Breast Conditions

Approximately 1 in 8 women will develop breast cancer in her lifetime. It is the second most common cause of death related to cancer after lung cancer.

"When and how should I be screened for breast cancer?"

All women over the age of 40 should have a mammogram every year. Many women without risk factors for breast cancer feel protected and wonder whether they need screening. It is important to note that about 70-75% of breast cancers occur in women without any risk factors. This means that all women should undergo screening.

Mammography is currently the best tool that we have for detecting early breast cancer, but it is also important for women to perform monthly self breast exams and to have annual breast exams by their physician or experienced care provider. Women with a family history of women developing breast or ovarian cancer before menopause may need earlier screening and should see a breast specialist to discuss this.

"What are the risk factors for breast cancer?"

1) Being female

2) Risk increases with age

3) Personal or family history of breast cancer

4) Previous breast biopsy with atypical hyperplasia or lobular or ductal carcinoma in situ

5) Not having children before the age of 30

6) Starting menstrual periods at a young age (younger than 10) or going through menopause after the age of 55.

"Is there anything I can do to decrease my risk for breast cancer?"

Studies have shown that women can decrease their risk for breast cancer by changing some of their lifestyle habits. If you smoke, decreasing your risk of breast cancer is another reason to quit. You should follow a low fat diet and keep your weight near your ideal body weight. Your doctor can calculate your body mass index for you which can tell you your ideal weight range. Women who are more than 50 pounds overweight have higher rates of breast cancer. Women who drink more than 9 alcoholic drinks per week increase their risk for breast cancer by 2 ½ times. Women who take combination (estrogen and progesterone) hormone replacement therapy for greater than 5 years also have slightly higher rates of breast cancer. If you are on estrogen and progesterone hormones replacement therapy or considering it for symptom relief you should discuss this with your doctor.

Women with a strong family history of breast and ovarian cancer may be candidates for gene testing to see if they are a carrier of a high risk gene or for certain medications such as Tamoxifen which can decrease their risk.

Ductal Carcinoma in Situ

"What is Ducal Carcinoma in Situ?"

Ductal carcinoma in situ, also know as DCIS or intraductal carcinoma, is a breast cancer that has been found before it has spread outside of the breast duct. This is in contrast to invasive breast cancer which is no longer confined to the milk duct and has spread to adjacent tissue and potentially to the lymph nodes and other sites in the body.

"How is the diagnosis of DCIS made?"

DCIS is usually diagnosed on a mammogram. It is often identified by calcifications (calcium deposits) on a mammogram. Rarely an area of DCIS can be felt on a breast exam or seen with the ultrasound. If DCIS is suspected we must first confirm the diagnosis by getting a sample of the area. This can be done in the office with either a stereotactic or mammotome biopsy or in the hospital as an outpatient surgery.

"How is DCIS treated?"

DCIS can be treated with either a wide excision of the area of DCIS or with a mastectomy. Some women will also benefit from receiving radiation therapy after their surgery. The type of surgery a woman has is determined by many factors such as a woman’s preference, the size of the tumor, and the type of DCIS she has. Some types of DCIS are known to be more aggressive and more likely to progress on to invasive cancer. Women who have had DCIS are considered at higher risk for an invasive breast cancer later in life and your doctor may discuss medications to decrease your risks after you have completed your surgery. Women with DCIS do not need chemotherapy.

Because DCIS is not visible to the naked eye and the extent of it can only be determined by the pathologist when looking under a microscope it is usually not possible to tell if all of the abnormal cells are removed during surgery. If any of the surgical margins or “edges” are positive for abnormal cells it is recommended that women have a second re-excision or a mastectomy.

Because DCIS is confined to the duct and has not spread women with DCIS do not usually need evaluation of their lymph nodes. If the area of DCIS is very large or if high grade DCIS is present on your biopsy however, your surgeon may recommend a sampling of your lymph nodes in case a small area of invasive cancer is present.

"How will I be followed after I have completed my treatment?"

