Breast Cancer

Diagnosis

• Breast cancer is typically found by an abnormality seen on screening mammograms, or by the patient who feels a mass
• Further imaging is then done (mammogram, ultrasound and/or MRI)
• The mass/lesion is then biopsied by the radiologist
  • A “core needle biopsy” removes a small piece of the lesion to send to the pathologist
  • A small clip is left in your breast at the location of the biopsy to mark the site for future surgery.
• The pathologist then examines the biopsy and provides a diagnosis

Imaging

• Further imaging may be recommended after your diagnosis
• Mammogram, ultrasound, breast MRI are commonly used
• CT, PET/CT and bone scans are used less commonly

Staging

• Staging is done along your course of workup. Staging helps guide treatment recommendations, surveillance and prognosis. This can change when new information arises.
• TMN
  • T = size (and type)
  • N = number of lymph nodes
  • M = distant metastases
  • TMN staging will give you a final overall stage (0-4)
    • Stage 0 – DCIS. Non-invasive, has not broken out of breast ducts
    • Stage 1 – Cancer cells have spread to breast tissue but are small without significant spread
    • Stage 2-3 – Cancer is larger, more aggressive, or has spread into lymph nodes
    • Stage 4 – Cancer has spread to distant organs such as bones, liver, lungs or brain.
  • Clinical Stage
    • Based on physical exam, imaging, biopsy
  • Pathologic Stage
    • Based on final pathology review after your surgery

Types of breast cancer

• Ductal Carcinoma in Situ (DCIS)
  • If cancers arise in the ducts of the breast but do not grow outside of the ducts, the tumor is called ductal carcinoma in situ (DCIS)
  • DCIS cancers do not spread beyond the breast tissue, so in most cases you will not need surgery of your lymph nodes
  • Tis = Stage 0
• Invasive Ductal Carcinoma (IDC) or Invasive Lobular Carcinoma (ILC)
  • This type of breast cancer is classified because they have grown or “invaded” beyond the ducts or lobules of the breast into the surrounding breast tissue.
  • Surgery to the lymph nodes is almost always recommended in order to “stage” the cancer (to see if it has spread to the lymph nodes)

Treatments

• Treatment often involves multiple types of therapy which is provided by different physicians
• These 3 groups of physicians work together to provide all aspects of your cancer care
  • Surgical team (Surgery)
    • Dr. Swenson, Dr. Kane, Sommer Fields PA-C
  • Radiation oncology (Radiation)
    • Dr. Watkins, Dr. Reynolds, Dr. Kreofsky
  • Medical oncology (Chemotherapy, hormone therapy, immunotherapy)
    • Dr. Gray, Dr. Luebke, Dr. Rakshit
• What’s right for you depends on many factors, including the location and size of the tumor, the results of your lab tests and whether the cancer has spread to other parts of your body. Your team will tailor your treatment plan according to your unique needs.

Surgery

• Surgery is often the first step in treatment, but sometimes chemotherapy is recommended before surgery in certain situations.
• You may be recommended for one surgery, or offered a choice. Your surgeon will discuss this in depth with you.
• Types of surgery
  • Breast
    • Lumpectomy
      • Also called a partial mastectomy (or “breast conservation therapy” when combined with radiation)
      • This removes the tumor and a small margin of healthy tissue around it.
      • People who have a lumpectomy often have radiation therapy in the weeks following the procedure.
    • Mastectomy
      • Removal of your entire breast is another option.
      • You can choose to not undergo reconstruction, and will have a flat scar
      • You may choose to have reconstruction
        • You will be recommended to meet with a plastic surgeon (often preoperatively) to discuss plans for reconstruction, which can affect your type of mastectomy
        • If planning reconstruction, a skin-sparing, or nipple-sparing surgery may be offered, which can improve cosmetics

Axilla

• Sentinel node biopsy.
  • This is done for “staging” for invasive cancer
  • A few lymph nodes are removed, so the pathologist can look at them under the microscope to determine if the cancer has spread here.
  • This surgery was developed to prevent the unnecessary removal of large numbers of lymph nodes that aren’t involved by the cancer.
  • To identify the sentinel lymph node, doctors inject a dye that tracks to the first lymph node that cancer would spread to.
  • Often, there’s more than one sentinel node identified, but the fewer lymph nodes removed the lower the chance of developing swelling in your arm (lymphedema).
  • A sentinel lymph node biopsy can be done with either a lumpectomy or a mastectomy.
• Axillary lymph node dissection
  • If multiple lymph nodes are involved by the cancer, an axillary lymph node dissection may be done to remove them. This means removing many of the lymph nodes under your arm (your axilla)
  • This has a higher rate of lymphedema (swelling in the arm), so you will be referred to a physical therapist after surgery to help manage this if it occurs.

