- If approximately a quarter of the breast is removed the procedure is called a quadrantectomy. This reduces the size of the breast.
- Followed by radiation treatment and usually by hormone therapy and chemotherapy
- The purpose of a partial mastectomy is to remove the tumor while preserving the breast
- It is a new procedure and the techniques are still developing.
- Its cosmetic results are not always excellent.
? Skin sparing mastectomy
- the breast is removed leaving the skin intact. Most of the skin is preserved and ready for an immediate breast reconstruction.
- The breast removal can be a total mastectomy or a modified radical mastectomy
- This method creates the most normal looking breast with minimal scars
? Neither partial nor modified radical mastectomies cause great pain.
? Permanent or temporary numbness can occur in the underarm if lymph nodes were removed.
? Modified radical mastectomy
- general numbness of chest within area of incision will occur.
- Numbness usually disappears within months or sometimes within years
- The area may never feel completely normal
? Removal of the lymph nodes in the arm has these effects
- leaves the arm more vulnerable to infection
- does not impair the general immune system
- may cause phlebitis ? a clot developing in the vein of the arm after an incision. This condition is uncomfortable though not serious and usually disappears in four to six weeks
- may cause lymphedema, or swelling of the arm
? In deciding on the correct surgical procedure, two factors should be considered.
- the nature of the tumor, its characteristics and ?stage?
- your individual preference. How much risk is acceptable for you and your priorities
? tumors are classified in five stages.
- stage 0: cancers which remain in their site of origin, without spread
- stages 1 and 2: small cancers which show a tendency to spread
- stage 3 cancers: large (two inches or more), may have spread to the skin, may be inflammatory, may have spread extensively to the lymph nodes.
- Stage 4 cancers: cancers which have spread to other parts of the body
? Stage 0 cancers consist of lobular neoplasm or ductal carcinoma in situ.
? Lobular neoplasm
- Does not need be operated on
- must be closely watched because having this condition greatly increases the risk of later developing more serious infiltrating cancer
- 20 percent of women with this condition develop infiltrating cancer with ten years
- recent evidence suggests the risk of developing infiltrating cancer greatly reduced with hormone treatment
? Ductal carcinoma in situ
? must be treated with surgery. Two procedures: total mastectomy without removal of armpit nodes or a lumpectomy
? a total mastectomy eliminates the chances of recurrence but a lumpectomy leaves a one percent chance per year of recurrence .*****VERIFY*****
? of those having a recurrence, half will have an in situ recurrence and be treatable with a total mastectomy, while the other half will have an infiltrating recurrence, and some of these will die. Thus opting for a lumpectomy poses a very small, though potentially grave, risk.
- Nevertheless, over the past five years a lumpectomy has become the treatment of choice for most surgeons when dealing with small tumors.
- However, a mastectomy is usually done in the following cases: a large tumor, a spread out tumor, multiple tumors, and tumors involving the central ducts near the nipple
? When a mastectomy is not done, radiation therapy is effective in reducing the risk of a recurrence.
? Stage 1 and 2 cancers are small infiltrating cancers which can usually be treated with a lumpectomy, armpit lymph node removal, and radiation therapy.
? A mastectomy for stage 1 and 2 cancers is advised in the following cases.
- multiple tumors
- multiple areas of microcalcification
- a large tumor in a small breast
- a tumor in or near the center of the breast
- if there is extensive armpit lymph node involvement
? stage 3 cancers are treated first with chemotherapy followed by surgery, usually a modified radical mastectomy.
? Stage 4 cancers are treated primarily with chemotherapy. Surgery or radiation therapy can sometimes be used to help combat local tumors.
? Breast cancer in pregnant women is treated as follows.
- with a mastectomy if the woman is in the second or third trimester or later
- if breast cancer develops in the first trimester the woman usually aborts the baby and seeks the most appropriate treatment
- radiation therapy is not used on pregnant women as it risks the well-being of the baby
- chemotherapy may be started in the later half of pregnancy
? Two treatment factorsA combination of prognostic factors is used to determine statistical risk of relapse for patients.
Chapter 9
? TwoTreatmentChemotherapy drugs are powerful chemicals that arrest specific cancer cell cycle stages, and aim to destroy as many malignant cells as possible.
? Two Selection of the best chemotherapy drugs and dosage with minimal side effects is critical.
? TwoWhile some patients will respond favorably to any one or combination of chemotherapy drugs or radiation doses, no prediction of final patient outcome can be made.
? TwoMajor chemotherapy side effects include bone marrow damage, infections and increased gastrointestinal tract sensitivity. Some women experience permanent menopause.
? TwoMinor chemotherapy side effects include nausea and vomiting, sensitivity in the mouth, hair loss, finger and toe numbness, temporary memory changes.
