Breast cancer diagnosis treatment prognosis

Breast cancer is the most common malignancy in women. According to the Croatian Institute of Public Health, in 2001. more than 2,600 new cases of breast cancer were recorded in 2006. Approximately 50% of patients develop metastatic disease, which is generally an incurable condition. Breast cancer is an asymptomatic disease in the initial development stage and is usually detected by chance during a routine examination. Early detection of breast cancer significantly improves the prognosis. Therefore, it is recommended that all women over the age of 50 have a regular mammogram of their breasts once a year to detect possible breast tissue changes promptly.

Metastatic breast cancer occurs when tumor cells separate from the primary, original tumor and reach distant parts of the body through the blood or lymph. The most common sites where they stop and begin further growth and reproduction are the liver, lungs, bones, brain, and lymph nodes. Then, there are specific symptoms to the involvement of a particular organ with a tumor.

Liver: weakness, lethargy, nausea, loss of appetite, jaundice, itching
Lungs: shortness of breath, dry cough
Brain: headache, nausea, limb weakness
Lymph nodes: swelling in the armpit area and along part of the arm
Bones: constant pain

Other symptoms caused by too much calcium in the blood include thirst, frequent urination, nausea, fatigue, irritability, and confusion.

Risk factors for breast cancer

Aging:
the risk of breast cancer increases with age

The previous existence of breast cancer

Presence of breast cancer in the family:
If your mother, grandmother, or sister has this disease and you are at increased risk.

Genetic changes:
changes in certain genes (BRCA1, BRCA2)

Chest changes:
atypical hyperplasia or lobular carcinoma  in situ

Estrogens:
prolonged exposure estrogen

Older firstborns:
the birth of the first child after the age of 30

Excessive radiation:
radiation exposure before the age of 3. years of age

Alcohol and diet:
Research shows that excessive alcohol consumption may be associated with the onset of breast cancer and excessive intake of caloric and fatty foods.

Breast cancer warning signs

• A lump or thickening of tissue in the breast or underarm
• Changing the size or shape of the breast
• Bloody or clear discharge from the nipple of the breast
• Change in touch or appearance of breast or nipple skin (dimples, scaly skin, inflammation)
• Redness of the skin of the breast or nipple
• An area that looks or feels different from the rest of the breast. Hardening under the skin, you can find these warning signs during breast self-examination. Breast self-examination should be performed regularly, at the same time each month (3 to 5 days after completion of the menstrual cycle ). If a woman no longer gets her period, breast examination should continue on the same day each month.

How to diagnose breast cancer

Breast examination

Breast examinations can be done by any woman. in this way it is determined whether there are any changes such as lumps, hardening or changes in the shape of the breast.

Mammography

Mammography is a type of X-ray finding and is used to determine if there are any changes in the breast tissue. This is a precise analysis that can determine even the smallest breast tissue changes.

In breasts with a dense gland structure, mammography does not detect 15-20% of breast cancers, but it does detect most breast cancer. The first (basic) mammogram should be done around 40. Women under 40. years should not do routine mammograms unless there is evidence of breast cancer in female relatives. The risk of developing breast cancer at this age is lower. Women aged 40-49. They should have a mammogram according to their abilities (e.g., every third year), while women over the age of 50 (50-69 years old) should have a mammogram every two years. Women are older than 69. years agree on the frequency of mammography with the chosen doctor.

Breast mammograms use lower levels of radiation and are virtually harmless. In women with dense breasts who have the possibility of not detecting breast cancer by mammography, it is necessary to do an ultrasound examination of the breast after mammography. After the mammogram, the doctor should show the findings and agreed on when the next mammogram should be done. Old mammograms should be worn on every future mammogram.

Breast biopsy and pathohistological findings

Breast tissue with observed tumor changes is taken for  analysis to determine under a microscope whether it is a benign or malignant tumor and what type it actually is.

Magnetic resonance imaging (MR)

Magnetic resonance imaging is a type of search by which all the human body details are obtained through a powerful magnet located in the device, its waves, and the computer. In patients with breast cancer, magnetic resonance imaging is used to determine if the change is benign or malignant.

Breast cancer treatment

Your doctor will introduce you to the different treatment options for breast cancer. We distinguish between local and systemic treatments. Local treatment involves treating only the breast and surrounding lymph nodes’ area. Systemic treatment usually affects the whole body.

The type of treatment you will undergo depends on:

• characteristics of the tumor (cancer)
• tumor spread (i.e., stage of the disease)
• your general health
• your way of making decisions

Important notes about your treatment plan:

• treatment may include several types of local or systemic treatment
• most people need both local and systemic treatment
• some treatments are carried out simultaneously, and someone after the other
• The treatment plan can change depending on how successful it is for you

Local treatment of breast cancer

Topical treatment involves treating only the area of the breast and surrounding lymph nodes.

