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Breast Cancer
Breast cancer can occur in women and men. Of course, it is much more common in women. The cause of breast cancer is not known. Breast cancer can originate in different parts of the breast.
Diagnosis
Current mammography guidelines recommend screening mammography starting at age 45 or 50, unless you are at high risk of the disease, when screening may start at an earlier age.
Screening is usually performed with a mammogram, ultrasound or possibly MRI of the breast. A biopsy is performed if the findings are suspicious for breast cancer.
If a diagnosis of breast cancer has been established, staging is performed with radiographs and imaging studies that usually include CT scans, PET scans, and/or CT/PET.
Sometimes, changes or “mutations” occur that prevent genes from doing their job properly. Certain mutations in the BRCA genes (see below) make cells more likely to divide and change rapidly, which can lead to cancer.
Types of Breast Cancer
Ductal carcinoma in situ (DCIS) is not breast cancer, but it is a breast disease that may lead to breast cancer. The cancer cells are only in the lining of the ducts and have not spread to other tissues in the breast.
Invasive ductal carcinoma means the cancer cells are growing outside the ducts into other parts of the breast tissue. They can spread or metastasize throughout the body.
Invasive lobular carcinoma is where cancer cells spread from the lobules to the adjacent breast tissues and other parts of the body.
Inflammatory breast cancer is a rare and very aggressive disease in which the breast often looks swollen and red, or inflamed.
Grade
After a biopsy has been performed and the specimen is examined under the microscope, the pathologist will report the “grade” of the cancer. The grade indicates how aggressive or invasive the tumor is. The higher the grade, the more invasive the cancer cells are likely to be.
The “grade” of a tumor is different than the “stage” (see below). While the grade indicates invasiveness, the stage indicates how large the tumor is and how much it has spread.
Grade 1 are low grade or well differentiated cancers. They generally don't look too different from normal breast cancer cells and don't grow as fast as less differentiated cells.
Grade 2 or moderately differentiated cells grow faster and no longer look like normal cells.
Grade 3 or poorly differentiated cells look disorganized and completely different from normal cells. They grow faster and divide more quickly. They're the kind of cancer cells that pose the greatest risk of metastasizing.
Staging
The “stage” of breast cancer means whether it is localized or, if that is not the case, how far it has spread. The “TNM Staging System” is used for that purpose. The letter “T” designates the tumor size (usually in centimeters) when it is first diagnosed. “N” is for the number of lymph nodes that are “positive” and show evidence of spread. “M” is for distant “metastases” to other organs and tissues.
Breast cancers are further grouped into “Stage 0” tumors that are not invasive (“in situ” cancers). “Stage I” cancers are small and less than 2 cm in size. “Stage II” cancers are between 2 to 5 cm in size. “Stage III” cancers are >5 cm in size and 4 or more lymph nodes are involved. “Stage IV” is metastatic breast cancer, where it has spread beyond the breast and regional lymph nodes and to other parts of the body such as the bones, liver, or lungs.
For example, T1N2M0 means the breast cancer is small (1 cm), it has spread to only two regional lymph nodes, and it has not metastasized to other organs or tissues. All things considered, based on this information, the treatment would probably include a lumpectomy (with or without radiation) and the prognosis would be excellent.
The size of the tumor when it is first diagnosed is of considerable importance in determining treatment and predicting prognosis. Although size is not the only factor, it's an important one. If the tumor is <3 cm, the 5-year survival is 100%. If the size is 3 -4 cm, the survival is 86%; 4– 5 cm, 82%, and >5.0 cm, 81%.
Those 5-year survival statistics drop off by approximately 7-18%, if the regional lymph nodes are “positive” and show microscopic evidence of tumor spread.
However, there are many other factors that go into determining treatment and prognosis. Oncologists often say that each woman's breast cancer is unique.
BRCA 1 and BRCA 2 Genes
All women have BRCA1 and BRCA2 genes. When mutations occur in these genes (about 1 in every 500 women in the United States) the risk of breast cancer increases. It is estimated that 50% of women with a BRCA1 or BRCA2 gene mutation will develop breast cancer in their lifetime as compared to approximately 7% of women generally.
BRCA1 or BRCA2 gene mutations also increase the risk of developing ovarian cancer. Approximately 30% of women will develop ovarian cancer in their lifetime as compared to 1% in the general population.
Some women who are BRCA1 or BRCA2 positive elect to have prophylactic (preventive) mastectomy and/or salpingo-oophorectomy (removal of the ovaries and fallopian tubes). For example, the actress, Angelina Jolie, decided to do that.
Receptor Positivity
Once the breast cancer has been biopsied, it will be determined to be estrogen receptor (ER), progesterone receptor (PR) or human epidermal growth factor receptor-2 (HER2) positive or negative. Or, the breast cancer may be triple negative or triple positive.
Triple positive breast cancer has receptors for HER2, ER and PR. Triple negative breast cancer does not have receptors for HER2, ER and PR.
Estrogen and progesterone receptors are often referred to as “hormone receptors.” When a breast cancer is “hormone positive,” treatment may include a hormone therapy such as Tamoxifen. If a tumor is HER2 positive, treatment may include a “HER2” directed therapy, such as Herceptin.