Chapter 8 Radiation therapy
? TwoRadiation therapy uses a high-energy radiation beam directed to specific areas of the body. Radiation treatments consist of a string (25-30 sessions) of short treatments (lasting seconds to minutes)
? TwoR Cancer cells, dividing faster than normal cells, are affected more by radiation therapy. Cancer cells enter a cell death cell (apotosis) Normal cells have an abiltity to repair themselves, even after high dose radiation.
? TwoRAn oncologist may recommend giving ?boosts? or implantation of small iridium seeds, when radiation therapy is not proceeding as expected.
? TwoRRadiation therapy side effects include breast shrinkage, reduced skin elasticity and sensitivity. Some women experience temporary fatigue, decreased blood cell counts, and mild weight gain.
? TwoRWhen women require both chemotherapy and radiation therapy, chemotherapy is given first.
? TwoRMany patients do not understand the importance radiation therapy plays in their overall treatment plan?especially after mastectomy treatment.
? Two treatment factorsA combination of prognostic factors is used to determine statistical risk of relapse for patients.
Chapter 9
? TwoTreatmentChemotherapy drugs are powerful chemicals that arrest specific cancer cell cycle stages, and aim to destroy as many malignant cells as possible.
? Two Selection of the best chemotherapy drugs and dosage with minimal side effects is critical.
? TwoWhile some patients will respond favorably to any one or combination of chemotherapy drugs or radiation doses, no prediction of final patient outcome can be made.
? TwoMajor chemotherapy side effects include bone marrow damage, infections and increased gastrointestinal tract sensitivity. Some women experience permanent menopause.
? TwoMinor chemotherapy side effects include nausea and vomiting, sensitivity in the mouth, hair loss, finger and toe numbness, temporary memory changes.
Chapter 8
? TwoRadiation therapy uses a high-energy radiation beam directed to specific areas of the body. Radiation treatments consist of a string (25-30 sessions) of short treatments (lasting seconds to minutes)
? TwoR Cancer cells, dividing faster than normal cells, are affected more by radiation therapy. Cancer cells enter a cell death cell (apotosis) Normal cells have an abiltity to repair themselves, even after high dose radiation.
? TwoRAn oncologist may recommend giving ?boosts? or implantation of small iridium seeds, when radiation therapy is not proceeding as expected.
? TwoRRadiation therapy side effects include breast shrinkage, reduced skin elasticity and sensitivity. Some women experience temporary fatigue, decreased blood cell counts, and mild weight gain.
? TwoRWhen women require both chemotherapy and radiation therapy, chemotherapy is given first.
? TwoRMany patients do not understand the importance radiation therapy plays in their overall treatment plan?especially after mastectomy treatment.
? Two RClinical studies demonstrate that for older women *60 years, radiation therapy may not increase their success rate of recovery.
? almost all women who have had lumpectomies are now treated with radiation *****SHRAGA*****
? Although the cancer was removed by a lumpectomy, there is a high risk of recurrence in the affected breast. Radiation therapy is given to lessen this risk.
? radiation therapy consists of x-rays being trained on specific areas of the body. These rays destroy malignant cells though also healthy cells. The healthy cells are able to regenerate and in the treatment of breast cancer the damage is local, not bodywide.
? When the tumor is large or has spread to the lymph nodes, radiation therapy is sometimes used with a mastectomy. It is not normally used with a mastectomy.
? Radiation is sometimes used to treat the lymph nodes behind the breast bone or above the collarbone
? Extremely large tumors are sometimes combated partially with radiation
? A radiotherapist or radiation oncologist is a physician trained in the administration of radiation for medical purposes. Some radiation specialists are particularly expert in the treatment of breast cancer, and should be sought out.
? A proper treatment facility must contain the following: a radiation physicist, a radiation technologist, and radiation therapy nurses.
? Radiation therapy has the following effects.
- radiation therapy does not cause pain
- does cause swelling, redness of skin, and fatigue
- radiation can cause a malignancy of blood vessels, bone, or connective tissue at the site of treatment. This is called a hemangiosa and is a serious malignancy. It requires a mastectomy.
- Occasionally, radiation can cause a hairline fracture of the ribs.
- Radiation therapy can sometimes injure lungs .(neither of the last two conditions are likely to occur if radiation therapy is properly planned and administered.)
- Some women experience episodes of discomfort and report their breasts are more sensitive.
- Slight skin discoloration or thickening may occur.
- Radiation does not affect the immune system response
- Sometimes radiation can cause cancer. This depends on age and dosage.
- People age nineteen and younger are at the highest risk of radiation induced cancer. After thirty five, the risk is tiny.
- The risk of radiation induced-induced malignancy increases with dosage, but only from 300 to 1000 rads of radiation. The risk decreases as dose increases after 1000 rads
- With dosage close to 4,500 rads, the risk is negligible
? Radiation therapy cannot be used on a recurrence in the breast that has already been treated this way.
Most women who have had breast cancer now receive chemotherapy or hormone therapy to prevent recurrence.
