimates are re-evaluated, based on actually looking at these tissues under the microscope. So the clinically estimated stage may change based on the “pathologic” findings. You can learn more about staging breast cancer by following this link to our “Staging” page.

Treatment almost always includes surgery first, and there will be plans for radiation therapy for the breast as well. Your doctor will determine whether any other treatments, such as hormone blocking treatment, or chemotherapy, should be added, depending on some other test results. More about this below.

The standard surgical treatment is usually a “lumpectomy” (also called “partial mastectomy”), and a “sentinel lymph node biopsy”. Other terms that might be used are “breast-conserving surgery”, or “breast conservation”.

A lumpectomy 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 30-40% 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.

Many years ago, the standard treatment for all women with breast cancer was a mastectomy. This was because over a hundred years ago, when most women with breast cancer were dying, a radical mastectomy was the very first treatment discovered to give women a chance. Building on that first treatment option, surgeons through the years gradually tested less radical surgical procedures. In parallel, women began discovering their breast cancers at earlier stages, such that less radical procedures were more easily applied. About 40 years ago, studies that compared breast conservation finally were being published. Surgeons and women were actually initially reluctant to consider this option. That is less of an issue these days, as most women are very much in favor of keeping their breast if possible, and this indeed usually is.

A mastectomy is still an option instead of breast conservation, and there are a number of reasons why a woman or her surgeon may choose this alternative. Some women, in our experience, may prefer the “simplicity” of a mastectomy, in that it usually eliminates the need to have radiation therapy to the breast after surgery. If a woman has had a previous cancer treated in the same breast, with lumpectomy and radiation, a repeat breast conserving procedure is not usually recommended. If a woman tests positive for one of the BRCA genes, the much higher risk of having more breast cancer in the future usually steers your surgeon to recommending, not just mastectomy, but bilateral mastectomy. If there are numerous calcifications seen in your breast on mammography, mastectomy may be preferred as well. Some women have more than one cancer in the breast at the time of initial diagnosis, and if these cancers are too far apart in the breast, a mastectomy will be necessary. In some unusual cases, a woman cannot receive the necessary radiation therapy after surgery, and in these cases, mastectomy will usually be necessary (one example of this is for women who have scleroderma). Some women have what might be called “cancer phobia”, and no amount of discussion or reasoning or logic will dissuade them from wanting a mastectomy. It’s at least helpful to know that mastectomy is an option. In most cases, your surgeon should be offering breast conservation, unless it is made very clear why it would not be appropriate.

If you do have a mastectomy, in most cases, a breast reconstruction is an option. In many cases this can be done immediately. In other words, you have your surgery for the mastectomy, and you wake up afterward with the reconstructed breast. Not all women choose to undergo breast reconstruction, or may choose to delay the reconstruction until a later date. The discussion about what is best for you can get a bit complicated, and is best done with your surgeon and plastic surgeon. There are many options available these days, including the use of some tissue from other adjacent parts of your body, silastic or saline implants, or a combination of these. A common reconstruction method is to use fatty tissue and muscle tissue from the abdominal wall, which is rotated upward to replace the breast mound. Surgeons may leave the skin “envelope” of your breast (a “skin-sparing mastectomy”), and then re-fill the skin with the transferred tissue or with an implant. This method seems to give better cosmetic results in general.

It is important to know that if radiation therapy is necessary, it can affect the cosmetic results of a reconstruction, so if you are going to need radiation even after a mastectomy, your doctors should discuss the possible added risks.

Your cancer tissue will be tested for any sensitivity to hormones. The two routine tests are “estrogen receptor (ER)” and “progesterone receptor (PR)”. The ER is considered the more important one, but basically if either or both of these is “positive (+)”, then it means the cancer cells can be stimulated by estrogen. There are a number of drugs which can block the effects of estrogen on any cancer cells remaining in the body, and so one of these drugs is routinely used for ER+ cancers. But, these drugs might blunt the effectiveness of chemotherapy or radiation therapy if given at the same time. For this reason, any hormone blocking treatment is usually held until after the other treatments (surgery, radiation therapy, chemotherapy) are completed. The estrogen blocking drugs include tamoxifen, Arimidex, Femara, and Aromasin. Tamoxifen works differently from the other three, by blocking the receptors for estrogen on the breast cells. The other three are all in the class of drugs call “aromatase inhibitors”. These act by blocking the production of estrogen in the body. An important thing to understand about these drugs is that they do not inhibit production of estrogen in functional ovaries. For this reason, aromatase inhibitors are not effective in women before menopause. And so, for women who have not yet gone through menopause, tamoxifen is the only tried and true option for hormone-blocking treatment in ER+ women.

In Stage 1 breast cancer, the likelihood of cancer coming back after initial treatment is fairly low. And so, some of the weapons we have to fight breast cancer might not always be necessary. On the other hand, there is almost always at least some small chance that a cancer may come back in the future. This uncertainty is what makes it hard to decide when to use “everything we’ve got”, which usually boils down to whether to add chemotherapy to the treatment plan. Fortunately, we have several tools to help us decide with each individual patient what is the best plan. This may include chemotherapy in some cases; for young women, this will more often be the case, especially if your cancer does not show sensitivity to hormones, or if the cancer shows sensitivity to a specific chemotherapy drug, like Herceptin.

The choice of chemotherapy is dependent on a number of factors. We can now test your cancer to see in advance if it will be sensitive to certain types of chemotherapy, so it is critical to do these tests before deciding on which specific drugs to use. Whatever drugs are recommended, they are typically given in “cycles”. A “cycle” is typically a two or three week interval. Carefully calculated doses of the selected drugs are given at the beginning of the cycle, and you are monitored for side effects as the drugs work on the cancer. The drugs also affect normally dividing cells in your body, and this is the source of the potential side effects. The cells in the body that are dividing the most include blood cells in the bone marrow, hair cells, and the cells lining the digestive tract, from the mouth all the way through the rectum. Knowing this, it is no surprise that the side effects include anemia, and other changes in the blood, like lowered white blood cell count, hair loss, and nausea and vomiting. Fortunately, oncologists are good at preventing or at least managing these potential side effects in most cases. Prior to initiating the treatments, your oncologist will no doubt discuss the potential side effects with you, and any alternative regimens that might be used. The various chemotherapy drugs have different potential side effects, so you should discuss these issues with them prior to your starting your treatment.

One routine assay done on breast cancers is called the HER2 assay. We have learned that when this gene is “overexpressed” in a cancer, it is more likely to act aggressively, by spreading to other organs. But we have also discovered a drug, which was specifically designed to block this protein’s function is very effective in decreasing the aggressiveness of these cancers. Only about 15% of breast cancers have this genetic dysfunction, but if your cancer is “HER2 positive”, you likely will be advised to receive this specific chemotherapy, called Herceptin, in addition to some other drugs. The Herceptin is usually given in cycles over the entire first year following the initial treatment.

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Other Resources

You can find a comprehensive educational patient resource on the National Comprehensive Cancer Network website.  There is a direct link to their online “virtual book” for with Stage I or II  breast cancer.