guide to breast cancer

8/7/2019 Guide to Breast Cancer

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GUIDE TOBREAST CANCER

Comprehensive, oncologist-approved cancer informationfrom the American Societyof Clinical Oncology (ASCO)

www.cancer.net

Made available through:


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ABOUT ASCOThe American Society of Clinical Oncology (ASCO) is the worldsleading professional organization representing physicians of all

oncology subspecialties who care for people with cancer.

ABOUT THE CANCER.NET GUIDES TO CANCERThe Cancer.Net Guides to Cancer provide patients withcomprehensive, peer-reviewed information based on contentfrom Cancer.Net (www.cancer.net), ASCOs patient

information website.

Good cancer care starts with good cancer information. Well-informed patients are their own best advocates, and invaluablepartners for physicians. The ASCO Cancer Foundation supportsoncologists and patients by providing unquestionably accurate,physician-approved cancer information. This content is available

publicly both in print and online, to provide trusted, authoritativeinformation for people living with cancer and those who carefor and care about them. People in search of cancer informationcan feel secure knowing that the programs supported by TheASCO Cancer Foundation provide the most thorough, accurate,and up-to-date cancer information found anywhere.


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1

TABLE OF CONTENTS

Overview .................................................................................2

Statistics ...............................................................................3

Risk Factors ..............................................................................4

Prevention ................................................................................7

Symptoms ................................................................................8

Diagnosis .................................................................................8Imaging tests .......................................................................9Surgical tests ......................................................................10Testing the tissue ............................................................... 11Testing a tumors genes ...................................................... 11Blood tests ......................................................................... 12

Additional tests ..................................................................12

Staging ..................................................................................13Cancer stage grouping ....................................................... 14

Treatment ..............................................................................17Overview of breast cancer treatment ..................................18

Surgery ..............................................................................19Radiation therapy ...............................................................21Chemotherapy ...................................................................24Hormone therapy ...............................................................25Targeted therapy ................................................................26Recurrent and metastatic breast cancer ..............................27

Clinical Trials Resources ..........................................................28

Side Effects ............................................................................29

After Treatment .....................................................................30

Questions to Ask the Doctor ..................................................32

Advances in the diagnosis, treatment, and prevention of cancer occur

regularly. For more information, visit Cancer.Net (www.cancer.net).

Information in ASCOs patient information materials is not intended

as medical advice or as a substitute for the treating doctors own

professional judgment; nor does it imply ASCO endorsement of any

product, service, or company.

Additional information about breast cancer can be found at

www.cancer.net/breast.


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3OVERVIEW

Cancer may begin as a single, genetically abnormal cell. As thisone cell divides, it eventually becomes a tumor and develops ablood supply to nourish its continued growth. At some point,

cells may break off from the primary mass and move to otherparts of the body in a process called metastasis.

Breast cancer spreads when breast cancer cells move to othersites in the body through the blood vessels and/or lymph vessels.A common site of spread is the regional lymph nodes. Thelymph nodes can be axillary (located under the arm), cervical

(located in the neck), or supraclavicular (located just above thecollarbone). The most common sites of distant metastasis arethe bones, lungs, and liver. Less commonly, breast cancer mayspread to the brain. The cancer can also recur (come back aftertreatment) locally in the skin, in the same breast (if it was notremoved as part of treatment), other tissues of the chest, orelsewhere in the body.

Most of the time, breast cancer is diagnosed and treatedbefore metastasis occurs. According to the latest data fromthe National Cancer Institute (NCI), 61% of breast cancersare diagnosed while the cancer is still in the breast, 31% arediagnosed after the cancer has spread to nearby lymph nodesor just outside the breast, and 6% are diagnosed once the

cancer has metastasized beyond the adjoining lymph nodes todistant sites.

StatisticsIn 2009, an estimated 192,370 women in the United States willbe diagnosed with invasive breast cancer, and 62,280 womenwill be diagnosed with in situ breast cancer. An estimated 1,910men in the United States will be diagnosed with breast cancer. It

is estimated that 40,610 deaths (40,170 women, 440 men) fromthis disease will occur this year.

Anatomical and staging illustrations for many types of cancer are available at

www.cancer.net.


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4 RISK FACTORS

If the cancer is limited to the breast, the five-year relativesurvival rate (percentage of people who survive at least fiveyears after the cancer is detected, excluding those who die from

other diseases) is 98%. If the cancer has spread to the regionallymph nodes, the five-year relative survival rate is 84%. If thecancer has spread to a distant site, the five-year relative survivalrate is 27%. Even if the cancer is found at a more advancedstage, new treatments enable many people with breast cancerto experience the same quality of life as before their diagnosis.

It is important to note that these statistics are averages, andeach individuals risk depends upon numerous factors, includingthe size of the tumor and the number of positive lymph nodes(lymph nodes that contain cancer; this is called node-positivecancer, see the Diagnosis section). The survival rate is higherand the chance of recurrence is lower for a smaller tumor withnegative lymph nodes (lymph nodes that do not contain cancer;

this is called node-negative cancer). The recurrence rateincreases with an increase in tumor size and number of positivelymph nodes.

Since 1990, the number of women who have died of breastcancer has declined steadily each year. In women younger than50, there has been a decrease of 3% per year; in women age

50 and older, the decrease has been 2% per year. Currently,there are about two and a half million women living in theUnited States who have been diagnosed with and treated forbreast cancer.

Cancer survival statistics should be interpreted with caution.These estimates are based on data from thousands of cases

of this type of cancer in the United States each year, but theactual risk for a particular individual may differ. It is not possibleto tell a person how long he or she will live with breast cancer.Because the survival statistics are measured in five-year intervals,they may not represent advances made in the treatment ordiagnosis of this cancer.

Statistics adapted from the American Cancer Societys publication, Cancer Facts &Figures 2009.

Find out more about basic cancer terms used in this section at www.cancer.net/

dictionaryresources.

RISK FACTORSA risk factor is anything that increases a persons chance ofdeveloping cancer. Some risk factors can be controlled, such asphysical activity and diet, and some cannot be controlled, suchas age and family history. Although risk factors can influencethe development of cancer, most do not directly cause cancer.Some people with several risk factors never develop cancer,

while others with no known risk factors do. However, knowingyour risk factors and communicating them to your doctor may


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5RISK FACTORS

help you make more informed lifestyle and health care choices.

Many cases of breast cancer occur in women with no obvious

risk factors. This means that all women need to be aware ofpossible changes in their breasts and schedule a clinical breastexamination (breast exam performed by a doctor or otherhealth care professional) and mammogram (x-ray of thebreast that can detect a tumor that is too small to be felt). Itis likely that multiple risk factors influence the development ofbreast cancer.

The following factors may raise a womans risk of developingbreast cancer:

Age. The risk of developing breast cancer increases as awoman ages, with most cases developing in women over 50.

Race and ethnicity. Although white women are more likely todevelop breast cancer, black women are more likely to die fromthe disease. Reasons for survival differences are unclear andprobably involve both socioeconomic and biologic factors.

Personal history of breast cancer. A woman who has hadbreast cancer in one breast has a 1% to 2% chance per year of

developing a second breast cancer in her opposite breast.

Family history of breast cancer. Women who have a first-degree relative (mother, sister, daughter) diagnosed withbreast cancer are at increased risk for the disease. More thanone first-degree relative with breast cancer elevates that risk,especially if the cancer occurred before menopause. Women

who have a second-degree relative (aunt, niece, grandmother,granddaughter) diagnosed with breast cancer also have ahigher risk of breast cancer. The fathers (paternal) side ofthe family should also be considered equally to the mothers(maternal) side when evaluating a family history. For example,you may be at higher risk if your fathers sister or mother hadbreast cancer.