? Systematic treatment, treatment with drugs that circulate throughout the body, are needed to reduce the risk of cancer spreading to other parts of the body.
? Systematic treatment reduces the risk of recurrence by one third/
? Systematic treatment must begin immediately after surgery, to reduces likelihood of recurrence and to combat cancer spread.
? Systematic treatment also combats cancers which have already spread but are too subtle to be detected yet.
? Chemotherapy and hormone treatment are the two most common methods of systematic treatment.
? Which patients should receive chemotherapy is generally determined by these factors.
- the size of the tumor
- whether the tumor was ?in situ? or invasive
- whether the tumor has hormone receptors
- whether the tumor has spread to the lymph nodes
- whether you are pre-menopausal or post-menopausal at the time the tumor appeared
? chemotherapy works best in pre-menopausal women
? hormone therapy works best in post-menopausal women, especially if their tumors had hormone receptors
? however, chemotherapy is useful in post-menopausal women as well, together with hormone therapy.
? Hormone therapy can benefit premenopausal women together with chemotherapy
? For infiltrating cancers, chemotherapy with or without hormone therapy is most common
? For ?in situ? cancers, hormone therapy is most common
? Drugs used for chemotherapy are cytotoxic ? they act by destroying cells. Cancer cells are much more sensitive to their effects than regular cells, although some normal cells die as well.
? Dosage is tailored for minimizing side effects and maximizing curative effects.
? Most chemotherapy is completed within three to six months. Hormone treatment can last up to five years.
? A combination of drugs is required, no single drug is effective.
? There are four types of drugs: alkylating agents, antimetabolites, natural products, and hormones
Chapter 11
? IIITwoHTamoxifen, a hormone-like substance of the SERM family, binds to estrogen receptors on cancer cells, interferes with cellular functions and eventually destroys them.
? TwoHConflicting opinions exist over the optimal length of time a patient should continue tamoxifen treatment.
? TwoHMost patients with breast tumors who are estrogen and progesterone receptor positive will respond to tamoxifen therapy.
? TwoHMajor tamoxifen side effects include cancer in the uterus and higher risks of stomach and colon cancer development. Tamoxifen causes greater bone loss in pre-menopausal women as well as the development of early on-set menopause.
?
? TwoHMinor tamoxifen side effects include vaginal dryness, hot flashes, mild weight gain, and depression.
? IIITwoHEvista, a newly released hormone-like substance of the SERM family is being reviewed for its breast cancer treatment potential.
?
? Hormone therapy may produce increased sweating, chilliness, and hot flashes.
? The side effects of chemotherapy
- are usually transitory
- some side effects are acute right after treatment, but soon go away
- There is no way to avoid the side effects of chemotherapy completely, though they can be alleviated
- There is no pain resulting from chemotherapy
- Nausea – most drugs do not cause immediate nausea. Some nausea can result from acid secretion, but are easily treated with standard anti-nausea medicine
- Serious nausea may occur, requiring prescription drugs to be taken before each treatment session.
- Hair loss may occur as a result of treatment, but will fully grow back after treatment is complete
- With certain drugs, it may be possible to eliminate or reduce hair loss by use of a tourniquet
- Treatment does cause some initial fatigue which subsides in a day or two
- Weight gain is a common side effect of treatment
- Menstruation may stop during treatment, but will likely resume if patient is young enough
- it is possible to experience several or none of these side effects
- individual drugs can have side effects particular to the drug in question.
- Phlebitis ? occurs frequently in the legs and must be treated promptly
- Some people develop arthritis when chemotherapy is discontinued. This usually disappears a year after its onset
- Some women report problems with memory. It is unclear if this is caused by the chemotherapy or just stress. Memory usually returns to normal.
? Most chemotherapy drugs are given intravenously, directly into a vein. Some, however, can be taken orally.
? In some situations plastic tubing is inserted under the skin and connected to one of the larger veins leading to the heart and chemotherapy administered.
? Tamoxifen is one of the most common hormone related drugs used. Tamoxifenn should be given for a period of five years. Taking tamoxifen for more than five years provides no additional benefit
? Tamoxifen should begin four weeks after surgery or after radiation therapy is complete
? Most programs of chemotherapy and hormone treatment last for three to six months. Some programs last a year, but this is rare.
? Tamoxifen occasionally causes nausea or weight gain, and younger women sometime have menopausal symptoms. Rarely, some facial hair occurs.
? Chemotherapy programs must be tailored for each patient. These factors help determine which program each patient will be put on: the level of risk of recurrence, whether patient is pre- or postmenopausal, level of invasion, size of tumor, lymph node involvement
? The following are general guidelines for tailoring chemotherapy and hormone treatment:
- cancers which are ?in situ? and are noninvasive have a very low risk of spreading to other body parts and chemotherapy is not used. However, tamoxifen might be used.