? Microcalcification – tiny flecks of calcium, which can be an early sign of cancer and must be biopsied.
? Specimen radiography- the excised segment from the needle localization biopsy is x-rayed before surgery is complete to ensure that all tissue containing calcification is removed. Specimen radiography is used when microcalcifications are picked up by a mammogram but are not visible during surgery. This can lead to overlarge samples being taken during biopsy. To avoid this specimen radiogrophy is used.
? You should not feel serious pain during a biopsy. If you do, immediately tell your doctor so he can alleviate it The pathologist provides this information about the tumor.
- whether the tumor is malignant or not
- how advanced, or what stage it is in, which affects treatment
- if currently benign, whether it reveals a high risk of developing a malignancy in the future
- if it has spread to other parts of the body
-whether it is hormone receptive, something that affects whether hormone treatment is given
? The risk of recurrence generally depends on the stage of the original cancer.
- Recurrence can occur either in the breast or in another part of the body
- The risk of recurrence for an ?in situ? cancer after mastectomy is almost zero. **CONTRA?**
- With infiltrating cancers, chances of recurrence are determined by tumor size and pattern of infiltration.
- The larger the tumor, the higher the risk of recurrence.
- If the tumor was less than one centimeter (three eighth of an inch), the chances the patient will be cancer free after 5 years is more than ninety percent.
- If the cancer was up to two centimeters (three fourth of an inch), the chances the patient will be cancer free after five years is seventy five percent
- If the cancer was two to five centimeters (three fourth of an inch to two inches), the chances the patient will be cancer free after five years is thirty to forty percent.
- If the cancer was five centimeters (2 inches) or larger, the chances the patient will be cancer free after five years is twenty five percent.
- Cancers which infiltrated to the lymphatics of the skin or to the chest muscle greatly increase the chances of spread to other parts of the body, regardless of tumor size.
? There is some correlation between tumor size and lymph node involvement.
- approximately twenty percent of patients with tumors smaller than one centimeter had cancerous lymph nodes.
- Sixty percent of patients with tumors larger than five centimeters had cancerous lymph nodes
? The following pattern of lymph node involvement affects risk of recurrence.
- the more lymph nodes are cancerous, the higher the risk of recurrence.
- The highest risk of recurrence exists among patients with ten or more cancerous nodes
- The larger a specific tumor in the node, the greater the risk of recurrence
- If the tumor breaks through the capsule of the node and they (node and tumor) adhere together, the risk of recurrence increases.
- In one study in which people only had surgery, five year survival rate for people with level one lymph lymph node involvement was sixty five percent, forty five percent for people with level two involvement, and twenty percent for those with level three involvement. (SOURCE & LEVEL)
? Women whose tumors have hormone receptors have a slightly lower risk of recurrence. Hormone receptors, however, are less significant than tumor size or lymph node involvement when evaluating chances of recurrence.
? The genetic material of cells affects chances of recurrence.
? Cells which duplicate normally, producing two chromosomes, are called diploid. Those which produce less or more are called aneuploid.
? The higher the number of diploid cells, the lower the chance of recurrence.
? The S phase is the period in which the cell is synthesizing DNA in preparation for dividing. The higher the number of cells in the S phase, the higher the chance of recurrence.
*********SHRAGA***********
? It is possible the cancer has spread to other parts of the body even though there is no evidence of this
? Even after surgery, the risk remains that cancer will spread to other parts of the body.
? Cancer may recur at the site where the breast used to be, even after a mastectomy. Cancer may also recur after a lumpectomy in tissue near the site of the original cancer. Cancer may also spread to other parts of the body. For these reasons it is important to have regular follow up exams to search for recurrence.
? It is more difficult to cure a recurrence than the initial cancer
? Breast cancer cells are most likely to produce a recurrence in the bone
? Any part of the skeleton may be affected, but the spine, ribs, pelvis, and upper arms and legs are the most frequent sites
? Bones below the elbow or the knee are seldom affected.
? If breast cancer occurs in the treated breast after a lumpectomy, it indicates either a new cancer or a recurrence in that spot. It does not mean the cancer has spread.
? You should also continue self examination of the breasts after surgery. This should be done once a month
? The risk of recurrence of breast cancer has gone down in recent years.
? Search for a qualified and capable doctor who will provide thorough medical care while taking into account your expressed wishes.
? The following exams should be performed to search for a recurrence
- every six months a physical exam is necessary
- a blood count should be performed every six months
- a mammogram should be given at least once a year
- if the patient had a mastectomy, the remaining breast should be x-rayed .