Genetic predisposition. Mutations to the breast cancergenes 1 or 2 (BRCA1 or BRCA2) are associated with increasedbreast cancer risk. Blood tests are available to test for knownmutations to these genes, but are not recommended foreveryone and only after a person has received appropriategenetic counseling. Men in families may also carry these gene

mutations. Breast cancer in male family members significantlyincreases the risk of having a family breast cancer gene.Researchers estimate that breast cancers due to inherited geneswith high risk for developing cancer make up only 5% to 10%of all breast cancers. If a woman learns she has these geneticmutations, there are steps she can take to lower her risk ofbreast and ovarian cancers. Learn more about the genetics of

breast cancer, genetic testing, and genetic counseling atwww.cancer.net/genetics.


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6 RISK FACTORS

Personal history of ovariancancer. A history of ovarian cancercan increase a womans risk of

breast cancer. Breast cancer genemutations, such as BRCA1 orBRCA2, greatly increase the risk ofboth ovarian and breast cancers.

Estrogen and progesteroneexposure. Estrogen and

progesterone are hormonesin women that control thedevelopment of secondary sexcharacteristics (such as breastdevelopment) and pregnancy. A

womans production of estrogen and progesterone decreases atmenopause. Prolonged exposure to these hormones increases

breast cancer risk.Women who began menstruating before age 11 or went

through menopause after age 55 have a higher risk of breastcancer because their breast cells have been exposed toestrogen and progesterone for a longer time.

Women who have their first pregnancy after age 35 orwho have never had a full-term pregnancy have a higher

risk of breast cancer. Pregnancy may protect against breastcancer, because it pushes breast cells into their final phase ofmaturation.

Recent use (within the past five years) and long-termuse (several years or more) of postmenopausal hormonereplacement therapy increases a womans risk of breast cancer.

Removing the ovaries, a source of estrogen and progesterone,

can greatly lower breast cancer risk; this procedure is called anoophorectomy. Some women with inherited BRCA1 or BRCA2mutations undergo prophylactic oophorectomy as a preventivemeasure to lower their risk of breast and ovarian cancers.

There is no clear link between the use of oral contraceptives(birth control pills) to prevent pregnancy and development ofbreast cancer.

Atypical hyperplasia of the breast. This condition increasesthe risk of breast cancer and is characterized by abnormal, butnot cancerous, cells found in a breast biopsy.

LCIS. As explained in the Overview section, this conditiondescribes abnormal cells found in the lobules or glands of the

breast. LCIS increases the risk of developing invasive breastcancer (cancer that spreads into surrounding tissues). Talk withyour doctor about the best way to monitor this condition.

Lifestyle factors. As with other types of cancer, studiescontinue to show that various lifestyle factors may contribute tothe development of breast cancer.Recent studies have shown that postmenopausal women who

are obese have an increased risk of breast cancer.


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8 SYMPTOMS & DIAGNOSIS

the tool provides a five-year and lifetime estimate of the riskof developing invasive breast cancer. Because it only asks forinformation about breast cancer in first-degree family members

and doesnt include their age at diagnosis, the tool works bestat estimating risk in women without a strong inherited breastcancer risk.

For most women, regular mammography and clinical breastexaminations can help find early signs of breast cancer. Inaddition, women should become familiar with their own

breasts. Checking your own breasts for lumps and changes withbreast self-examination may help if performed correctly. Talkwith your doctor for more information.

Learn more about breast cancer screening and prevention at www.cancer.net/

prevention.

SYMPTOMSWomen with breast cancer may experience breast abnormalitiesor symptoms, but many women do not show any of thesefindings at the time of diagnosis. Many times breast symptomscan be caused by a medical condition that is not cancer. If youare concerned about a breast finding or symptom, please talk

with your doctor.

The signs and symptoms to look for include:New lumps (many women normally have lumpy breasts) or a

thickening in the breast or under the armNipple tenderness, discharge, or physical changes (such as a

nipple turned inward, a persistent sore, or a change in the size

or shape of the breast)Skin irritation or changes, such as puckers, dimples, scaliness,

or new creasesWarm, red, swollen breasts with a rash resembling the skin of

an orange (called peau dorange)Pain in the breast (usually not a symptom of breast cancer, but

should be reported to a doctor)

DIAGNOSISDoctors use many tests to diagnose cancer and determineif it has metastasized. Some tests may also find out whichtreatments may be the most effective. For most types of

cancer, a biopsy (the removal of a small amount of tissue forexamination under a microscope) is the only way to make adefinitive diagnosis of cancer. If a biopsy is not possible, thedoctor may suggest other tests that will help make a diagnosis.Imaging tests may be used to find out whether the cancer hasmetastasized. Your doctor may consider these factors whenchoosing a diagnostic test:Age and medical conditionThe type of cancer suspected


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9DIAGNOSIS

Severity of symptomsPrevious test results

The diagnosis of breast cancer usually begins when a womanor her doctor discovers a mass or abnormal calcification (tinyspot of calcium usually found on an x-ray) on a screeningmammogram, or an abnormality in the womans breast byclinical examination or self-examination. Several tests may bedone to confirm a diagnosis of breast cancer. Not every personwill have all of these tests.

In addition to screening mammography, the following tests maybe used to diagnose breast cancer:

Imaging testsDiagnostic mammography.Diagnostic mammography

is similar to screeningmammography except that moreviews (pictures) of the breastare taken, and it is often usedwhen a woman is experiencingsigns, such as nipple dischargeor a new lump. Diagnostic

mammography may also be usedif something suspicious is foundon a screening mammogram.

Ultrasound. An ultrasound useshigh-frequency sound waves tocreate an image of the breast

tissue. An ultrasound may distinguish between a solid mass,which may be cancer, and a fluid-filled cyst, which is usuallynot cancer.

MRI. An MRI uses magnetic fields, not x-rays, to producedetailed images of the body. A contrast medium (a special dye)may be injected into a patients vein to create a clearer picture.

An MRI may be used once a woman has been diagnosed withcancer to check the other breast for cancer, but the benefit ofthis is questionable. It may also be used for screening. Accordingto the American Cancer Society, women at high risk for breastcancer (for example, women with BRCA gene mutations ora strong family history of breast cancer) should receive MRI

screening along with a mammogram. MRI is often better thanmammography and ultrasound at finding a small mass in awomans breast, especially for women with very dense breasttissue. However, an MRI has the risk of having a higher rate offalse-positive test results (a test result that indicates cancer whenthere is no cancer present) and may result in more biopsies andother tests. In addition, an MRI does not show calcifications,

which could indicate in situ breast cancer (DCIS). Talk with yourdoctor for more information.


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10 DIAGNOSIS

Surgical testsBiopsy. A biopsy is the removal of a small amount of tissuefor examination under a microscope. Other tests can suggest

that cancer is present, but only a biopsy can make a definitediagnosis. The sample removed from the biopsy is analyzed by apathologist (a doctor who specializes in interpreting laboratorytests and evaluating cells, tissues, and organs to diagnosedisease). A biopsy is specified by the technique and/or size ofneedle used to collect the tissue sample.A fine needle aspiration biopsy (FNAB) uses a small needle to

remove a small sample of cells.A core needle biopsy uses a larger needle to remove a larger

sample of tissue. This is usually the preferred biopsy techniquefor determining whether a physical exam or imaging finding iscancer. A vacuum-assisted biopsy removes multiple large coresof tissue.

A surgical biopsy removes the largest amount of tissue. This

biopsy may be incisional (removal of part of the lump) orexcisional (removal of the entire lump). Because definitivesurgery is optimally done after a cancer diagnosis has beenmade, a surgical biopsy is usually not the recommendedapproach to determining whether an abnormality iscancerous. If a surgical biopsy confirms cancer, then furthersurgery is usually required to remove remaining cancer in the

breast and evaluate the lymph nodes. Therefore, in orderto keep surgery to one operation, its best when a patientreceives a core biopsy to diagnose the cancer, followed by thetype of cancer surgery with the best chance at removing all ofthe disease, as determined by the doctor.

