Breast Cancer Diagnosis & Treatment

Diagnosis

For most patients, a breast cancer diagnosis starts with an imaging exam. This can be a routine screening such as a yearly mammogram or can be prompted by a suspicious lump, redness or thickening of the breast skin.

Most breast imaging is carried out with a mammogram or ultrasound. Occasionally, doctors will use magnetic resonance imaging (MRI) or other specialized examinations.

If the imaging exam shows an unusual or suspicious mass or skin thickening, doctors will need a tissue sample in order to make a definitive diagnosis. Tissue is typically retrieved through an image-guided core needle biopsy. During this procedure, a needle is used to extract a bit of tissue from the suspicious area of the breast. In many cases, this biopsy is performed during the initial imaging exam in order to speed up the diagnosis.

If the biopsy reveals cancerous tissue, additional imaging and biopsies may be needed to determine the exact scope of the disease. This part of the diagnosis shows whether the cancer has spread to nearby lymph nodes or other parts of the body.

Doctors will perform additional analysis of the cancer cells themselves to determine the disease’s receptor subtype. By understanding the subtype, they can develop a comprehensive, personalized treatment plan.

Breast cancer staging

Staging is a way of determining how much disease is in the body and where it has spread. This information is important because it helps your doctor decide the best type of treatment for you and the outlook for your recovery (prognosis).

Stages

(source: National Cancer Institute)

Stage 0 (carcinoma in situ)

There are 3 types of breast carcinoma in situ:

• Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues over time. At this time, there is no way to know which lesions could become invasive.
• Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer. Information about LCIS is not included in this summary.
• Paget disease of the nipple is a condition in which abnormal cells are found in the nipple only.

Stage I

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

• In stage IA, the tumor is 2 centimeters or smaller. Cancer has not spread outside the breast.
• In stage IB, small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes and either:
  • no tumor is found in the breast; or
  • the tumor is 2 centimeters or smaller.

Stage II

Stage II is divided into stages IIA and IIB.

• In stage IIA:
  • no tumor is found in the breast or the tumor is 2 centimeters or smaller. Cancer (larger than 2 millimeters) is found in 1 to 3 axillary lymph nodes or in the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or
  • the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has not spread to the lymph nodes.
• In stage IIB, the tumor is:
  • larger than 2 centimeters but not larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes; or
  • larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy); or
  • larger than 5 centimeters. Cancer has not spread to the lymph nodes.

Stage IIIA

In stage IIIA:

• no tumor is found in the breast or the tumor may be any size. Cancer is found in 4 to 9 axillary lymph nodesor in the lymph nodes near the breastbone (found during imaging tests or a physical exam); or
• the tumor is larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes; or
• the tumor is larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy).

Stage IIIB

In stage IIIB, the tumor may be any size and cancer has spread to the chest wall and/or to the skin of the breast and caused swelling or an ulcer. Also, cancer may have spread to:

• up to 9 axillary lymph nodes; or
• the lymph nodes near the breastbone.

Cancer involving skin of the breast may also be inflammatory breast cancer.

Stage IIIC

In stage IIIC, no tumor is found in the breast or the tumor may be any size. Cancer may have spread to the skin of the breast and caused swelling or an ulcer and/or has spread to the chest wall. Also, cancer has spread to:

• 10 or more axillary lymph nodes; or
• lymph nodes above or below the collarbone; or
• axillary lymph nodes and lymph nodes near the breastbone.

Cancer that has spread to the skin of the breast may also be inflammatory breast cancer.

Stage IV

In stage IV, cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.

While stage IV breast cancer is usually not curable, it can respond (either shrink or remain stable) for some time with different medical therapies.  Sometimes radiation is used to treat specific areas.

Treatment

MD Anderson’s Nellie B. Connally Breast Center provides patients with truly multidisciplinary care. That means your medical oncologist, radiation oncologist, surgical oncologist and reconstructive surgeon work together as a team to achieve the best possible outcome. They coordinate care and develop a comprehensive treatment plan that’s unique to each patient’s disease and needs.

Surgery

Like all surgeries, breast cancer surgery is most successful when performed by a specialist with a great deal of experience in the particular procedure. MD Anderson’s breast cancer surgeons are among the most skilled and renowned in the world. They perform a large number of surgeries for breast cancer each year, using the least-invasive and most-effective techniques. At the start of treatment, care teams asses if the patient needs reconstructive surgery. If so, our breast cancer surgeons and reconstructive surgeons work together to plan procedures that minimize incision and possible scarring. Their goal is to achieving the most effective surgery and the best possible cosmetic outcome and symmetry.

Some patients will receive chemotherapy or targeted therapy prior to surgery. The goal of these treatments is shrink the tumor and any involved lymph nodes in order to make the procedure and recovery as easy as possible on the patient. This also allows the treating team to assess how the cancer has responded to treatment, which can be important for some breast cancer subtypes.

The surgeries themselves fall into one of two categories: lumpectomies and mastectomies. Your surgeon will recommend the best option for you based on the size and location of tumors in the breast, the size of the breast itself and the need for radiation treatment.

In a typical lumpectomy surgery, the tumor and a small amount of surrounding normal tissue is removed. Lumpectomies are generally outpatient procedures and have shorter recovery times. These procedures are usually followed by radiation therapy.