Women who have had DCIS are at higher risk for invasive breast cancer than someone who has not had it. Depending on which surgery you have, initially you may have mammograms every 6 months; you will then have them on a yearly basis. Your doctor will also want to see you for regular exams and examine your breasts every 6 months.

Abnormal Mammogram

Being told that you have an abnormal mammogram is a frightening experience. It is important to reduce this stress by diagnosing &, if necessary, treating the problem as quickly and accurately as possible. Often, more specific studies such as compression views or an ultrasound will be recommended. If the abnormality is still present and is still indeterminate, a consultation with us may be indicated.

A consultation includes a thorough history, exam and review of previous mammograms and ultrasounds. Based on this review we can discuss the full range of diagnostic options. If the mass appears to be benign you may be offered short interval follow-up. Some women may chose a diagnostic biopsy for peace of mind.

If the lesion is suspicious a biopsy to obtain some tissue cells for a diagnosis will be recommended. If the lesion is palpable we can perform a fine needle aspirate or core biopsy in the office under local anesthesia. If the lesion is not palpable and not visualized on ultrasound, we recommend outpatient biopsy either in the radiology department or in the operating room. If the biopsy reveals atypical or malignant cells, we will discuss the various options of breast-conserving procedures versus mastectomy with you & make a decision together as to your best options. Many factors enter into this discussion including the nature of the lesion, the presence of suspicious axillary lymph nodes, & your family history. We will work closely with you through the entire diagnostic & therapeutic phases, & coordinate any additional health care you may require.

Treatment of Breast Cancer

"What are my surgical treatment options if my breast cancer is found early?"

For any woman with a new diagnosis of breast cancer curing the cancer is our primary goal. For most women, surgery is the first step in treatment. Surgery is the most effective treatment that we have for breast cancer. It gives us valuable information about the size of the cancer, helps determine whether the cancer has spread outside of the breast, and decreases your risk of cancer recurrence.

The surgical treatment options for early stage breast cancer generally fall into two categories, lumpectomy with radiation, or mastectomy. A lumpectomy, which is also known as breast conserving surgery, involves removing the breast cancer as well as a rim or margin of normal breast tissue surrounding the lump. The goal is to maintain as much of the normal breast tissue and contours as possible. In most cases the nipple can be preserved. Removing all of the cancer and having a “margin” or free space removed around the tumor site is important. Some women will have to go back for a second surgery if this margin is not obtained in the first surgery. When lumpectomy is chosen it is followed by radiation therapy which consists of treatments every weekday for approximately 6 weeks. If chemotherapy is needed it is usually given first and radiation therapy would follow.

A mastectomy involves removing all of the breast tissue including the nipple. A mastectomy can be combined with breast reconstruction either at the time of the mastectomy or later once all treatments are completed. There are many reconstructive options which provide women with a natural and satisfying cosmetic result. Some women who have a mastectomy will also need chemotherapy and radiation treatments following their surgery.

Whether a woman chooses lumpectomy or mastectomy, she also needs evaluation of her lymph nodes. This procedure is discussed in the next section.

The survival and long term outcome of women who have a lumpectomy and radiation compared to those who have a mastectomy are equal. Most women are free to choose the surgery which they decide is best for them. In some cases however, other considerations such as the size or location of the cancer might take precedence. Choosing which type of surgery you will have is one of the first and most difficult decisions you need to make when you are diagnosed with breast cancer. We will discuss your options at length and together will make a treatment decision.

"Why are lymph nodes important in breast cancer and how are they evaluated?"

Lymph nodes are small collections of glands that are part of our immune system. When we refer to lymph nodes in breast cancer we are referring to a cluster of lymph nodes in the axilla (armpit). These are important because they are the first place that cancer goes when it spreads. Knowing whether cancer has spread to the lymph nodes is one of the most important factors we look at to plan further treatments and estimate the chances that a woman will remain free of her cancer after treatment. If the lymph nodes have cancer in them removing them helps prevent recurrence of the cancer. At the time of your initial surgery the lymph nodes will be sampled in one of two ways. Either with a complete axillary node dissection or a sentinel lymph node biopsy.