Image-guided biopsy is used when a distinct lump cant befelt, but an abnormality is seen on a radiologic image such

as a mammogram. During this procedure, a needle is guidedto the area of concern with the help of mammography,ultrasound, or MRI. A stereotactic biopsy is performed withmammography guidance. A small metal clip may be put intothe breast to mark the site of biopsy, in case the sampletissue proves cancerous and additional surgery is required. Animage-guided biopsy can be done using a fine needle, core, or

vacuum-assisted biopsy, depending on the amount of tissuebeing removed.

If cancer is diagnosed, surgery is needed to remove the cancerin the breast and evaluate the lymph nodes for the presenceof cancer (discussed in the Treatment section). The goal is toachieve clear surgical margins (no cancer cells at the edge of the

tissue removed during surgery). If lymph nodes show evidenceof cancer, the cancer is called lymph node-positive breast cancer(or node-positive for short); if the lymph nodes do not showevidence of cancer, the cancer is called lymph node-negativebreast cancer (or node-negative for short).

Additional information about lymph node evaluation can be found in the

Staging section.


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11DIAGNOSIS

Testing the tissueThe pathologist tests the tissue from the biopsy and the surgeryfor the following to help guide treatment decisions:

Tumor features. Examination of the tumor under themicroscope determines if it is invasive or in situ; ductal orlobular; grade (how different the cancer cells look from healthycells); and whether the cancer has spread to the lymph nodes.The margins (edges) of the tumor are also examined.

Estrogen receptor (ER) and progesterone receptor (PR)tests. Breast cancer cells with these receptors depend on thehormones estrogen and progesterone to grow. The presenceof these receptors helps determine both the patients prognosis(chance of recovery) and whether the cells are likely to respondto hormone therapy. Generally, ER-positive or PR-positive tumorsrespond to hormone therapy. About 75% to 80% of breast

cancers express estrogen and/or progesterone receptors.

HER2 tests. There is too much of the protein called humanepidermal growth factor receptor two (HER2) in about 20% to25% of invasive breast cancers, and this type of cancer is calledHER2-positive cancer. The HER2 status helps determine whethera drug, such as trastuzumab (Herceptin), might be useful for

treating breast cancer. Read ASCOs recommendations for HER2testing for breast cancer at www.cancer.net/whattoknow.

If a persons tumor does not have ER, PR, and HER2, the tumoris called triple-negative. Triple-negative breast cancers compriseabout 15% of invasive breast cancers. This subtype of breastcancer is frequently more aggressive, and seems to be more

common among black women and younger women diagnosedwith breast cancer.

Testing a tumors genesTests that look at the biology of the tumor are becoming morecommon to understand more about a womans breast cancer.The tests below look at the expression of genes in a tumor

sample to predict the risk of cancer recurrence. A person with ahigher risk of recurrence will likely receive additional treatment,while a person with a lower risk of recurrence can avoid extratreatment and its possible side effects. For more informationabout these tests, what they mean, and how it might affectyour treatment plan, talk with your doctor.Oncotype Dx is a test that evaluates 21 genes to estimate the

risk of distant recurrence (return of the cancer in a place otherthan the breast) at 10 years for women with stage I or stageII (see the Staging section) node-negative, ER-positive breastcancer treated with hormone therapy alone. It is mainly usedto help make decisions about whether chemotherapy shouldbe added to a persons treatment.

Mammaprint is another, similar test using about 70 genes to

predict the risk of the cancer coming back. It is approved in


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early-stage, low-risk breast cancer. Although it is approved bythe U.S. Food and Drug Administration (FDA) for estimatingthe risk of recurrence in early-stage breast cancer, it requires a

frozen sample of tumor, which is not how cancer samples aregenerally collected and stored in the United States, therebylimiting its use.

Blood testsThe doctor may also need to do blood tests to learn more aboutthe cancer.

A serum chemistry panel is frequently done to evaluate bloodelectrolytes (minerals in your body, such as potassium andcalcium) and enzymes (specialized proteins) that can be abnormalif cancer has spread. However, it is important to note that manynoncancerous conditions can cause variations in these tests, andthey are not specific to cancer.

Alkaline phosphatase is an enzyme that can be associatedwith disease that has spread to the liver, bone, or bile ducts.Blood calcium levels can be elevated if cancer has spread to

the bone.Total bilirubin count and the enzymes alanine

aminotransferase (ALT) and aspartate aminotransferase(AST) evaluate liver function. High levels of any of these

substances can indicate liver damage, a signal of possiblespread to that organ.

Blood tumor marker tests

A serum tumor marker (also called a biomarker) is a substancefound in a persons blood that can be associated with thepresence of cancer. An elevated serum tumor marker may

indicate an abnormal process in the body, which could be dueto cancer or a noncancerous condition. Tumor marker testingis not usually recommended in early-stage breast cancer, butthese markers may be useful in the follow-up care of recurrentor metastatic disease. Common tumor marker assays in breastcancer include CA27.29, CA15-3, and CEA.

Learn more about tumor markers for breast cancer at www.cancer.net/whattoknow.

Additional testsThe doctor may order additional tests (depending on theindividuals medical history and results of the physicalexamination) to evaluate the stage of the cancer. Read the

Staging section for more information. These tests are generallyonly recommended for patients with more advanced stagedisease.A chest x-ray may be used to look for cancer that has spread

from the breast to the lung.A bone scan may be used to look for spread to the bones. A

bone scan uses a radioactive tracer to look at the inside of the

bones. The tracer is injected into a patients vein. It collects inareas of the bone and is detected by a special camera. Healthy


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bone appears gray to the camera, and areas of injury, such asthose caused by cancer, appear dark.

A computed tomography (CT or CAT) scan may be used to

look for distant tumors. A CT scan creates a three-dimensionalpicture of the inside of the body with an x-ray machine.A computer combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors.Sometimes, a contrast medium is injected into a patients veinto provide better detail.

A positron emission tomography (PET) scan may be used to

determine whether the cancer has spread. A PET scan is away to create pictures of organs and tissues inside the body.A small amount of a radioactive substance is injected into apatients body and absorbed by the organs or tissues beingstudied. This substance gives off energy that is detected by ascanner, which produces the images.

Learn more about what to expect when having common tests, procedures, andscans at www.cancer.net/tests.

Find out more about common terms used during a diagnosis of cancer at

www.cancer.net/dictionaryresources.

STAGINGStaging is a way of describing a cancer, such as where it islocated, if or where it has spread, and if it is affecting thefunctions of other organs in the body. Doctors use diagnostictests to determine the cancers stage, so staging may not becomplete until all the tests are finished. Knowing the stagehelps the doctor to decide what kind of treatment is best and

can help predict a patients prognosis. There are different stagedescriptions for different types of cancer.

One tool that doctors use to describe the stage is the TNMsystem. This system uses three criteria to judge the stage of thecancer: the size of the tumor itself, the presence of cancer inthe lymph nodes around the tumor, and whether the tumor has

spread to other parts of the body. The results are combined todetermine the stage of cancer for each person. There are fivestages: stage 0 (zero) which is non-invasive ductal carcinomain situ (DCIS), and stages I through IV (one through four) forinvasive breast cancer. The stage provides a common way ofdescribing the cancer so doctors can work together to plan thebest treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis(M). Doctors look at these three factors to determine the stageof cancer:How large is the primary tumor and where is it located?

(Tumor, T)Has the tumor spread to the lymph nodes? (Node, N)Has the cancer metastasized to other parts of the body?

(Metastasis, M)


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Tumor. Using the TNM system, the T plus a letter or number(0 to 4) is used to describe the size and location of the tumor.Some stages are divided into smaller groups that help describe

the tumor in even more detail.

