STAGE 3 (INVASIVE) BREAST CANCER

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If your cancer is a Stage 3, it means that the tumor in your breast is a bit larger than most, and/or there is disease seen in the lymph nodes under the arm (in the axilla). There is no evidence of disease spread to organs beyond the breast and the lymph nodes. Using the TNM staging, the possible combinations within stage 3 are

  • Stage IIIA: T0 to T2, N2, M0 / T3, N1 or N2, M0
  • Stage IIIB: T4, N0 to N2, M0
  • Stage IIIC: any T, N3, 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.

Surgery plays an important role in Stage 3 breast cancer, but chemotherapy is equally, if not more important. With these more advanced cancers, the order of treatment more often begins with chemotherapy. For this group of women, there is no consensus among physicians about using chemotherapy first or surgery first. The DeKalb Surgical doctors typically support the use of chemotherapy before surgery. This method allows us to see that in your individual case, the selected chemotherapy is effective in shrinking the tumor down in size. Not only does this let us know with certainty that your cancer is not resistant to the selected treatment, the shrinking tumor makes it easier to surgically remove it with clear margins later on. 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, for Stage 3 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.

Chemotherapy is a standard part of treatment for most women with Stage 3 breast cancer, although the decision for chemotherapy is based on several different factors. Your age and general health, including any other major medical problems must be considered. The characteristics specific to your cancer may indicate that chemotherapy won’t have much impact. Each woman brings her own priorities and concerns regarding chemotherapy, and these are of course considered by your doctors. There are a number of ways to try to predict your risk for recurrence, and depending on how high or low that risk is, each individual woman may make their own choice.

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.

Whether surgery is done before or after chemotherapy, breast conservation is typically very desirable. The surgery for breast conservation is usually called “lumpectomy and axillary dissection”, or “partial mastectomy and axillary dissection”, and almost always requires radiation therapy afterward. In Stage 3 breast cancer, mastectomy may be recommended instead. This may be necessary if the cancer is very large, if there is more than one place in the breast where cancer is present, if the cancer in the breast has involved the overlying skin, or if this is a second cancer in the breast. There are other scenarios where mastectomy may be a preferred choice, for instance, if it is the woman’s preference, if there has previously been cancer in the opposite breast, if a genetic test called BRCA is positive, or if there is some reason that radiation therapy cannot be given.

In addition to the lumpectomy or mastectomy, the lymph nodes under the arm will be removed, or in some cases, just sampled. In Stage 3, most patients will already be known to have some cancer cells in at least one or more of the lymph nodes. If it is already known that there is some involvement of some lymph nodes, it is almost always appropriate to remove all of the fatty tissue under the arm (the axilla) where the lymph nodes are found. This tissue is sent to the pathology department and then placed formaldehyde, which “fixes” or “preserves” the tissue, to keep it from decaying. The tissue is then dissected to find out how many lymph nodes are contained in it, and how many of the lymph nodes have cancer. This information is then used to update the staging of the cancer.

Radiation therapy is virtually always used after lumpectomy, to decrease the likelihood of recurrence of cancer in the breast. And in Stage 3 cancers, even after mastectomy, radiation therapy may be recommended for treatment of the chest wall. The radiation therapy is given as small doses on a daily basis, 5 days a week for about 6 weeks. You may have heard about a radiation therapy treatment given over just one week, and this is discussed elsewhere in this website, but it is not a good option for women with Stage 3 cancer.

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.

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