All Your Questions About Breast Cancer, Answered

What is breast cancer?

Breast cancer begins when abnormal cells start to grow and eventually form a tiny mass (tumour) in the breast. About 90 per cent of the time, this malignancy occurs in the milk ducts (called ductal carcinoma), or in the milk glands (called lobular carcinoma).

Sometimes, an overgrowth of abnormal cells along the lining of a milk duct stays confined to one spot, or in situ, a condition known as ductal carcinoma in situ, or DCIS. Only rarely, however, does a tumor develop in the connective tissue or fat that makes up the rest of the breast.

At diagnosis, a breast cancer tumour is classified by stage – from 0 for the smallest to IV for the most serious – to indicate a tumour’s size and whether malignant cells have spread elsewhere in the body.

You may already know the stage of your disease. This is important because it helps clarify the best treatment options for your particular case. Another important factor determined at breast cancer diagnosis is whether the tumour is hormone receptor-positive (hormone sensitive).

Who is at risk for breast cancer?

The majority of breast cancer cases are in women aged over 50, and the incidence rises with age. The earlier the diagnosis and the start of treatment, the better your chances of survival.

Treatment for breast cancer

No single breast cancer treatment strategy works for everyone. What’s recommended for you may not be what’s best for another woman.

In general, key factors in determining the best treatment will be the tumour’s size, aggressiveness, and location. The earlier the stage and the smaller the tumour, the more likely that surgery can remove it all and offer a total cure. There are also good options for more advanced stages, where the cancer has spread beyond the breast.

In designing a treatment, your doctor will also consider your age and general health, the size of your breasts, and whether or not you’ve gone through menopause. The strategy you’re ultimately given will probably feature a mix-and-match of surgery, chemotherapy or hormone-blockers, and radiation.

Deciding which approach will be most successful for you can be tricky. It’s normal to feel scared and overwhelmed by all the information and differing opinions you are offered. The appeal of one treatment over another can be frustratingly small. The most difficult program may not necessarily be the best: Some arduous regimens increase success rates by as little as one per cent.

On the bright side, unless the breast cancer is advanced, you have at least several weeks to research various options before starting treatment. See other doctors to confirm your diagnosis and discuss the treatment plan recommended for you. If you get two different opinions, see a third or fourth doctor.

Try to find experts you feel comfortable talking with about your fears – being anesthetized for surgery, losing part of your femininity, having cancer develop elsewhere in your body. Good doctors are familiar with such concerns and can give you insightful ideas for handling them. The decision is then up to you; many women find that writing in a journal and talking with friends and family leads them to a decision that they feel comfortable with.

Medications for breast cancer

After surgery for a stage I, II, or III cancer, you and your doctor make a decision about using anticancer drugs.

Both chemotherapy and hormone therapy can be enlisted to patrol the whole body and destroy wayward cancer cells. This is often referred to as systemic therapy.

The heavyweight here is chemotherapy, which benefits most women with breast cancer. Whether you’re pre- or postmenopausal, whether lymph nodes are involved or not, you’re more likely to enjoy a long-term, relapse-free recovery if you undergo chemotherapy. Chemotherapy destroys normal healthy cells, as well as cancerous ones. So while it reduces the risk of cancer in another part of your body, your doctor won’t recommend it if it poses more of a health risk than cancer. Chemotherapy probably won’t be suggested if you have a cancer unlikely to spread, are over age 70, or are otherwise quite ill.

Most women start chemotherapy after surgery for breast cancer and continue treatments for about three months. If you have a relatively large tumour (more than 5 centimeters), your doctor may suggest presurgery chemotherapy with six months or so of additional chemo after surgical recovery. Good results have been seen by prolonging chemotherapy in women with lymph node involvement.

Chemotherapy agents all work a little differently. Some are taken orally, others by IV or injection. Side effects vary as well: If your reactions are very severe, talk with your doctor about switching drugs. Most regimens are given in cycles. Combinations such as CMF (cyclophosphamide, methotrexate, and 5-fluorouracil) or CA (cyclophosphamide and Adriamycin) are common. The hormone-receptor status of the tumour is also a factor in choosing chemotherapy. For example, adding paclitaxel (Taxol, derived from the Pacific yew tree) after CA further lowers the risk of recurrence with a hormone-receptor negative tumour.

If the tumour is hormone-positive, you will receive hormonal therapy (anti-estrogen treatment) following surgery – regardless of your age, menopausal status, lymph node involvement, or the tumour size. Anti-estrogen therapy is helpful even if only a tiny amount of hormone action is present: It can prevent your own estrogen hormones from stimulating cancer cells and growing new tumours.