Node. The N in the TNM staging system stands for lymphnodes. Lymph nodes located under the arm, above and belowthe collarbone, and under the breastbone are called regionallymph nodes. Lymph nodes in other parts of the body are calleddistant lymph nodes.

If there is cancer in the lymph nodes, it also helps doctors toplan treatment to know how many lymph nodes are involved.The pathologist can determine the number of axillary lymphnodes affected by cancer. It is not common to remove thesupraclavicular or internal mammary lymph nodes at the timeof surgery. Rather, if involvement of these nodal groups is

suspected or confirmed they are included in radiation treatmentfields when planning treatment.

Distant metastasis. The M in the TNM system indicateswhether the cancer has spread to other parts of the body.

For specific information on substages for T, N, and M, visit www.cancer.net/breast.

Cancer stage groupingDoctors assign the stage of the cancer by combining the T, N,and M classifications.

Stage 0: Disease that has not spread past the naturalboundaries of the breast. It is also called noninvasive cancer.

Stage I: The tumor is small and has not spread to thelymph nodes.

Stage IIa: Any one of these conditions:The tumor is smaller than or equal to 2 centimeters (cm) and

has spread to the axillary lymph nodes under the arm.

The tumor is larger than 2 cm but not larger than 5 cm andhas not spread to the axillary lymph nodes.

There is no evidence of a tumor in the breast, but there iscancer in the axillary lymph nodes.

Stage IIb: Any one of these conditions:The tumor is larger than 2 cm but not larger than 5 cm and

has spread to the axillary lymph nodes.The tumor is larger than 5 cm but has not spread to the

axillary lymph nodes.

Stage IIIa: Any of these conditions:The tumor is smaller than 5 cm and has spread to the axillary

lymph nodes.The tumor is larger than 5 cm and has spread to the axillary

lymph nodes.


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15STAGING

Illustration of breast cancer at stage I.

Illustration of breast cancer at stage IIa.

Illustration of breast cancer at stage IIb.


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16 STAGING

Illustration of breast cancer at stage IIIa.

Illustration of breast cancer at stage IIIb.

Illustration of breast cancer at stage IIIc.


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17TREATMENT

Illustration of breast cancer at stage IV.

Anatomical and staging illustrations for many types of cancer are available at

www.cancer.net.

Stage IIIb: The tumor has spread to the chest wall orcaused swelling or ulceration of the breast or is diagnosed asinflammatory breast cancer. It may or may not have spread tothe lymph nodes under the arm, but has not spread to other

parts of the body.

Stage IIIc: A tumor of any size that has not spread to distantparts of the body but has spread to 10 or more lymph nodesunder the arm and elsewhere.

Stage IV (metastatic): The tumor can be any size and has

spread to distant sites in the body, usually the bones, lungs orliver, or chest wall. Metastatic cancer spread is found at the timeof breast cancer diagnosis about 5% to 6% of the time. Mostcommonly, metastatic breast cancer is the result of a recurrencemany months to years following the original cancer diagnosisand treatment.

Recurrent: Recurrent cancer is cancer that comes back aftertreatment.

Used with permission of the American Joint Committee on Cancer (AJCC),

Chicago, Illinois. The original source for this material is the AJCC Cancer Staging

Manual Sixth Edition (2002) published by Springer-Verlag New York,

www.cancerstaging.net.

TREATMENTThe treatment of breast cancer depends on the size and locationof the tumor, whether the cancer has spread, and the personsoverall health. In many cases, a team of doctors will work withthe patient to determine the best treatment plan.

This section outlines treatments that are the standard of care


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18 TREATMENT

(the best treatments available) for this specific type of cancer.Patients are also encouraged to consider clinical trials whenmaking treatment plan decisions. A clinical trial is a research

study to test a new treatment to prove it is safe, effective, andpossibly better than standard treatment. Your doctor can helpyou review all treatment options. For more information, read theClinical Trials section.

Overview of breast cancer treatmentThe biology and behavior of a breast cancer affects the

treatment. Some tumors are small but grow fast, while othersare large and grow slower. When planning the treatment forbreast cancer, the doctor will consider many factors, including:The stage and grade of the tumorThe tumors hormone receptor status (ER, PR) and HER2 status

(see the Diagnosis section)The patients age and general health

The patients menopausal statusThe presence of known mutations in inherited breast cancer

genes (BRCA1 or BRCA2)

Even though the doctor will specifically tailor the treatment foreach patient and the breast cancer, there are some general stepsfor treating breast cancer.

For both DCIS and early-stage invasive breast cancer, doctorsgenerally recommend surgery to remove the tumor. To ensurethat the entire tumor is removed, the surgeon will also removea small area of tissue around the tumor. Although surgery aimsto remove all of the visible cancer, it is known that many timesmicroscopic cells can be left behind, either in the breast or

elsewhere.

The next step in the management of early-stage breast canceris to lower the risk of recurrence (return of the cancer) andto get rid of any hidden remaining cancer cells. This is calledadjuvant therapy. Adjuvant therapies include radiation therapy,chemotherapy, hormone therapy, and/or targeted therapy (see

below for more information on these types of treatment). Theneed for adjuvant therapy is determined based on an estimateof the chance of residual cancer in the breast or the body.Although adjuvant therapy lowers the risk of recurrence, it doesnot necessarily eliminate it.

Along with staging, other sophisticated tools can help

determine prognosis and help you and your doctor makedecisions about adjuvant therapy. The website Adjuvant! Online(www.adjuvantonline.com) is one such tool that your doctor canaccess to interpret a variety of prognostic factors. This websiteshould only be used with the interpretation of your doctor. Inaddition, other tests that can predict the risk of recurrence (suchas Oncotype Dx and Mammaprint; see the Diagnosis section)

may be used to find out whether your doctor recommendsadjuvant chemotherapy.


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When surgery to remove the cancer is not possible,chemotherapy, radiation therapy, hormone therapy, and/ortargeted therapy may be used.

The treatment of recurrent cancer and metastatic cancerdepends on how the cancer was first treated and thecharacteristics of the cancer mentioned above (such as ER, PR,and HER2 status).

Additional descriptions of the most common treatment options

for breast cancer are listed below.

SurgerySurgery is performedto remove thetumor in the breastand to evaluate

the surroundingaxillary (underarm)lymph nodes. Asurgical oncologistis a doctor whospecializes in treatingcancer using surgery.

Generally, thesmaller the tumor, the more surgical options a patient has. Thetypes of surgery include the following:A lumpectomy is the removal of the tumor and a small, clear

(cancer-free) margin of tissue around the tumor. Most of thebreast remains. For both DCIS and invasive cancer, follow-upradiation therapy to the remaining breast tissue is generally

recommended. A lumpectomy may also be called breast-conserving surgery, a partial mastectomy, or a segmentalmastectomy.

A mastectomy is the surgical removal of the entire breast.

Lymph node removal and analysis

Lymph nodes can trap cancer cells traveling away from the

original tumor site. It is important to find out whether any of thelymph nodes near the breast contain evidence of cancer.

In an axillary lymph node dissection, the surgeon removesmany of the lymph nodes from under the arm, which are thenexamined by a pathologist for cancer cells. The actual numberof nodes removed varies.

Sentinel lymph node biopsy

The sentinel lymph node biopsy procedure allows for theremoval of one to a few lymph nodes, reserving a bigger axillarylymph node dissection procedure for patients whose sentinellymph nodes show evidence of cancer. The smaller lymph nodeprocedure helps patients lower the risk of lymphedema (swelling

of the arm) and decreases arm mobility and range-of-motionproblems.


