Breast Cancer : Determining Therapy, Reconstruction Options

by Food and Drug Administration (FDA)

(Page 3 of 4)

Other means of reversing drug resistance with various agents are under study. One such agent, verapamil (approved for treating high blood pressure), has been shown in laboratory studies to block a cell surface protein that pumps chemotherapy drugs out of a cell, thereby making it drug resistant.

Fortunately, most breast cancers are now detected at the earlier, more treatable stages. (See accompanying article, "Determining Treatment.") Seventy-five to 80 percent of women diagnosed with breast cancer in 1990 had small, localized tumors, and about two-thirds of those had no lymph node involvement. According to the American Cancer Society, the five-year survival rate for localized breast cancer has risen from 78 percent in the 1940s to 91 percent today.

Scientists are continually researching more effective treatments for both early and advanced breast cancer. It is important to remember that cancer risk and survival statistics are averages based on large numbers of people. The chance of developing breast cancer is unique to each individual, as is the chance of recovery of any given patient.

NCI's Bates sums up: "For the medical community, the direction is clear — research. For women, the direction is also clear — take charge. Eat right, avoid a diet and a lifestyle that might increase your risk of cancer. At the age of 40 begin to get mammograms and get them on schedule."

Determining Therapy

Treatment is based on the extent of the disease and the biology of the specific tumor. Evaluation of these factors guides the approach to surgery and, if needed, adjuvant therapy. In addition, a woman's age and menopausal status are significant. Breast cancer tends to be more aggressive in younger, pre-menopausal women.

First, based on tumor size and degree of metastasis, the disease is classified into one of the following stages:

Carcinoma in situ: Very early breast cancer that has not invaded nearby tissues.

Stage I: The tumor is localized and no larger than 2 centimeters (about 1 inch).

Stage II: The tumor is no larger than 2 cm, but the cancer has spread to the underarm lymph nodes, or the cancer is between 2 and 5 cm (about 2 inches) and may or may not have spread to the lymph nodes, or the cancer is bigger than 5 cm, but has not spread to the lymph nodes.

Stage III: The tumor is larger than 5 cm and has spread to underarm lymph nodes, or the tumor is smaller than 5 cm and the underarm lymph nodes have grown into each other or into other tissues, or the tumor has spread to tissues near the breast (such as the chest muscles and ribs) or to lymph nodes near the collarbone, or it is inflammatory breast cancer. (Inflammatory breast cancer is fast-progressing with infection-like symptoms in which the skin is warm and reddened and may appear pitted.)

Stage IV: The cancer has spread to other organs of the body, usually the lungs, liver, bone, or brain.

Carcinoma in situ has a cure rate approaching 100 percent with surgery alone. Tumors of 1 cm or less also carry a particularly good prognosis — less than 10 percent recurrence in 10 years. In general, the risk of recurrence rises with increasing tumor size and lymph node involvement.

Breast tumor tissue can be examined for important "markers" that give clues to the aggressiveness of the disease and can, therefore, help guide therapy. Some of these markers are:

Estrogen and progesterone receptors. Patients whose cancer cells have proteins (receptors) to which these hormones bind have a better prognosis because the cells can be treated with hormone therapy.

Histologic type. Breast cancers vary in their cell type. For example, invasive ductal cancers can sometimes be categorized into further subtypes, such as mucinous, tubular and medullary. Lobular cancers are another cell type. The various types have different rates of growth and metastasis.

DNA studies. The degree of disruption of DNA in the cell nucleus correlates with the disease aggressiveness. The more disarrayed the DNA, the greater the risk of relapse. Also, cells that divide more rapidly carry a poorer prognosis.

HER-2 oncogene. This gene is sometimes found in tumors of patients whose cancer has spread. Detected early, it could predict metastasis and identify patients who would benefit from more aggressive treatment.

Cathepsin D. High levels of this protein are associated with a poorer prognosis. Secreted by the cancer cells, cathepsin D may aid their spread to other parts of the body.

Reconstruction Options

Breast reconstruction after mastectomy used to be very complex, and the results were often disappointing. So, as recently as the 1960s, few women chose to have it done. Many were not aware it was a possibility. Since then, however, advances in plastic surgery have made breast reconstruction easier, more successful, and more popular.

Not every woman who has had a mastectomy chooses reconstruction. Some women decide against it because they don't want to have any more surgery or they feel the risks outweigh the benefits or for other reasons. Many women prefer to wear breast forms (prostheses).

For women who desire reconstruction, however, the option is now available with few limitations. Even women who have had radical surgery or whose skin has been grafted, damaged by radiation therapy, or is otherwise thin or tight can have successful reconstructive surgery.

Although some women have breast reconstruction during the same surgery as their mastectomy, many surgeons recommend waiting three to six months. This allows time to complete radiation or chemotherapy and for the mastectomy incision to heal.

There are three major types of breast reconstruction. "Simple" reconstruction uses a silicone gel breast implant. It is usually done in patients who have healthy chest muscles to support the reconstructed breast and enough good skin to cover the implant. "Latissimus dorsi" and "rectus abdominus" are used in patients with more extensive loss of muscle and skin. This situation is less common with the trend to less radical surgeries.

About the Author

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