A complete axillary lymph node dissection means all of your axillary lymph nodes will be removed on the side of the cancer.

A sentinel lymph node biopsy involves isolating and removing the 1-3 lymph nodes in the axilla that are most likely to be positive if cancer has spread to the lymph nodes. The sentinel node is the first lymph node to receive drainage from the breast and would also be the first lymph node to have cancer in it if the cancer had spread to the lymph nodes. With this procedure a radioactive dye is injected around the nipple the morning of the surgery. During the surgery, the surgeon may also inject a blue colored dye into the breast. Both of these dyes or “markers” travel along the lymph pathways in the breast to the sentinel node. If the sentinel nodes are negative for cancer we can safely assume that all of the other lymph nodes in the axilla are also negative. If any of the sentinel nodes are positive a second surgery is required to remove the remainder of the axillary lymph nodes.

Side effects from removal of lymph nodes are directly related to the number of lymph nodes removed. The sentinel lymph node biopsy decreases the total number of lymph nodes removed and thus decreases the risk of side effects. The most common side effects are numbness and discomfort in the arm, armpit, and along the chest wall, and heavy swelling in the arm, known as lymphedema.

"What other factors should I consider to help me make a decision on surgery?"

Some women choose to have the breast on the opposite side of their cancer removed either at the time of their cancer surgery or later. Generally these are women who have a very high risk for cancer recurrence. Other reasons to choose this would be to enable a woman to have bilateral breast reconstruction or to maintain breast symmetry. Women with very large breasts may feel “off-balance” after mastectomy and may choose to meet with a plastic surgeon for consideration of a procedure to make the breasts more symmetrical.

All women want to be cured of their cancer, but other issues such as quality of life, self image, sexuality, and anxiety over recurrence should also be factored into your decision.

"What is involved with radiation treatment?"

Radiation therapy uses high-energy electromagnetic waves to kill cancer cells. If radiation may be a benefit to you, you will meet with a radiation oncologist who will discuss the treatment with you in detail. Treatments usually start 2-4 weeks after surgery and chemotherapy is completed and will consist of treatments each weekday for 6 weeks. At your initial visit your breast and the treatment area will be carefully outlined. After this first visit treatments generally last only a few minutes and are painless. The most common side effect for woman undergoing radiation treatments is fatigue. Many women find that they can continue to work and do their usual activities with minor adjustments. Other common side effects are irritation, itching or increased sensitivity of their skin. After the radiation is completed some women will have permanent changes in the breast skin such as swelling, discoloration or thickening.

"Will I need chemotherapy and if so what is involved?"

Chemotherapy involves the use of medications either intravenously or by mouth to treat any cancer cells that have traveled away from the breast. Whether or not you will need chemotherapy is determined by many factors such as your age, the size and type of tumor you have, and whether it has spread to the lymph nodes. Once you have completed your surgical treatment you will meet with a medical oncologist who specializes in chemotherapy and will discuss the benefits and risks of chemotherapy for you. The type of medications that are used and the length of time that chemotherapy is given vary from person to person. Generally treatments are given in cycles where each course of treatment is followed by a rest period. The treatments will last for 3-6 months.

Usually chemotherapy follows surgery, but a small percentage of women will get chemotherapy first. These may be women with large cancers, cancers involving the skin,

or women with a type of breast cancer known as inflammatory. Some women who have larger tumors and want a lumpectomy may decide to have chemotherapy before surgery to shrink the tumor so that a lumpectomy can be performed.

The side effects of chemotherapy vary depending on which drugs are given and whether they are given in the veins or by mouth. Possible side effects include fatigue, nausea, hair loss, and changes in your blood counts such as a drop in your white or red blood cells or platelets. Before you start chemotherapy your medical oncologists will explain what side effects you may experience. There are many effective medications to decrease your symptoms.

"What things are important to know about my breast cancer?"