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20 TREATMENT

In this procedure, the surgeon finds and removes the sentinel(first) lymph node (as a practical matter, one to three nodes)that receives drainage from the breast. The pathologist then

examines it for cancer cells. To identify the sentinel lymph node,the surgeon injects a dye and/or a radioactive tracer into thearea of the cancer and/or around the nipple. The dye or tracertravels to the lymph nodes, arriving at the sentinel node first.The surgeon can find the node when it turns color (if the dye isused) or emits radiation (if the tracer is used).

If the sentinel node is cancer-free, research has shown thatthere is a good possibility that the subsequent nodes will alsobe free of cancer and no further surgery of the lymph nodes isperformed. If the sentinel lymph node shows cancer is present,then the surgeon will perform an axillary lymph node dissection,removing additional lymph nodes to look for the presence ofmore cancer. Find out more about ASCOs recommendations for

sentinel lymph node biopsy at www.cancer.net/whattoknow.

Most patients with invasive cancer will undergo either sentinellymph node biopsy or an axillary lymph node dissection. Forthose with sentinel nodes that indicate cancer, an axillary lymphnode dissection is still considered the standard procedure. Ifthere is obvious evidence of cancer in the lymph nodes before

any surgery, then the preferred approach is a full axillary lymphnode dissection without a sentinel lymph node biopsy.

Reconstructive (plastic) surgery

Women who undergo a mastectomy may wish to considerbreast reconstruction, which is surgery to rebuild the breast.Reconstruction may be done with tissue from another part of

the body, or with synthetic implants. A woman may be able tohave this done at the same time as a mastectomy (immediatereconstruction) or at some point in the future (delayedreconstruction). In addition, reconstruction may be done aftera lumpectomy to improve the look of the breast. Talk with yourdoctor for more information.

Read more about after a mastectomy, preventing lymphedema after breastcancer treatment, breast reconstruction, and choosing a breast prosthesis at

www.cancer.net/features.

Summary

To summarize, surgical treatment options include the following:Removal of cancer in the breast: Lumpectomy (partial

mastectomy) almost always followed by radiation therapy ormastectomy, with or without immediate reconstruction

Lymph node evaluation: Sentinel lymph node biopsy and/oraxillary lymph node dissection

Women are encouraged to talk with their doctors about whichsurgical option is right for them. More aggressive surgery

(such as a mastectomy) is not always better and may result inadditional complications. The combination of lumpectomy and


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21TREATMENT

radiation therapy has a higher risk of the cancer coming back inthe same breast or near the breast, but the long-term survivalof women is the same as those who have a mastectomy. Hear

from an ASCO expert on mastectomy vs. lumpectomy atwww.cancer.net/features.

Learn more about cancer surgery at www.cancer.net/features.

Radiation therapyRadiation therapy is the use of high-energy x-rays or other

particles to kill cancer cells. A doctor who specializes in givingradiation therapy to treat cancer is called a radiation oncologist.The lowest risks of cancer recurrence in the breast afterlumpectomy are associated with the use of radiation therapy.Early randomized clinical trials showed, in general, recurrencerates of 30% or more without radiation therapy, compared with10% recurrence rates with radiation therapy.

After surgery, adjuvant radiation therapy is given regularlyfor a number of weeks after a lumpectomy to eliminate anyremaining cancer cells near the tumor site or elsewhere withinthe breast. Adjuvant radiation therapy is also recommended forsome women after a mastectomy depending upon the size oftheir tumor, number of cancerous lymph nodes under the arm,

and width of the tissue margin around the tumor removed bythe surgeon.

Adjuvant radiation therapy is effective in reducing the chanceof breast cancer returning in both the breast and the chestwall. Neoadjuvant radiation therapy is radiation therapy givenbefore surgery to shrink a large tumor, which makes it easier to

remove, although this approach is rare.Radiation therapy can cause side effects, including fatigue,swelling of the breast, and skin changes. A small amount ofthe lung can be affected by the radiation, although the risk ofpneumonitis, or a radiation-related inflammation of the lungtissue, is low. In the past, with older equipment and techniques

of radiation therapy, women treated for left-sided breast cancershad a small increase in the long-term risk of heart disease.Modern techniques are now able to spare most of the heartfrom radiation damage.

Although exposure to radiation is thought to be a risk factorfor cancer after many years, less than one in 500 survivors will

develop a different kind of cancer other than a breast cancer(usually a type of cancer called sarcoma), within the area thatwas treated. Clinical trials comparing lumpectomy and adjuvantradiation therapy with mastectomy have not shown a differencein the number of patients developing or dying of other cancerswithin a 20-year time span.

The most common type of radiation treatment is called externalbeam radiation therapy, which is radiation therapy given from


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22 TREATMENT

a machine outside the body. Many types of radiation therapymay be available to you; talk with your doctor about theoptions, advantages, and disadvantages of these options.

Radiation therapy schedule

Standard radiation therapy after a lumpectomy is external-beam radiation therapy given daily for five days per week(Monday through Friday) for six to seven weeks. This usuallyincludes radiation therapy to the whole breast first for four-and-a-half to five weeks, followed by a more focused treatment

to the site of the tumor bed in the breast for the remainingtreatments.

This focused part of the treatment, called a boost, is standardfor women with invasive breast cancer to reduce the risk of arecurrence in the breast. If there is evidence of cancer in theunderarm lymph nodes, radiation therapy may also be given to

the lymph node areas in the neck or underarm near the breastor chest wall. Usually, patients who undergo mastectomy donot require radiation therapy. However, for patients with largecancers, many involved lymph nodes, or extension of cancerinto the skin or chest wall, radiation may still be recommendedafter a mastectomy. Standard radiation therapy after amastectomy is given to the chest wall for five days (Monday

through Friday) for five to six weeks.

There has been growing interest in newer radiation regimens(schedules) to shorten the length of treatment from six to sevenweeks to periods of three to four weeks. In one method (calledhypo-fractionated radiation therapy), a higher daily dose isgiven to the whole breast each day so that the overall length

of treatment is shortened to three to four weeks. This canalso be combined with a higher dose given to the tumor bedin the breast either during or after the whole breast radiationtreatments. Clinical trials from Canada and the United Kingdomhave shown that these shorter schedules can be equallyaccepted by patients with the same cancer control rates andside effects as longer radiation treatment schedules in patients

with node-negative breast cancer. These shorter schedules maybecome more accepted in the United States and are one wayto improve the convenience and time required to complete acourse of radiation (see also partial breast irradiation below).

Partial breast irradiation

Partial breast irradiation (PBI) is radiation therapy that is given

directly to the tumor area, usually after a lumpectomy, insteadof the entire breast, as is routinely done with standard radiationtherapy. Targeting the radiation to the tumor area more directlyusually shortens the amount of time that patients need toundergo radiation therapy.

When radiation treatment is given using localized radiation

delivery methods, it is called brachytherapy. Brachytherapy caninvolve the implantation of small radioactive pellets, placed in


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23TREATMENT

or near the site of the breast tumor, or within plastic cathetersplaced temporarily in the breast. Mammosite is a type of ballooncatheter placed near the breast that delivers radiation therapy.

Most types of breast brachytherapy involve short treatmenttimes, ranging from one dose to one week.

Additionally, PBI can be done with standard external-beamradiation therapy that is focused on the area of the tumor bedand not the entire breast. However, only some patients maybe eligible for PBI. Although preliminary results have been

promising, PBI is still being studied. It is the subject of a large,nationwide clinical trial, and the results proving the safetyand effectiveness compared with standard radiation therapyare pending. This trial will help determine which patients andtumors are the best candidates for PBI.

Intensity-modulated radiation therapy

Intensity-modulated radiation therapy (IMRT) is a moreadvanced way to deliver external-beam radiation therapy tothe breast. The intensity of the radiation directed at the breastis varied to target the tumor more precisely, give a uniformdistribution of radiation throughout the breast tissue, and avoiddamaging healthy tissue more than is possible with traditionalradiation treatment. IMRT may reduce the dose to nearby

important organs, such as the heart and lung, and reduce therisks of some immediate side effects, such as peeling of the skinduring treatment. This can be especially important for womenwith medium to large breasts who are at greater risk for sideeffects such as peeling and burns, compared with women withsmaller breasts. IMRT also may help to reduce long-term effectson the breast tissue that were common with older radiation

techniques such as hardness, swelling, or discoloration.