The most common form of anti-estrogen therapy is a class of medications called selective estrogen receptor-modulators (SERMs). Most widely used is tamoxifen (Nolvadex), which blocks estrogen from latching onto breast cell receptors through trickery: Because tamoxifen closely resembles estrogen, breast cancer cells accept it instead. This prevents your own estrogen from delivering its growth (and cancer-stimulating) signal. It also prompts the cancer cells to die. Tamoxifen cuts the risk of a new cancer in the other breast by 50 per cent and reduces the risk of cancer elsewhere in the body. Studies show that taking it for five years is better than for one to two; hot flashes and vaginal discharge are common side effects. If you have the BRCA1 gene (a genetic mutation linked to an inherited form of breast cancer), tamoxifen probably won’t help prevent a new cancer, but it might fight breast cancer that’s already there. Tamoxifen also lowers the risk for cancer if you have BRCA2, another gene variation.

New hormone therapy agents called aromatase inhibitors (AI) target estrogen – by blocking the action of an enzyme (aromatase) crucial to estrogen production. These drugs won’t help if you’re premenopausal, because they can’t keep up with your ovaries’ prodigious natural estrogen output. You can benefit, however, if you’re postmenopausal and your breast cancer is advanced. The new drug anastrazole (Arimidex) appears to be at least as effective as tamoxifen.

Another treatment option for premenopausal women with hormone-positive tumours is medical or surgical removal of the ovaries. This halts production of estrogen, which fuels breast cancer growth, but it also ends fertility and can be emotionally taxing. If a breast cancer is very aggressive and has spread, the doctor may recommend a biological agent, the monoclonal antibody drug trastuzumab (Herceptin). It blocks the growth of cancer cells in about 30 per cent of cases by targeting a protein (HER2) abundant in some tumors.

Lifestyle Changes

A good treatment strategy for breast cancer considers your emotions as well as your body. Here are a few things you can do:

• Join a support group. This can be tremendously important in helping you deal with fear, anger, loneliness, betrayal by your body, despair, and other feelings. There are groups to help your kids and other family members cope as well.
• Exercise regularly. Many women report exercise helps them tolerate therapy better. Ask about special arm and shoulder exercises if you’ve had lymph node surgery.
• Eat a balanced and nutritious diet. Good eating can bolster your body’s drive to stay healthy and fight the breast cancer.
• Keep weight under control. Excess pounds may lower your odds or raise the risk of a cancer recurrence.
• Concentrate on de-stressing. Get plenty of rest; then explore techniques such as biofeedback, massage, and meditation.

Related Procedures for Breast Cancer

The first step in breast cancer treatment is surgery to determine, among other factors, exactly what kind of tumour it is and whether it contains hormone receptors. A surgeon or radiologist performs this initial procedure, called a biopsy. The next step for most women is to have the cancer excised. This is your best shot at a cure, at stopping the cancer from getting any bigger or spreading. If retaining the natural shape of your breasts is important to you, discuss different reconstruction options with a plastic surgeon.

For tumour removal, there are also a number of options.

• If your tumour is stage I or II, your surgeon should be able to remove the cancer completely, keeping your breast largely intact. Procedures called a lumpectomy or a partial mastectomy are used. You’ll then need six or seven weeks of radiation to the breast to destroy any leftover cancer cells. Thousands of women now choose one of these breast-conserving approaches. The latest major research trials indicate your chance for long-term survival is the same with a lumpectomy as with partial or even radical mastectomy.
• If your tumor is stage III or at an early stage but you have small breasts, you may be better off having the entire breast removed with a procedure called a mastectomy. There are several variations. Most women have an operation called a modified radical mastectomy, which removes breast tissue, chest muscle lining, and axillary nodes. Only if the cancer has spread to muscles in the chest will a surgeon recommend a radical mastectomy, in which the breast, nodes, and muscles beneath the breast are removed. Sometimes presurgery chemotherapy shrinks a tumor sufficiently to make lumpectomy possible. Finally, a total mastectomy is a treatment option for DCIS.

After surgery, many women pursue radiation therapy, or radiotherapy, to destroy any wayward cancer cells in the breast, chest wall, or underarm area. (Sometimes radiation is recommended before surgery to shrink a tumor.) Sometimes key to surviving breast cancer, radiation is often worth the discomfort of fatigue, red or blistered skin, skin color changes, and other possible side effects. On a positive note, technical innovations in radiation have reduced the risk of such side effects.

Widely recommended external beam radiation focuses two opposing beams of high-energy x-rays on the breast, angling them away from vital organs. The procedure is done five days a week, for about five weeks. Additional, even more precisely focused radiation is often given for another one to two weeks.