Radiation

There are different types of radiation. The most common type of radiation sends a high-energy beam of air to the breast area and sometimes to nearby lymph nodes.

It is performed if there are still residual cancer cells after the operation. Treatment is usually carried out five days a week for approximately six weeks.

Radiation is carried out in the following situations:

1. Your nodule has been removed. Radiation treats the rest of the breast.
   In women with low tumor mass, radiation is directed only to the tumor site. In doing so, the radiation is usually directed to the area where the tumor was located.
2. Your breast has been removed. Radiation to the breast site may be recommended if there is a greater chance of cancer recurrence.
3. There is a suspicion that cancer cells are present in the lymph nodes.

Due to the radiation of the breast area or lymph nodes, YOU WILL NOT :

• vomit or feel nauseous
• lose hair (nor reduce the possibility of hair regrowth)
• become “radioactive.”
• increase the risk of breast cancer on another breast

Radiation, however, has other side effects. Some of them are as follows:

• feeling tired
• skin irritation and
• soreness and swelling in the breast and chest area

Most of these side effects disappear within a few weeks or months of completing treatment.

Lymph node removal (dissection)

Lymph nodes under the armpits may need to be removed during or after breast surgery. This is because tumor cells can spread from the breast to these nodes.

Therefore, it is necessary to check the status of lymph nodes to determine tumor cells’ existence, which means an increased risk of spreading the tumor to other parts of the body and choosing the most appropriate treatment.

There are two types of lymph node removal:

1. Standard lymph node removal
   Lymph nodes of the first two levels are removed from the axillary area if there are tumor cells. The third level is usually not touched. (There are three levels of lymph nodes.)
2. Removal of sentinel lymph nodes
   Only one or fewer lymph nodes are removed to determine tumor cells’ presence. The nodes to be removed are carefully selected. These nodes are responsible for draining the breast’s area affected by the tumor. If tumor cells are present in the lymph node guard, the surgeon may decide to remove the additional nodes.

Lymph node removal: what to expect?

Lymph node removal is performed under anesthesia. The procedure can be performed at the same time as breast surgery. It may be necessary to stay in the hospital for one or more days.

Breast removal surgery

Breast removal surgery removes the entire breast. The wart and the tissue around the nipple are removed.

There are several types of place comes:

Complete story – the complete breast is removed.

Modified mestomy – the breast is removed together with the lymph nodes with which it is connected.

Radical placecomia – the breast is removed together with the axillary lymph nodes. Also, the pectoral muscle under the breast is removed.

Lumpectomy – sparing breast surgery

Spare breast surgery is also called partial breast removal, or lumpectomy excisional biopsy. This operation removes the tumor, i.e., a lump on the breast and a part of the healthy tissue surrounding it (so-called edges).

Spare breast surgery: what to expect?

Removal of a lump in the breast requires applying a local anesthetic to the area being operated on. This is performed daily and does not require an overnight stay (hospitalization). For the first few days after removing the lump, you may feel the pain you can relieve with analgesics. You may also lose sensation in part of the breast. For most women, part or most of the breast returns sensation within a few months. Fluid may accumulate in the operated area, and redness and swelling may occur. There is a small risk of infection.

Is sparing breast surgery the right choice for you?

If you have only one tumor in your breast, removing the lump in combination with radiation can be just as effective as removing the breast entirely. This is true if the tumor is:

1. less than three inches
2. possible to remove along with the edge of the healthy tissue surrounding it

Re-excision operation

This operation removes extra tissue from where the first lump was removed. It is performed to clean the edges around where the tumor was located.

It is recommended for women who have had tumor cells in the marginal area (so-called positive edges) or very close to the edge (close edges) of the removed breast tissue. This option is suitable for women who want to keep the breast.

This operation is also performed on an outpatient basis using a local anesthetic and does not require hospitalization. The same incision used to remove the primary nodule is used, and the same side effects may occur.

Systemic treatment of breast cancer

Systemic treatment usually affects the whole body.

There are three main types of systemic treatment:

Breast cancer immunotherapy

The immune system participates in the body’s defense against disease. Immunotherapy assists this system in controlling or destroying cancer cells.

Herceptin

Herceptin is currently the most commonly used immunotherapeutic drug for advanced breast cancer. (The chemical name is Herceptin trastuzumab.)

How does Herceptin work?

Herceptin is effective only against breast cancer whose cells show elevated HER2 receptors. These receptors function as receiving sites on breast cancer cells that receive signals for cell growth and proliferation.

Herceptin works by targeting the receiving sites (HER2 receptors) so that signals for growth and reproduction cannot reach the destination. By binding to tumor cells, Herceptin also triggers an immune response to destroy those cells.