Radiation

• Radiation therapy for breast cancer is typically given after a lumpectomy or mastectomy to kill remaining cancer cells and decrease the chance this returns
• It can also be used to treat cancer in the lymph nodes, or individual metastatic tumors that are causing pain or other problems.
• Radiation therapy typically involves daily radiation treatments, ranging from 1 to 6 weeks
• Length of treatment can depend upon multiple factors, including stage and other tumor characteristics
• With modern breast or chest wall radiotherapy, you should not feel sick, lose your hair, or have nausea or vomiting, and you are safe to be around (not radioactive). You are also safe to drive yourself to and from appointments.
• Your radiation oncologist will discuss these options with you further

Chemotherapy, hormone therapy, immunotherapy

• Chemotherapy
  • Chemotherapy may be recommended before a lumpectomy in an effort to shrink the tumor or lessen the cancer in the axilla.
  • Sometimes, it’s given after surgery to kill any remaining cancer cells and reduce the risk of recurrence (coming back).
  • If the cancer has spread beyond your breast to other parts of your body, then your healthcare provider may recommend chemotherapy as a primary treatment.
• Hormone therapy
  • Some types of breast cancer use hormones — such as estrogen and progesterone — to grow. In these cases, hormone therapy can either lower estrogen levels or stop estrogen from attaching to breast cancer cells.
  • Hormone therapy may be offered after surgery to reduce the risk of breast cancer recurrence.
  • It may be used to shrink the tumor or to treat cancer that has spread to other parts of your body.
• Immunotherapy
  • Some drugs can target specific cell characteristics that cause cancer. Your healthcare provider might recommend targeted drug therapy in cases where breast cancer has spread to other areas of your body 
• These are prescribed and managed by your medical oncologist

Surveillance

• This is done to monitor for a recurrence, or detect distant spread
• This can be done with office visits, blood tests, imaging (mammograms, CT/PET) and is tailored to your specific risk

Prognosis

• Is breast cancer fatal?
  • People with early-stage breast cancer often manage their condition successfully with treatment. In fact, most people who’ve received a breast cancer diagnosis go on to live long, fulfilling lives.
  • Late-stage breast cancer is more difficult to treat, however, and can be fatal.
• What is the survival rate?
  • The overall five-year survival rate for breast cancer is 90%. This means that 90% of people diagnosed with the disease are still alive five years later.
  • The five-year survival rate for breast cancer that has spread to nearby areas is 86%, while the five-year survival rate for metastatic breast cancer is 28%.
  • Fortunately, the survival rates for breast cancer are improving as we learn more about the disease and develop new and better approaches to management.
• Please keep in mind that survival rates are only estimates. They can’t predict the success of treatment or tell you how long you’ll live. If you have specific questions about breast cancer survival rates, talk to your healthcare provider.
• What can you do?
  • Continue with recommended surveillance to detect recurrence/spread early if this occurs
  • Healthy habits that have been proven to improve cancer-specific outcomes are
    • Eat a balanced diet
    • Maintain a healthy weight
    • Exercise regularly
    • Stop smoking
    • Limit excessive alcohol use

Local support groups

• Breast Cancer Support Group
  Bismarck Cancer Center
  5:30 p.m. – Second Thursday of each month
  Contact Jen @ 222.6113 for virtual options

• Caregivers Cancer Support Group
  Bismarck Cancer Center
  5:30 p.m. – Third Tuesday of each month
  Contact Jen @ 222.6113 for virtual options

• All Cancer Support Group
  Bismarck Cancer Center
  5:30 p.m. – Third Thursday of each month
  Contact Jen @ 222.6113 for virtual options

• Equine Therapy
  TR4 Heart and Soul
  Contact Katie at oakland@live.com to schedule your session

• Healing Art Workshop with Art from the Heart
  Art from the Heart Studio, 311 N Mandan St Ste 4, Bismarck 6- 8 p.m. – First Tuesday of each month
  Limited seating available. To register, please visit bismarckcancercenterfoundation.com

• Yoga for Healing
  Bismarck Cancer Center
  In-Person or Virtual
  Every Monday (4pm)
  To register, contact Allexis at 701.222.6179