Treatment
Treatment of breast cancer includes surgery (lumpectomy or mastectomy) with “curative intent” to remove all the cancer, if possible. Chemotherapy and radiation therapy (including intraoperative radiation treatment or “IORT”) are used to kill breast cancer cells that may not have been removed during surgery, but they also cause injury to surrounding normal tissues. Hormonal therapy in HER2, ER and PR positive tumors blocks cancer cells from getting the hormones that help them grow. “Triple negative” breast cancer cannot be treated with hormone therapy and is usually treated with chemotherapy. There are also biologic or immune therapies that activate the body's immune system to attack the cancer cells.
If your breast cancer is estrogen-positive, treatment with estrogen blockers is often recommended with drugs such as tamoxifen or aromatase inhibitors, such as anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin).
If your breast cancer is HER2-positive, treatment is often recommended with drugs such as trastuzumab (Herceptin), pertuzumab (Perjeta), and lapatinib (Tykerb).
Years ago, the diagnosis of breast cancer was often considered a death sentence. However, treatments can now cure or control breast cancer in many women and to a sometimes-amazing degree.
Side Effects of Treatment
There are several adverse reactions and complications of treatment that can be debilitating, sometimes recalling the saying “the cure is worse than the disease.”
Breast cancer surgery causes pain, but it also can result in lymphedema in one or both arms (depending whether surgery involves one or both breasts). Lymphedema causes chronic swelling in the arm, hand, breast, or chest. While it is usually a complication of breast surgery, it can also occur after radiation treatments for breast cancer. Lymphedema can appear soon after surgery or radiation therapy, but it can also develop for the first-time months or years later.
The cause of lymphedema is damage from surgery or radiation to the lymph nodes and the lymph channels through which lymph moves around in the body. Symptoms of lymphedema include persistent swelling (sometimes severe) in the affected extremity, numbness, tingling, aching pain, fullness, heaviness, decreased flexibility, and tightness in the surrounding tissues.
Hormonal therapy can cause hot flashes, joint pain, cognitive dysfunction, and bone thinning (osteoporosis). Radiation therapy can cause itching, soreness, fatigue, and peeling skin, as well as lymphedema.
Chemotherapy can cause hair loss, diarrhea, neuropathy, fatigue, nausea, vomiting, loss of appetite, constipation, skin and nail changes, cognitive dysfunction (memory and concentration), and mouth sores. Chemotherapy can rarely cause damage to the heart muscle (cardiomyopathy) and bone marrow (leukemia, myelodysplasia).
Neuropathy is a potentially disabling complication of chemotherapy. It can start any time after treatment begins, and it may worsen and become permanent as treatment continues. Common symptoms include pain, tingling, burning, weakness, and numbness in fingers, toes, arms, hands, legs, and feet. The pain may be sharp, stabbing, intense, and sudden. Neuropathy may cause extreme clumsiness in the hands, making it difficult or impossible to do fine manipulation or to even pick-up items from a desk or counter. Neuropathy may cause disequilibrium, difficulty walking, loss of hearing, bowel disorders (constipation), sensitivity to temperature (hot or cold), difficulty swallowing, urination problems, and labile blood pressure resulting in falls.
Fatigue is one of the most debilitating problems for many breast cancer patients. It can occur from chemotherapy and radiation therapy, and/or from the cancer itself. It can be aggravated by anemia, which can occur as a result of chemotherapy. The fatigue is not just “feeling tired.” It is typically much more than that and can be one of the most debilitating symptoms of breast cancer.
Studies examining fatigue in breast cancer patients have emphasized its debilitating effects. To wit: “Cancer fatigue differs from other manifestations of fatigue in that it is generally not alleviated by sleep or rest, is typically of greater duration and severity, is often associated with high levels of distress, and is disproportionate to the level of exertion.” [Ref: Bardwell WA, Ancoli-Israel S. Breast cancer and fatigue. Sleep Med Clin. 2008 Mar; 3(1): 61–71.]
Chronic inflammation may be a significant contributory factor to cancer fatigue. Studies show that fatigue was observed to be positively associated with elevated levels of inflammatory cytokines, including IL-6, IL-1ra, and neopterin, but not with IL-1β or TNF-α. Id.
Disability Benefits for Breast Cancer Patients
Survivors of breast cancer can have multiple disabling symptoms related to not only their underlying cancer, but also to the treatment they have received. Surgery and radiation can result in lymphedema. Chemotherapy can cause neuropathy. Chronic fatigue, cognitive dysfunction, and other problems are common to many patients.
It is important for your healthcare providers to document in your medical records not only your symptoms, but to also set forth how your symptoms affect your exertional functional capability. For example, the symptoms from your lymphadenopathy (e.g., swelling, numbness, tingling, pain, decreased flexibility in one or both hands and upper extremities) may cause you to be unable to type, write, pick-up a pen, or do any fine manipulation. Or, your fatigue may cause you to be unable to sit more than 4-6 hours out of an 8-hour workday and require you to lie down to rest for 1-2 hours every day. Or, your neuropathy (e.g., pain, tingling, burning, weakness, numbness in the hands and feet) may limit your ability to stand/walk to no more than 2 hours in an 8-hour day and/or restrict your ability to lift/carry to less than 10 pounds.