Adjuvant radiation therapy concerns for older patients

and/or those with small tumors

Recent studies have looked at the consequences of usingno radiation therapy for women age 70 or older or forthose women with a small tumor size. Overall, these studies

demonstrate that radiation therapy minimizes the risk of breastcancer recurrence in the same breast, compared with noradiation therapy, but does not affect overall survival. Guidelinesfrom the National Comprehensive Cancer Network (NCCN)continue to recommend radiation therapy as the standardoption after lumpectomy. However, they also indicate thatwomen with special personal or tumor characteristics (such

being age 70 or older and having other medical conditions thatcould limit life expectancy within five years, a small tumor, noevidence of cancer in the lymph nodes or surgical margins, andan ER-positive cancer) could reasonably choose not to haveradiation therapy and use hormone therapy (see below) aloneafter lumpectomy, if they are willing to accept a higher risk rateof local recurrence.

Learn more about radiation therapy at www.cancer.net/features.


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24 TREATMENT

ChemotherapyChemotherapy is the use of drugs to kill cancer cells. Systemicchemotherapy is delivered through the bloodstream, targeting

cancer cells throughout the body. Chemotherapy is given by amedical oncologist, a doctor who specializes in treating cancerwith medication. Most people with breast cancer receivechemotherapy in their doctors office or outpatient clinic. Anadjuvant chemotherapy regimen consists of a specific treatmentschedule of drugs given at repeating intervals for a specificnumber of times.

Chemotherapy may be given intravenously (injected into avein) or occasionally orally (by mouth), and is usually given incycles. Chemotherapy may be given before surgery to bothshrink a large tumor and reduce the risk of recurrence or givenafter surgery to reduce the risk of recurrence. Chemotherapy isalso commonly given at the time of a metastatic breast cancer

recurrence. Patients in clinical trials may be offered new drugs ornew combinations of existing drugs.

The side effects of chemotherapydepend on the individual and thedrug and the dose used, but caninclude fatigue, hair loss, risk of

infection, nausea and vomiting, lossof appetite, and diarrhea. Theseside effects usually go away oncetreatment is finished. Rarely, long-term side effects may occur, suchas heart damage, nerve damage, orsecondary cancers, but studies have

shown that these side effects do notshorten a womans survival time.

Different drugs are useful for different types of cancer, andresearch has shown that combinations of certain drugs aresometimes more effective than individual ones. The followingdrugs or combinations of drugs may be used as adjuvant

therapy to treat breast cancer:Cyclophosphamide (Cytoxan)Methotrexate (multiple brand names)Fluorouracil (5-FU, Adrucil)Doxorubicin (Adriamycin)Epirubicin (Ellence)Paclitaxel (Taxol)Docetaxel (Taxotere)CMF (cyclophosphamide, methotrexate, and 5-FU)CAF (cyclophosphamide, doxorubicin, and 5-FU)CEF (cyclophosphamide, epirubicin, and 5-FU)EC (epirubicin and cyclophosphamide)AC (doxorubicin and cyclophosphamide)TAC (docetaxel, doxorubicin, and cyclophosphamide)AC followed by T (doxorubicin and cyclophosphamide,

followed by paclitaxel)


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25TREATMENT

TC (docetaxel and cyclophosphamide)

Trastuzumab (Herceptin), a HER2 targeted therapy (see below),

may also be given with chemotherapy as an adjuvant treatmentin HER2-positive breast cancer.

In addition to the drugs and combinations of drugs listed above,the following additional drugs may be used to treat recurrent ormetastatic breast cancer, either individually or in combination:Vinorelbine (Navelbine)

Capecitabine (Xeloda)Protein bound paclitaxel (Abraxane)Pegylated liposomal doxorubicin (DOXIL, Dox-SL, Evacet,

LipoDox)Gemcitabine (Gemzar)Carboplatin (Paraplat, Paraplatin)Cisplatin (Platinol)

Ixabepilone (Ixempra)

Trastuzumab and lapatinib (Tykerb) are HER2-targeted therapiesthat may be given with chemotherapy in HER2-positivemetastatic breast cancer. Bevacizumab (Avastin), a blood vesselblocking drug (called anti-angiogenic), is another targetedtherapy approved in combination with chemotherapy in the

treatment of metastatic breast cancer. (See the Targeted Therapysection below.)

Learn more about chemotherapy and preparing for treatment at www.cancer.net/

features. The medications used to treat cancer are continually being evaluated.

Talking with your doctor is often the best way to learn about the medications

prescribed for you, their purpose, and their potential side effects or interactions

with other medications. Learn more about your prescriptions by using searchable

drug databases at www.cancer.net/druginforesources.

Hormone therapyHormone therapy helps manage a tumor that tests positive foreither estrogen or progesterone receptors in both early-stageand metastatic cancer. This type of tumor uses hormones to fuelits growth. Blocking the hormones usually limits the growth of

the tumor.

If it is determined that the tumor is hormone receptor-positive(ER-positive or PR-positive; see the Diagnosis section), thenadjuvant hormone treatment may be used alone or afterchemotherapy. Examples of hormone therapy used as adjuvanttherapy are tamoxifen, anastrozole (Arimidex), letrozole

(Femara), and exemestane (Aromasin).

Tamoxifen is the drug that researchers have studied the longestfor use as a hormone therapy. It blocks estrogen from bindingto breast cancer cells. It has been shown to be effective forreducing the risk of recurrence in the treated breast, the risk ofdeveloping cancer in the other breast, and the risk of distant

recurrence. It is also approved for the chemoprevention of breastcancer in women at high risk for developing the disease and for


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26 TREATMENT

reducing local recurrence in DCIS. Current research shows thatthe optimal duration of adjuvant tamoxifen is five years.

Tamoxifen is a pill that is taken daily by mouth. The side effectsof tamoxifen include hot flashes, vaginal dryness, dischargeor bleeding, a small increased risk of uterine (endometrial)cancer and uterine sarcoma, and an increase in the risk ofblood clots. Tamoxifen actually has favorable effects on thebone and cholesterol levels, resulting in less osteoporosis andlower cholesterol levels. Tamoxifen can be effective for both

premenopausal and postmenopausal women.

An aromatase inhibitor (AI) decreases the amount of estrogenin postmenopausal women by blocking the aromatase enzyme,which is needed to make estrogen. These drugs includeanastrozole, letrozole, and exemestane. All of the AIs are pillstaken daily by mouth. The side effects of AIs may include

muscle and joint pain, hot flashes, vaginal dryness, an increasedrisk of osteoporosis and fractures (broken bones), and increasesin cholesterol. Clinical trials are evaluating whether womenbenefit by taking an AI for more than five years. Studies arealso evaluating sequences of taking tamoxifen and AIs (takingboth together has been shown to be suboptimal). These drugsare not appropriate for women who have not gone through

menopause. Learn more about AIs for early breast cancer atwww.cancer.net/whattoknow.

Tamoxifen and AIs are also commonly used to treat metastaticrecurrences. In addition, fulvestrant (Faslodex) is a hormonetherapy approved for patients with metastatic cancer.Fulvestrant is in a class called selective estrogen receptor

downregulators (SERDs). Unlike the other oral hormonaltherapies used to treat breast cancer, fulvestrant is givenmonthly by intramuscular injection. Its side effects are due toit being a complete estrogen blocker, and include menopausalsymptoms such as hot flashes and vaginal dryness.