After you have had your surgery and the pathologist has examined all of the tissue that the surgeon removed we can determine the stage of the cancer. This enables us to estimate the chances that the cancer has spread beyond the breast and the chances of the cancer coming back. The stage is determined by the final size of the tumor and the number of lymph nodes which were positive for cancer. We may also want to find out whether the cancer has spread outside of the breast and axilla. We do this by performing blood work and a combination of radiology studies such as CT scans and bone scans. The type of breast cancer, the tumor grade, and other “markers” such as Her2Neu also give us clues about how the tumor will act. We test all breast cancers to see if they respond to estrogen and progesterone. Knowing whether your tumor is estrogen receptor and progesterone receptor positive or negative helps guide your treatment after surgery.

Breast Ultrasound

Ultrasound of the breast is a valuable tool in the management of breast problems. The primary benefit of breast ultrasound is to determine if a mass seen on mammogram or felt on exam is cystic or solid. If a lesion is confirmed to be a simple cyst it is benign and if asymptomatic can be observed. A mass which is solid or complex requires further diagnostic evaluation.

Ultrasound provides us with the most versatile biopsy options. I routinely perform either a fine needle aspiration or a core biopsy using the ultrasound for guidance. A fine needle aspiration obtains cells which are evaluated by cytology. In contrast, a core biopsy provides tissue for histology which significantly decreases the chance of a false negative report or inadequate sampling. Core biopsy is done at the time of ultrasound with local anesthesia and is very well tolerated. Performing a core biopsy will often allow a woman to avoid surgical resection of a benign lesion.

The main advantage of the surgeon viewing the ultrasound in “real-time” is that we can identify the location and nature of a lesion more accurately than viewing still images remote from the exam. As a breast clinician and surgeon combining my review of a patient’s mammogram, my clinical exam, and a breast ultrasound is invaluable towards developing a comprehensive diagnostic and therapeutic plan.

Breast ultrasound is not routinely indicated for breast cancer screening, but it is an extremely useful adjunct to mammography in women who have very dense breasts on mammography or exam, or in women who are at high risk for breast cancer. It is a technology that has no known risks, is painless to perform, and is vital to our management of women with breast problems.

Sentinel Node Biopsy

The status of the axillary lymph nodes has important prognostic significance in breast cancer. In the past, the axillary lymph nodes were routinely removed. This surgery is associated with significant morbidity including lymphedema and numbness and pain in the arm, shoulder, and axilla.

Sentinel lymph node biopsy is a new technique that decreases these complications by decreasing the number of lymph nodes removed and decreasing the number of women that need complete dissection of the axilla.

The sentinel lymph node is the first lymph node to receive drainage from the breast. To perform the procedure a Technetium-99 labeled radioactive tracer is injected into the breast preoperatively. Lymphazurin blue dye may also be used intraoperatively to visualize the nodes which will turn blue. Using careful surgical exploration of the axilla the nodes which contain high counts of radioactivity and blue dye are isolated and removed. The one to three lymph nodes which are removed are predictive of the rest of the axilla. If a woman’s sentinel nodes are negative for metastases, we can assume that the rest of her lymph nodes are also negative. Women with positive sentinel nodes will need additional surgery to remove the remainder of her lymph nodes.

By correctly selecting patients for sentinel node biopsy rather than complete axillary dissection, women without axillary metastases are spared unnecessary morbidity.

Digital Mammography

Digital mammography is performed in exactly the same way as screen film mammography. Instead of using film, however, the images are captured by technology similar to that used for digital cameras which convert the image to an electrical signal. The image is then stored electronically which allows for easier storage & transmission of images & allows for manipulation of the image such as adjusting contrast & magnification to asses calcifications. The ease of manipulating the image leads to a decrease in “call-backs” & less patient stress. In addition, digital mammography requires less compression resulting in greater comfort & less radiation exposure to the breast.

The question of whether digital mammography increases early detection of breast cancer was addressed in a recent study in the NEJM. Overall, there was no difference in cancer detection or stage of breast cancer between the 2 modalities. However, digital mammography was more sensitive than traditional screen film mammography in detecting abnormalities in women aged less than 50, women with dense breasts, & pre or peri-menopausal women.

There are still many questions including whether the increased detection in this subgroup translates into a difference in survival, & whether the increased cost of the new technology is justified.