- if the patient had a lumpectomy, both breast should be x-rayed
- a chest x-ray, to detect cancer spread to the lung, should be performed once a year
- if the initial cancer was invasive, a bone scan is necessary to establish whether any cancer has spread to the bone
- back, joint, or other bone pains are symptoms which require an immediate bone scan
? most local occurrences, as well as most cancer spread, occur in the first two top three years after surgery
? Women who have advanced cases of cancer, ten years without a recurrence suggest, although does not guarantee, there will be none. These women can scale back their follow up exams to an annual basis only after ten years
? the risk factors that played a role in the original cancer may still be present after treatment
? a woman is at risk of breast cancer recurrence her entire life. Thus it is necessary to have regular follow up exams.
? The frequency and intensity of the follow up exams depend on the extent of the original cancer
? Breast cancer has a tendency to recur locally and spread to other parts of the body
? Searching for a recurrence is especially important the first five years
? Even after a mastectomy, cancer can recur where the breast used to be. It can also recur in the lymph nodes in the underarm and neck.
? ?distant recurrence? is the term used to describe cancer which has spread to other parts of the body.
? Following a lumpectomy with radiation treatment, there still remains the chance cancer remains in nearby healthy tissue
? The most common occurrence site after a lumpectomy is in the original area of the tumor
? If cancer recurs on the chest wall at the site of the mastectomy, this indicates the original cancer has regrown and carries a high risk of spread to other parts of the body.
Chapter fourteen: Prevention
Chapter fifteen: New Directions
? BRCA1 and BRCA2 are genes which are directly related to breast cancer
? Women with defective BRCA1 genes have a 56 percent risk of developing breast cancer by age seventy
? Half of those cases attributable to genetics are linked to BRCA1
? It is expected that BRCA2 will be proven to account for forty percent of hereditary cases
? Tests for both breast cancer genes are widely available
? testing positive for a breast cancer gene implies a higher risk for other family members as well
? currently, intensive research is being conducted to develop drugs which inhibit or prevent uncontrolled growth of cells
Medications, Treatments, and Pain management
? There is no treatment which guarantees you will survive breast cancer
? A radical mastectomy is a surgery once used to treat breast cancer. Of all possible surgeries, it disfigures most, but fortunately is no longer needed.
? A modified radical mastectomy is a surgery in which the breast is removed but the muscles left intact. This permits breast reconstruction to be done more easily and successfully.
? Most women are treated with a lumpectomy, often called a ?wide excision?. In this procedure, only the tumor, some healthy tissue, and nearby lymph nodes are taken, without removing the entire breast. The remainder of the breast is then treated with radiation.
? Breast reconstruction surgery is a form of plastic sujrgery.
? (ELEVEN) A single doctor cannot diagnose and treat breast cancer alone. A team of doctors is needed.
- The team of doctors requires a leader, which doctor fulfills this role depends on the nature of the illness and shifts as need arises. Usually the surgeon is the initial team leader
- The doctor who makes the initial discovery of something suspicious is usually your regular doctor or the radiologist who performs your annual mammograms. The radiologist performs all mammograms and x-rays.
- You will then be referred to a surgeon who will perform the biopsy. The biopsy is an essential early step in finding out what?s wrong.
- You may then need to return to the radiologist for additional mammograms and x-rays.
- An oncologist is a cancer specialist who treats you after diagnosis is confirmed and after surgery performed. If no surgery is needed then the oncologist treats you from the beginning. An oncologist treats the whole body with hormone therapy and/or chemotherapy to prevent recurrence.
- You may need to see a radiotherapist. The radiotherapist handles the radiation treatment.
- A plastic surgeon may be required for breast reconstruction.
The patients have time to find best quality doctors without the situation worsening.
? You can find a good cancer specialist in the following ways:
-National Alliance of Breast Cancer Organization (NABCO)
-National Cancer Institute (NCI) (800-4-CANCER)
-American Cancer Society (800-ACS-2345)
-American College of Surgeons (1-312-664-4050)
-Breast cancer hotlines
-Call best hospital in region
-Local women?s health groups
-Call a clergyman or social worker at a mental health institution
-Friends, relatives and colleagues are valuable sources of information in this regard.
? After compiling a list of doctors, it is important to verify their credentials.
- These include training, experience, hospital affiliation, peer recognition.
- Credentials can be checked by consulting medical directories, public libraries, the county medical society, or medical libraries.
- The Internet is also a valuable resource for checking credentials. Consult these organizations online-The National Library of Medicine, The National Cancer Institute ?PDQ?
- It is important to be treated in those hospitals that are especially excellent in treating breast cancer. Here are some.