Targeted therapy

Targeted therapy is a treatment that targets genes or proteinsthat contribute to cancer growth and development, or the tissueenvironment that surrounds the cancer and helps it grow andsurvive. Currently the two main classes of biologically targetedtherapy approved in breast cancer treatment are targeted to theHER2 molecule (HER2 targeted therapy) and the blood vesselsin the area of the tumor (anti-angiogenic therapy). Learn more

about targeted treatments at www.cancer.net/features.

HER2 targeted therapy

Trastuzumab is approved for both the treatment of advancedbreast cancer and as an adjuvant therapy for early-stagebreast cancer for HER2-positive tumors. At this time, one yearof trastuzumab is recommended for early-stage breast cancer.

In the metastatic setting, the length of treatment is not limited(it is given as long as it is still working). Patients receiving


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27TREATMENT

trastuzumab have a small (2% to 5%) risk of heart problems,and this risk is increased if a patient has other risk factors forheart disease. These heart problems do not always go away,

but they are usually treatable with medication.Lapatinib is commonly used in women with HER2-positivebreast cancer that no longer responds to trastuzumab. Thecombination of lapatinib and capecitabine is approved forthe treatment of women with advanced or metastatic HER2-positive breast cancer who have previously been treated withchemotherapy and trastuzumab.

Anti-angiogenic targeted therapy (blood vessel

blocking therapy)

Bevacizumab is used to treat metastatic or recurrent breastcancer (see below). This drug blocks angiogenesis (the formationof new blood vessels), which is needed for tumor growth andmetastasis. When combined with paclitaxel, bevacizumab

appears to shrink the tumor and keep it smaller for a longertime in women whose breast cancer has spread compared withpaclitaxel alone. Recent studies have shown a benefit of addingbevacizumab to other chemotherapy as well.

Anti-osteoclast targeted therapy (drugs that block

bone destruction)

Bisphosphonates are a class of drugs that block the cellsthat cause bone destruction (osteoclasts). Bisphosphonatesare commonly used in relatively low doses to prevent andtreat osteoporosis. In patients with breast cancer that hasspread to bone, higher doses of bisphosphonates have beenshown to reduce the complications of cancer in the bone,including bone fractures and pain. Pamidronate (Aredia) and

zoledronic acid (Zometa) are two intravenous bisphosphonatesused to treat breast cancer bone metastasis. Recent studieshave suggested that these drugs may also be able to reducebreast cancer recurrences when given in the adjuvant setting,although more data are needed.

Denosumab (Prolia) is in another new class of osteoclast-targeted therapies called RANK ligand inhibitors. Although not

yet approved for patients with breast cancer, recent studieshave shown great promise of these drugs in treating breastcancer bone metastases and osteoporosis.

Learn more about bisphosphonates for breast cancer at www.cancer.net/

whattoknow.

Recurrent and metastatic breast cancerBreast cancer is called recurrent if the cancer has come backafter it was first diagnosed and treated. It may come back inthe breast (a local recurrence); in the chest wall (a regionalrecurrence); or in another part of the body, including distantorgans such as the lungs, liver, and bones. A local recurrenceis frequently considered curable with further treatment. A

metastatic (distant) recurrence is generally considered incurable,but is frequently treatable. Some patients live years after a


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28 CLINICAL TRIALS RESOURCES

metastatic recurrence of breast cancer. The goal of treatmentfor advanced disease is to prolong survival and/or improvequality of life.

Generally, a recurrence is detected when a person hassymptoms. These symptoms depend on the site of therecurrence and may include:A lump under the arm or along the chest wallBone pain or fractures, which may signal bone metastasesHeadaches or seizures, which may signal brain metastases

Chronic coughing or trouble breathing, which may signal lungmetastasesAbdominal pain or jaundice (yellow skin and eyes), which may

be associated with liver metastases

Other symptoms may be related to the location of metastasisand may include changes in vision, changes in energy levels,

feeling ill, or extreme fatigue. A biopsy of the recurrent site isoften recommended to be certain of the diagnosis and to checkfor ER, PR, and HER2 status, because this may have changedfrom the time of the original diagnosis.

The treatment of metastatic or recurrent breast cancer dependson the previous treatment(s), the time since the original

diagnosis, and the characteristics of the tumor (such as ER, PR,and HER2 status).For women with a local recurrence within the breast after initial

treatment with lumpectomy and adjuvant radiation therapy,the treatment is mastectomy. This usually results in cure.

For women with a local or regional recurrence of the chestwall after an initial mastectomy, resection (surgical removal of

the recurrence) followed by radiation therapy to the chest walland lymph nodes is the treatment, unless radiation therapyhas already been given (radiation therapy cannot usually begiven at full dose to the same area more than once).

Total-body therapies such as chemotherapy, hormone therapyand targeted therapies are generally the primary treatmentin recurrent metastatic cancer. Radiation therapy and surgery

may be used in certain situations for women with a distantmetastatic recurrence. Often radiation is used to treat painfulbone metastases.

Find out more about common terms used during cancer treatment at


CLINICAL TRIALS RESOURCESDoctors and scientists are always looking for better ways totreat patients with breast cancer. A clinical trial is a way totest a new treatment to prove that it is safe, effective, andpossibly better than a standard treatment. The clinical trialmay be evaluating a new drug, a new combination of existing

treatments, a new approach to radiation therapy or surgery, anew method of treatment or prevention, ways to help patients


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29SIDE EFFECTS

manage symptoms, or improve a patients quality of life.Patients who participate in clinical trials are among the firstto receive new treatments before they are widely available.

However, there is no guarantee that the new treatment will besafe, effective, or better than a standard treatment.

Patients decide to participate in clinical trials for many reasons.For some patients, a clinical trial is the best treatment optionavailable. Because standard treatments are not perfect, patientsare often willing to face the added uncertainty of a clinical

trial in the hope of a better result. Other patients volunteer forclinical trials because they know that finding new drugs andother therapies is the only way to make progress in treatingbreast cancer. Even if they do not benefit directly from theclinical trial, their participation may benefit future patients withbreast cancer.

Sometimes people have concerns that, by participating in aclinical trial, they may receive no treatment by being given aplacebo or a sugar pill. The use of placebos in cancer clinicaltrials is rare. When a placebo is used in a study, it is done withthe full knowledge of the participants. Find out more aboutplacebos in cancer clinical trials at www.cancer.net/features.

To join a clinical trial, patients must participate in a processknown as informed consent. During informed consent, thedoctor should list all of the patients options, so that theperson understands the standard treatment, and how the newtreatment differs from the standard treatment. The doctor mustalso list all of the risks of the new treatment, which may or maynot be different from the risks of standard treatment. Finally,

the doctor must explain what will be required of each patient inorder to participate in the clinical trial, including the number ofdoctor visits, tests, and the schedule of treatment. Learn moreabout clinical trials, including patient safety, phases of a clinicaltrial, deciding to participate in a clinical trial, questions to askthe research team, and links to find cancer clinical trials atwww.cancer.net/clinicaltrials.

For specific topics being studied for breast cancer, learn more in the Current

Research section at www.cancer.net/breast.

SIDE EFFECTSCancer and its treatment can cause a variety of side effects.

However, doctors have made major strides in recent yearsin reducing pain, nausea and vomiting, infection, fatigue,and other physical side effects of cancer treatments. Manytreatments used today are less intensive but as effective astreatments used in the past. Doctors and nurses also havemany ways to provide relief to patients when such side effectsdo occur.

Fear of treatment side effects is common after a diagnosis of


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30 AFTER TREATMENT

cancer, but it may be helpful to know that preventing andcontrolling side effects is a major focus of your health careteam. Before treatment begins, talk with your doctor about

possible side effects of the specific treatments you will bereceiving. The specific side effects that can occur depend on avariety of factors, including the type of cancer, its location, theindividual treatment plan (including the length and dosage oftreatment), and the persons overall health.