If you’ve had a lumpectomy for a small, early tumour, and are postmenopausal, you may be a candidate for internal radiation therapy, or brachytherapy. In this procedure, radioactive seeds (the size of rice grains) are implanted directly into the site of the excised tumor, where cancer is most likely to recur. You only need twice-a-day treatments for four or five days, and side effects appear to be mild. Much about this new technique remains unknown, but early results indicate that for some women, brachytherapy is as effective as standard radiation at preventing recurrence of breast cancer.

The latest findings show that combining radiation with breast-conserving surgery for stage I or II breast cancer offers the same odds for long-term survival as mastectomy. But without the postsurgery radiation, the risk of recurrence at or near the original tumour site is much higher. So if you’re slated for a mastectomy, your doctor will likely recommend radiation therapy, especially if your tumour is large or many lymph nodes (usually four or more) are involved. It’s less certain that radiation will benefit you if fewer (one to three) lymph nodes are involved.

Questions for Your Doctor

• What are my chances of surviving this breast cancer?
• What side effects can I anticipate from this treatment?
• Will my figure ever recover? What about reconstruction?
• Does this mean I’m at greater risk for other cancers?
• What experience do you have with breast cancer? What’s your patients’ survival rate?

Living with Breast Cancer

If you have been diagnosed with Breast Cancer, you will be faced with some life-altering decisions. To help you get through the process, here are a few quick tips to help you take control of the situation:

• Bring a friend along. When discussing treatment options with your doctor, have an advocate in the room to take notes and pose questions you can’t ask. Even better: tape record the appointment. You can later review what was said at your leisure.
• Pose key questions to yourself. Feeling comfortable with a treatment choice is critical, because there’s often no right choice. Ask yourself: What feels best for me? Can I manage the side effects? What kind of support can I expect from family or friends?
• Sign up for a clinical trial. This can put you in the hands of highly experienced doctors.
• Plan for a wig. Before you lose your hair from chemo, visit a wigmaker to choose a style and colour that match your own. A hairdresser can add finishing touches. With a doctor’s prescription, insurance companies will cover the expense.

Prevention of Breast Cancer

• Be choosy about fats. Certain types of fats seem to increase estrogen levels, which in turn raise breast cancer risk. A recent Swedish study has suggested that monounsaturated fats may help reduce risk and polyunsaturated fats may increase it. Lean toward monounsaturated oils like olive and canola, and omega-3 fatty acids, found in salmon, sardines, and herring. Steer clear of trans fats, found in stick margarine, packaged baked goods, and snack foods (check for partially hydrogenated on the label), and the polyunsaturated fats abundant in corn, sunflower, and safflower oils.
• Bring on the fibre. Fibre binds up excess estrogen and carries it away through your intestinal tract. Good sources include beans, brown rice, whole-grain breads and cereals, and many fruits and vegetables.
• Eat your fruits and veggies. In particular, get enough cruciferous vegetables, such as broccoli, cabbage, and cauliflower – all of which can boost cancer-fighting enzymes.
• Savour soy. Isoflavones in soy foods are weak estrogen-like compounds that block the action of estrogen, which may contribute to breast cancer. Use soy flour in recipes, add tofu to soups or main dishes, eat green soybeans, or drink soy milk.
• Avoid additives. When possible, buy hormone-free organic meats, poultry, and dairy foods. Be sure to wash fresh produce and, when feasible, remove peels to get rid of pesticide residue.
• Get active. Studies show that women who exercise at least four hours a week reduce their breast cancer risk by 37 percent as compared with less active women. Exercise may cut estrogen production by burning calories and reducing fat.
• Keep on top of it. Mammograms can detect breast cancer two to five years before you can feel a lump. If you’re age 50 to 69, have a mammogram – and a clinical breast exam – at your doctor’s office every two years. (High-risk women may need more frequent mammograms.) Also, if you’re still menstruating, be sure to do a monthly breast self-exam 7 to 10 days after the beginning of your period. If you’re postmenopausal, do your self-exam on the same day each month. It is estimated that if every woman examined her breasts monthly and had mammograms at the recommended times, it would save more than 15,000 lives in North America each year.
• Consider a SERM. Tamoxifen – a common breast cancer treatment – may also help prevent the disease. But many doctors believe its side effects (increased risk of endometrial cancer and blood clots) outweigh its benefits. It should be considered only for high-risk women. Researchers are now studying a newer selective estrogen receptor modulator, Evista, which may have similar benefits but fewer side effects.
• Try vitamin E. In a small study at SUNY-Buffalo, participants with a family history of breast cancer had an 80 percent lower risk for developing breast cancer if their diets contained 10 or more IU per day of vitamin E. Ask your doctor or nutrition counselor about the dosage that’s safe for you.
• Limit your alcohol. Too much alcohol is linked with increased risk for breast cancer. Limit yourself to no more than two or three drinks a week.