-Dana-Faber cancer center in Boston
-Memorial-Sloan-Kettering Cancer Center in NY
-MD Anderson Cancer Center in Houston
? When you make your decision of treatment, consider these factors:
- Survival should be your primary concern, but can be balanced with other considerations.
- Breast preservation,
- Leading a normal life
- Survival at all costs without consideration of other factors.
? You make your own decisions from the options presented from your doctor.
? Precise identification is required to determine risk and decide on best treatment. The following factors must be determined before treatment;
? The type of the tumor – its size, whether the skin around the tumor site is broken, red, or swollen, whether the nipple has retracted into the breast, and whether the tumor is attached to the pectoral muscle or chest wall.
? Spread to the lymph nodes – whether there is no cancer present or if it has spread to the nodes above the collarbone.
? The degree of spread (metastasis) to other parts of the body must be established.
These factors determine the stage of the cancer. The stage of the cancer affects risk assessment and treatment choice.
Chapter Four: Diagnosis
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? It is common for biopsy and surgical procedures to be performed in separate stages.
? In the following cases it is best to perform the biopsy and any attendant surgery in one stage:
? If mastectomy or other surgery is agreed upon in the event that a malignancy is found.
? If the cancer is discovered to be at a stage which does not permit breast reconstruction
Chapter five: pathology
Chapter six: After the Diagnosis
? The doctors demeanor plays an important role in the patients overall emotional reaction. He must be sympathetic and compassionate.
? People react differently to cancer: some delay acceptance and some seem to accept it only to break down later.
? Your insurance plan may require a second opinion.
? You should begin treatment of breast cancer within the first three to four weeks.
****VERIFY*****-It is not dangerous to wait this long, as cancer does not grow measurably in so short a period
-it is worth waiting a short time for an excellent surgeon
? You should avoid surgeons who can receive you immediately since they are unlikely to be good. Good surgeons are busy.
? Surgery is the primary treatment for breast cancer
? Cancers detected early do not necessitate breast removal.
? Treatments evolve. Find a doctor open to new ideas or you will be limiting your options
? There are two general surgical categories:
-Lumpectomy – the cancer is removed without removing the entire breast
-Mastectomy – the entire breast is removed.
? Breast cancer usually requires only local anesthesia. Anesthesia can numb locally or induce total unconsciousness.
? Stop taking aspirin a week or two before surgery. Aspirin is a blood thinner and therefore may interfere with blood clotting
? Prepare a precise list of all the medications and dosages you are taking and inform the nurse, also inform the nurse of all over the counter medicines and allergies you may have.
? The use of monoamine oxidase inhibitors (MAOIs) such as Nardil or Parnate should be stopped at least two weeks before surgery.
? A mastectomy is the surgical removal of the breast. There are several general categories of mastectomy: modified radical, radical, total, and partial.
? Modified radical mastectomy:
- most common procedure for breast cancer
- has the best long-term results with the fewest complications
- the effectiveness of all other techniques are measured against it
- consists of the following elements: removal of the portion of the breast that visually protrudes, removal of the breast tissue that extends towards the breast bone, the collarbone, the lowest ribs, and the latissimus dorsi, and the removal of the lymph nodes in the armpit.
- The minor pectoral muscle is removed only if it interferes with the removal of the lymph nodes, but its absence is hardly noticed
- The major pectoral muscle is never removed
? Care is taken to ensure that general appearance harmed.
- the cut is in the shape of an ellipse, avoiding a vertical line.
- The cut is slightly removed from the breastbone, so the scar won?t be visible in low cut clothing
- An effort is made to avoid unsightly folds
- Nevertheless, such folds sometimes do occur in heavier women
? Surgery to remove armpit lymph nodes creates a risk of future arm swelling, or lymphedema.
? Sentinel Node biopsy.
- seeks to lessen the risk of developing lymphedema
- this has not been proven effective
? Total (or simple) mastectomy
- the breast is removed
- the lymph nodes are not removed
- used to treat ductal carcinoma ?in situ?
? radical mastectomy.
- rarely used today
- most disfiguring and traumatic of all breast cancer surgeries
- it involves the removal of the breast, all muscles of the chestwall (minor and major pectorals), and sometimes, so much skin that skin grafting may be necessary
- the natural contours of the chest wall is lost, arm mobility may be temporarily reduced, and breast reconstruction is more difficult
- this technique is used only in those rare cases of breast cancer which have not been detected early and have already invaded the muscles of the chestwall
? Partial mastectomy
- Three types: lumpectomy, wide excision, or a quadrantectomy
- If the tumor is small in relation to the whole breast, then it and about two centimeters of surrounding tissue is removed. This is called a lumpectomy or wide excision