Ask your doctor which side effects are most likely to happen

(and which are not), which need to be reported right away,when side effects are likely to occur, and how they will beaddressed by the health care team if they do happen. Also, besure to communicate with the doctor and nurses about sideeffects you experience during and after treatment. Learn moreabout the most common side effects of cancer and differenttreatments, along with ways to prevent or control them at

www.cancer.net/sideeffects.

In addition to physical side effects, you may experiencepsychosocial (emotional and social) effects and sexual healthconcerns. Learn more about the importance of addressingsuch needs, including concerns about managing the cost ofyour cancer care at www.cancer.net/patientcare and

www.cancer.net/managingcostofcare.

Learn more about late effects or long-term side effects by reading the After

Treatment section or talking with your doctor.

AFTER TREATMENT

After treatment for breast cancer ends, talk with your doctorabout developing a follow-up care plan. This plan mayinclude regular physical examinations and/or medical teststo monitor your recovery for the coming months and years.Learn more about ASCOs recommendations for breast cancerfollow-up care, including regular physical examinations andmammograms, among other recommendations at www.cancer.

net/whattoknow. In addition, ASCO offers cancer treatmentsummaries and a survivorship care plan at www.cancer.net/treatmentsummaries to help keep track of the breast cancertreatment you received and develop a survivorship care planonce treatment ends. In some instances, patients may be seenat survivorship clinics that specialize in the post-treatmentneeds of people with cancer.

Breast cancer can come back in the breast or other areas ofthe body. The symptoms of a cancer recurrence include a newlump in the breast, under the arm, or along the chest wall;bone pain or fractures; headaches or seizures; chronic coughingor trouble breathing; extreme fatigue; and/or feeling ill. Talkwith your doctor if you have these or other symptoms. The

possibility of recurrence is a common concern among cancersurvivors.


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31AFTER TREATMENT

After surgery (mastectomy or lumpectomy) to treat breastcancer, the breast may be scarred and may have a differentshape or size than before surgery. If lymph nodes were

removed as part of the surgery or affected during treatment,lymphedema (swelling of the hand and/or arm) may occur, andthis is a life-long risk for patients.

Some patients experience breathlessness, a dry cough, and/or chest pain two to three months after finishing radiationtherapy because the treatment can cause swelling and fibrosis

(hardening or thickening) of the lungs. These symptoms areusually temporary. Talk with your doctor if you develop any newsymptoms after radiation therapy or if the side effects are notgoing away.

Patients who received trastuzumab or certain types ofchemotherapy called anthracyclines may be at risk of heart

problems. Talk with your doctor about the best ways to checkfor heart problems.

Women taking tamoxifen should have yearly pelvic exams,because this drug can increase the risk of uterine cancer.Tell your doctor or nurse if you notice any abnormal vaginalbleeding or other new symptoms. Women who are taking

an aromatase inhibitor, such as anastrozole, exemestane, orletrozole, should have a bone density test before they starttreatment and as recommended by their doctor, as these drugsmay cause some bone weakness or bone loss.

In addition, women recovering from breast cancer have othersymptoms that may persist after treatment. Learn about ways of

coping with cancer-related fatigue, a drop in cognitive function(sometimes called chemobrain) at www.cancer.net/features,and other late effects of cancer treatment at www.cancer.net/survivors.

Women recovering from breast cancer are encouraged to followestablished guidelines for good health, such as maintaining a

healthy weight, not smoking, eating a balanced diet, and havingrecommended cancer screening tests. Talk with your doctor todevelop a plan that is best for your needs. Moderate physicalactivity can help rebuild your strength and energy level andmay lower the risk of cancer recurrence. Your doctor can helpyou create a safe exercise plan based upon your needs, physicalabilities, and fitness level.

Find out more about common terms used after cancer treatment is complete at


Read more about these topics at www.cancer.net/features and

www.cancer.net/coping.


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32 QUESTIONS TO ASK THE DOCTOR

QUESTIONS TO ASK THE DOCTORRegular communication with your doctor is important in makinginformed decisions about your health care. Consider asking the

following questions of your doctors:

What type of breast cancer do I have?What is the grade and stage of this disease? What does

this mean?Can you explain my pathology report (laboratory test results)

to me?

What is the hormone status of my tumor? What doesthis mean?What is my HER2 status? What does this mean?What is a sentinel lymph node biopsy? What are the benefits

and risks? Would you recommend it for me?Has the cancer spread to my lymph nodes or anywhere else in

my body?

Could you explain my options for treatment?Am I candidate for a lumpectomy?Do I need a mastectomy? If so, would you recommend an

immediate breast reconstruction (plastic surgery)? What arethe advantages and disadvantages to this?

What clinical trials are available to me?What is the expected timeline for each treatment option?

What are the potential side effects of this treatment?What can be done to ease side effects?How will this treatment affect my daily life? Will I be able to

work, exercise, and perform my usual activities?Who is going to help coordinate my treatment and follow-

up care?If Im worried about managing the costs related to my cancer

care, who can help me with these concerns? Who can helpme understand what aspects of my care are covered by myinsurance?

Could this treatment affect my fertility (ability to have childrenin the future)?

Whom can I contact for supportive and emotional help forme? For my family?

Additional questions to ask your doctors can be found at www.cancer.net/breast.

Patient Information ResourcesFind organizations that offer information for breast cancer atwww.cancer.net/support.


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Dear Partner in the Fight Against Breast Cancer,

We know in the wake of a cancer diagnosis, knowledge

is power. Thats why The ASCO Cancer Foundation bringsyou resources developed through the expertise of theworlds leading cancer doctors. We support breakthroughresearch, education and cancer care programsso you canbe more informed, ask better questions, get involved and beempowered.

Join us in making a world of difference in cancer care.

The Foundations charitable mission is founded upon four coretenets: (1) research is at the heart of progress against cancer,(2) cutting-edge knowledge is essential when it comes totreating people with cancer, (3) getting good cancer care startswith getting good cancer information, and (4) all people with

cancer deserve access to the best possible care.

This year we are celebrating over 25 years of investigatorsupport through our grants programs. We have awarded over$40 million in grants since 1984 to over 600 worthy clinicalresearchers. We are pleased to be able to increase our grantsopportunities each year, but we always have more fundable

grant applications than we are able to fund.

The ASCO Cancer Foundation is also very proud to providesupport for ASCOs patient information resources includingthe award-winning website: Cancer.Net (www.cancer.net).Cancer.Net was developed and approved by the cancer doctorsat ASCO, making it the most up-to-date and trusted resource

for cancer information on the Internet.

If you are a current supporter of The ASCO Cancer Foundation,thank you! For those of you who have not partnered withThe ASCO Cancer Foundation before, we invite you to join usnow. Although we have accomplished much, there is still muchmore to achieve in research, patient education, and quality of

care. There are many ways you can help us make advances andtogether we will make a world of difference in cancer care.

Warmest regards,

Nancy Riese Daly, MS, MPHExecutive Director

The ASCO Cancer Foundation

PS: To learn more or support the work of TheASCO Cancer Foundation, please visit our website:www.ascocancerfoundation.org or call us at 888-220-2839.


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American Society of Clinical Oncology2318 Mill Road, Suite 800 | Alexandria, VA 22314

Phone: 571-483-1300 | Fax: 571-366-9530

www.asco.org | www.cancer.net

For more information about ASCOs patient information resources,

call toll-free 888-651-3038 or e-mail [email protected].

2009 American Society of Clinical Oncology

The ASCO Cancer Foundation funds research and education programs

both in the U.S. and abroad. By harnessing the knowledge of more

than 27,000 oncology professionals in the American Society of Clinical

Oncology (ASCO), we help deliver physician-approved information

directly to those in need. Through these efforts, we improve the lives

of those affected by cancer.

guide to breast cancer

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