Determination of HER2 receptor status

Since a positive HER2 receptor finding plays an important role in the further selection of therapy, all tumor tissue samples in which this finding is unclear (HER2: 2+, i.e., neither positive nor negative) should be retested one of the more sensitive methods such as FISH or CISH.

The CISH and FISH methods are particularly important in retesting tumor tissue samples described by the IHC method as HER2: 2+. Approximately 30% of re-tested samples have been shown to show clear HER2 receptor positivity.

Herceptin: what to expect?

Hormone therapy for breast cancer

The hormone estrogen can promote tumor cell growth in breast tumors. In this case, hormone therapy is applied. Hormone therapy involves medications or surgery to block estrogen flow into breast tumor cells. Hormone therapy is effective only in the case of a breast tumor that is:

• ER-positive (positive for estrogen receptors)
• PR-positive (progesterone receptor-positive)
• and ER-positive and PR-positive

Hormone therapy is effective for women of all ages. This is NOT the same as hormone replacement therapy (HRT). Some women receive hormone replacement therapy after menopause.

There are four types of hormone therapy:

1. SERMs (tamoxifen)
2. Aromatase inhibitors (AI)
3. ERDs (Faslodex)
4. Ovarian removal or suppression

SERMs (selective estrogen receptor modulators)

These drugs block estrogen because they bind to estrogen receptors (receiving sites) in breast cancer cells. Therefore, estrogen binding to tumor cells and the “transmission of signals” for their growth is disabled. SERMs are taken once a day in tablet form.

Tamoxifen

The most commonly used SERM is tamoxifen. It is used the longest with the best results.
Tamoxifen can reduce the chance of recurrence, spread, and even the development of breast cancer itself. It is used in pre-or post-menopausal women who have hormone receptor-positive breast cancer.

Tamoxifen: what to expect?

Tamoxifen is taken for five years, but its beneficial effects can last up to ten years.
Some of the possible side effects are the following:

• value
• vaginal dryness or discharge
• irregular menstruation
• nausea
• cataract

More serious but also less frequent side effects are the following:

• increased risk of endometrial cancer
• uterine wall cancer (rare)
• the appearance of blood clots that can travel to the lungs or brain

Other SERMs

• toremifene (trade name: Fareston)
• raloxifene (trade name: Evista) has not been tested in women with breast cancer. It may, however, reduce the risk of breast cancer in postmenopausal women who take it to maintain bone strength

Aromatase inhibitors (AI)

These drugs reduce the estrogen level produced in the body after menopause. There are three drugs – aromatase inhibitors:

• Arimidex (chemical name: anastrozole)
• Femara (chemical name: letrozole)
• Aromasin (chemical name: exemestane)

Aromatase inhibitors are taken once a day in tablet form.
It is only used in menopausal women who have hormone receptor-positive breast cancer.

All aromatase inhibitors are effective in women with advanced or metastatic breast cancer. Arimidex is also useful in the early stages of the disease. Some of the possible side effects are the following:

• nausea
• vomit
• jail
• diarrhea
• abdominal pain
• headaches
• back pain
• value
• muscle and joint pain
• sore throat

Compared to tamoxifen, aromatase inhibitors cause fewer hot flashes and do not increase uterine cancer risk. The risk of blood clots is also lower with aromatase inhibitors, but the risk of osteoporosis is higher.

ERDs (estrogen receptor destruction regulators)

These drugs block and destroy estrogen receptors on breast cancer cells. Receptors can be described as estrogen uptake sites. Without these uptake sites, estrogen cannot bind to cells and direct them to grow. There is currently only one ERD, and it is called Faslodex (the chemical name of Faslodex is fulvestrant.)

Faslodex is used in women who:

• have a tumor that has spread beyond the breast area
• have a tumor with positive hormone receptors
• are menopausal
• were receiving some other hormone therapy that stopped working

Faslodex is given once a month as an injection. The side effects are the same as those of aromatase inhibitors.

Suppression or removal of the ovaries

Ovarian removal or suppression is a very effective way to lower estrogen levels in pre-menopausal women. This procedure can be performed to treat women who have hormone receptor-positive breast cancer.

There are three main ways to achieve this:

1. Ovarian removal
   the procedure is performed using small incisions in the lower abdomen
2. Ovarian radiation
   this stops their ability to produce estrogen
3. Taking medication
   Zoladex is a drug that transmits a signal through the central nervous system to stop the production of estrogen in the ovaries (the chemical name of Zoladex is goserelin acetate)

Stopping estrogen production in the ovaries can be just as effective as taking tamoxifen. In some cases, the combination of Zoladex and tamoxifen may be just as effective as chemotherapy.

Ovarian suppression can cause the same side effects as menopause. Some of these side effects are hot flashes, vaginal dryness, and weaker bones.