In a typical mastectomy surgery, the tumor and the entire breast are removed. There are a number of different types of mastectomies, including procedures that spare the breast’s skin and nipple/areola. Often a mastectomy and breast reconstruction can be performed in the same procedure.

In some cases, both breasts are removed. This can help prevent the development of a new breast cancer. It is typically done for patients who have an elevated risk of developing breast cancer due to family history or their own genetic profile, such as a BRCA mutation.

In both lumpectomies and mastectomies, surgeons may also remove nearby lymph nodes. These are important parts of the lymphatic system, which helps the body fight disease. Breast cancer can spread through nearby lymph nodes. Doctors will study the ones that are removed to determine if there are cancer cells within the nodes. This information can help determine the risk of the disease spreading to distant organs, as well as the need for chemotherapy and radiation therapy.

Radiation therapy

Radiation therapy uses powerful beams of energy carefully designed to kill breast cancer cells.

At most hospitals, the radiation oncologist developing these treatments works on several different types of cancer. At MD Anderson’s Breast Center, radiation oncologists are dedicated exclusively to caring for patients with breast cancer. This gives them incredibly deep experience to draw from when designing treatment plans. In addition, each breast cancer radiation treatment plan is reviewed by every breast radiation oncology faculty member, ensuring that patients receive the best possible treatment.

Our physicians are recognized as world leaders in their field. MD Anderson radiation oncologists have developed radiation therapy treatments shown to deliver the most effective radiation courses in the shortest amount of time and with the fewest side effects.

For breast cancer patients, radiation therapy can be used before surgery to shrink large tumors or after surgery in order to kill any remaining breast cancer cells that can’t be seen by the naked eye. It can also be used as a palliative treatment to reduce symptoms caused by cancer spreading to other parts of the body and improve the patient’s quality of life.

Radiation can be given to the breast tissue surrounding the area where the tumor was located, as well as to nearby lymph nodes and the chest wall. After a lumpectomy, patients often receive three to four weeks of daily radiation therapy. In some cases one to two weeks may be appropriate. When the lymph nodes are involved or a mastectomy was needed, patients usually need six weeks of daily radiation therapy.

Radiation therapy treatments for breast cancer patients include:

• 3D conformal radiation therapy: This technique uses radiation beams that are shaped to the tumor’s dimension.
• Intensity modulated radiation therapy: IMRT uses multiple beams of radiation with different intensities to deliver a precise, high dose of radiation to the tumor.
• Volumetric arc therapy: A type of IMRT, in VMAT therapy, the section of the machine that shoots out the beam of radiation rotates around the patient in an arc. This can irradiate the tumor more precisely and shorten procedure times.
• Accelerated Partial Breast Irradiation: A form of brachytherapy, APBI uses radioactive pellets or seeds to kill cancer cells that may remain after a lumpectomy.
• Stereotactic body radiation surgery: SBRT administers very high doses of radiation, using several beams of various intensities aimed at different angles to precisely target the tumor.
• Stereotactic radiosurgery: Stereotactic radiosurgery most commonly used to treat breast cancer that has spread to the brain. Stereotactic radiosurgery uses dozens of tiny radiation beams to target tumors with a precise, high dose of radiation. Read more about stereotactic radiosurgery

Proton therapy

Proton therapy delivers high radiation doses directly into the tumor, sparing nearby healthy tissue and vital organs. For many patients, this results in better cancer control with fewer side effects.

Targeted therapy

Cancer cells rely on specific molecules (often in the form of proteins) to survive, multiply and spread. Targeted therapies stop or slow the growth of cancer by interfering with, or targeting, these molecules or the genes that produce them.

In recent years, targeted therapy has become a major weapon in the fight against breast cancer. Breast cancer subtypes that once had poor prognoses are now highly treatable.

One type of targeted therapy is endocrine therapy, which is given to patients with hormone receptor-positive breast cancer. This can be given before surgery to shrink the tumor. It is also given after surgery for five to 10 years to prevent recurrence. Patients with the metastatic form of this disease are also given endocrine therapy in order to prevent disease progression.

Patients with HER2-positive breast cancer also receive targeted therapies. These patients may receive a different set of targeted therapy drugs both prior to and after surgery. Since about half of patients with HER2-positive breast cancer also have hormone receptor-positive tumors, they are also given endocrine therapy.

While there are no targeted therapies for triple negative breast cancer, researchers are studying the disease to identify possible drug targets.

Chemotherapy

Chemotherapy uses powerful drugs to directly kill cancer cells, control their growth or relieve pain. It is often given to patients prior to surgery to shrink the tumor and simplify the procedure. Breast cancer patients can receive chemotherapy either orally or intravenously.

Angiogenesis inhibitors

Angiogenesis is the process of creating new blood vessels. Some cancerous tumors are very efficient at creating new blood vessels, which increases blood supply to the tumor and allows it to grow rapidly.

Researchers developed drugs called angiogenesis inhibitors, or anti-angiogenic therapy, to disrupt the growth process. These drugs search out and bind themselves to VEGF molecules, which prohibits them from activating receptors on endothelial cells inside blood vessels. Other angiogenesis inhibitor drugs work on a different part of the process, by stopping VEGF receptors from sending signals to blood vessel cells.