Breast cancer chemotherapy

Chemotherapeutic drugs destroy tumor cells, preventing their growth and forming new cells. Often two or more drugs are used simultaneously or one after the other. This increases the likelihood of destroying different cells that can arise from the same tumor. Women who have advanced the disease usually receive one type of chemotherapy at a time.

The following drug combinations are known by the first letters of the drug names. Here are some of the most important:

AC ± T
Adriamycin (chemical name: doxorubicin) plus
Cytoxan (Endoxan) (chemical name: cyclophosphamide),
with or without Taxol (chemical name: paclitaxel) or
Taxoterea (chemical name: docetaxel)

AT
Adriamycin with Taxol or Taxotere

CMF
cyclophosphamide, methotrexate, and fluorouracil
(also called “5-FU” or 5-fluorouracil)

CAF
cyclophosphamide, Adriamycin, and fluorouracil

WHIM
cyclophosphamide, epirubicin, and fluorouracil

FAC or CAF
fluorouracil, Adriamycin, and cyclophosphamide (these drugs are given in different order)

Your doctor can tell you which combination of medications is most likely to work best for you.

You will probably need chemotherapy if:

• there are tumor cells in the lymph nodes
• the tumor is larger than one centimeter or
• the tumor, although small, belongs to a species that could grow rapidly or spread. That would
  any of the following terms could describe the type of tumor:
  • “High degree.”
  • “Lymphatic invasion.”
  • “Vascular invasion.”
  • “Negative hormone receptors.”
  • “High growth rate.”
  • “HER2-positive”

You could come across these expressions in your pathological finding.
Chemotherapy is not used in tumors with a low risk of spreading to other parts of the body.

Chemotherapy: what to expect?

You will receive chemotherapy in the form of tablets or through a needle inserted into a vein.
To make it easier to take your medication and perform blood tests, you may need to have a catheter inserted. It is a plastic device located just below the upper chest or arm’s skin and which is emptied into a blood vessel.
A special needle is inserted into the catheter and allows you to receive chemotherapy and take blood for tests.

Where is chemotherapy received?

You can receive chemotherapy at a doctor’s office, clinic or hospital. Some chemotherapy types can also be taken at home, depending on the medication prescribed to you.

When is chemotherapy received?

You can take medicine for a few days with a break of a few weeks before the next dose. You can also take medicine once a week. This medication cycle and rest are repeated until the end of the treatment procedure. Depending on the medications you are taking, chemotherapy will be completed in three to six months.

Side effects of chemotherapy

Chemotherapeutic drugs act on all the fast-growing cells in the body. Cancer cells grow fast. Likewise, blood cells, cells in the oral cavity and nose, cells of the digestive and immune systems, and scalp cells also grow rapidly. The action of chemotherapeutic drugs on non-tumor cells leads to side effects.

Some of the most important side effects are the following:

• nausea
• vomit
• diarrhea
• sores in the mouth
• fatigue
• higher risk of infection
• hair loss
• pain and discomfort
• changes in the sense of taste and smell

Some medications can eliminate or alleviate most of the side effects. Some of these drugs power
you will take before and after each treatment. Most side effects disappear within a few
weeks or months from completion of treatment.

Experimental treatment of breast cancer

In addition to the described methods of local and systemic treatment, numerous studies are being conducted today to find new forms of treatment, i.e., new drugs for breast cancer. Some of these drugs may be more effective than today’s standard of care.

The only way to reliably determine the benefit of new treatments or new drugs is to conduct clinical trials in women with breast cancer who agree to participate in the trial.
Clinical trials involve testing new drugs or new ways of taking a drug.

People who agree to participate in clinical trials do their best
possible medical care. You may receive a new form of treatment in a clinical trial.
You may, in turn, receive the best-known form of treatment. There are new forms of treatment already
tested to confirm their safety. You can receive these new forms of treatment
only if you approach a clinical trial. Talk to your doctor to
learn more about such trials.

Don’t rush

Fortunately, there are many treatment forms, i.e., drugs that work effectively against breast cancer.
Choosing the best one can be difficult and confusing. It takes a lot of time and care
considerations to process all these complex data. Don’t feel obligated right away
to decide – most people can’t make a quick decision on such an important topic. Usually
You have a few weeks to gather the necessary information and decide which suits you
best suited. The opinion of another doctor can also be of great help.

More correct selections

You may find that your doctors disagree with your treatment choice. That doesn’t mean it is
one right and the other wrong. It may mean that they have different styles
of treatment. There are often several correct ways to treat cancer.

Talk to your doctor and loved ones about treatment options.
If you set your own health as your highest priority and focus on it, it will be
much easier for you to endure the treatment to the end, no matter how difficult and long it lasts.
Remember that this is the next step on a critical path: the path to a better, healthier life.
We hope the information in this booklet will help you achieve that goal.

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