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October 2009: Breast Cancer

30 Sep 2009

Drs. Keith Shulman and Stuart Krauss are oncologists at Weiss Memorial Hospital with a special interest in breast cancer. Dr. Krauss is the director of medical oncology at Weiss, and Dr. Shulman is the head of the institutional review board at Weiss.

Drs. Keith Shulman and Stuart Krauss
Oncologists
Lakefront Oncology Associates
Weiss Memorial Hospital
(773) 564-5030

Introduction
Breast cancer is the most common cancer among women in the United States, with one in eight developing the disease in their lifetime. Primarily because of better screening, the mortality rate of breast cancer has declined by 20 percent over the last 10 years. Nevertheless, among all cancers that occur in women, only lung cancer is more common than breast cancer as a cause of death.

Risk factors
No one knows why some women get breast cancer, but there are a number of risk factors.

Nonmodifiable risk factors include:

  • Age: The chance of getting breast cancer rises as a woman gets older, especially after age 55.
  • Family history: About 5 to 10 percent of all breast cancers are hereditary.  Women who have family members with breast cancer have a higher risk(about a twofold increase) of developing breast cancer. Families that have multiple relatives or younger women with breast cancer, are of Ashkenazi Jewish descent, or have members with ovarian cancer may be candidates for genetic testing for two genes, BRCA1 or BRCA2. Identified carriers of these genes have a 50 to 80 percent chance of developing breast cancer in their lifetime, and they have a high risk of ovarian cancer.
  • Personal factors: Beginning periods before age 12 or going through menopause after age 55.
  • Race: White women are slightly more likely to get breast cancer than African-American women. But African-American women are more likely to die of this cancer. At least part of the reason seems to be because African-American women have faster growing tumors and may have a higher incidence of so-called “triple negative” breast cancer (tumors lacking estrogen or the Her-2-Neu receptor). Asian, Hispanic and American-Indian women have a lower risk of getting breast cancer.

Modifiable risk factors include:

  • Being overweight or obese.
  • Past or current use of hormone replacement therapy (especially prolonged use or taking preparations containing both estrogen and progesterone).
  • Taking birth control pills.
  • Drinking alcohol (taking more than one drink a day increases the risk one and a half times normal).
  • Not having children or having your first child after age 35.
  • Having dense breasts.
  • Prior radiation therapy to the chest for Hodgkin’s disease at a young age.
  • Prior benign proliferative lesions, such as atypical hyperplasia of the breasts. 

Women can lower the risk of breast cancer by changing modifiable risk factors. Based on evidence from some studies, limiting alcohol use, exercising regularly and maintaining a healthy body weight may help decrease the risk of getting breast cancer.

Women who choose to breastfeed for at least several months may also get an added benefit of reducing their breast cancer risk. Women at high risk may want to discuss with their health care provider the benefits and side effects of either Tamoxifen or Raloxifene as preventative agents to reduce the risk of developing breast cancer. Men can have breast cancer, too, but the number of cases is small.

More information on these risk factors and prevention can be found on the American Cancer Society Web site: http://www.illinoiscancerhelp.org.

Symptoms, early detection and screening
Symptoms of breast cancer may include a lump in the breast, a change in size or shape of the breast or discharge from a nipple. Breast self-exam and mammography can help find breast cancer early, when it is most treatable.

Although mammography can detect most breast cancers, about 20 percent of breast cancers are not visible on mammogram, so a lump found on exam should always be evaluated even if the mammogram is negative. 

Recommendations for screening women in good health include annual mammography starting at age 40 and breast exam by a health care provider, initially every three years for women in their twenties and thirties and annually thereafter.

Women with higher risk of developing breast cancer, such as those with strong family history or BRCA1 or BRCA2 carriers, should begin earlier screening. Elderly women with other serious health conditions should evaluate the benefits of screening with their health care provider.

In addition to mammography, breast MRI is recommended in women who have greater than a 15 - 20 percent risk of developing breast cancer in their lifetime, including those who are BRCA1 and BRCA2 carriers, or women who have had prior chest wall radiation at a young age for diseases such as Hodgkin’s disease. Ultrasound as an imaging technique may be added to mammography to aid in evaluations of suspicious lesions.

Diagnosis
A suspicious lump on physical exam or finding on breast imaging such as mammography in general should be evaluated. In order to diagnose breast cancer, a piece of tissue must be removed and examined. Tissue can be obtained by fine needle aspiration, core needle biopsy or lumpectomy. The technique used depends on the size, nature and location of the abnormality, and the overall health and personal preferences of the patient.  

Prognosis and treatment
Once breast cancer is diagnosed, the tissue obtained is analyzed further to provide information to aid in determining prognosis and treatment. Information includes the grade of the tumor, size, presence of estrogen, progesterone or Her-2-Neu receptors and number of involved lymph nodes.
 
For tumors that are noninvasive (cells are confined to the ducts) such as ductal carcinoma in situ, treatment options include lumpectomy alone, lumpectomy and radiation, or mastectomy. Tamoxifen can be considered for prevention of recurrence in the case of lumpectomy. 

Treatment options for invasive breast cancer include lumpectomy with or without under the arm (auxiliary) lymph node dissection. Usually when a lumpectomy is performed, radiation also is administered to prevent recurrence in the remaining breast tissue. Modified radical mastectomy (removal of the whole breast tissue and auxiliary lymph nodes) can also be performed instead of lumpectomy and radiation, however larger tumors may still require chest wall radiation. Chemotherapy or hormonal therapy may be given to women prior to surgery to allow larger tumors to shrink making therapy less extensive.

Once the tumor is removed, depending on the risk, treatments such as hormonal therapy with Tamoxifen or an aromatase inhibitor, chemotherapy or biologics such as Traztuzamab (herceptin) can be administered to help prevent recurrence outside the breast. Tumors that are estrogen receptor positive and Her-2-Neu negative can be sent for Oncotype-Dx assay analysis to further estimate prognosis and benefit of adjuvant therapy. 

For tumors that have spread systemically beyond the breast, treatment options include chemotherapy, hormonal therapy and/or biologic agents such as herceptin and Avastin.  With more of these agents available, many patients are living longer and with a better quality of life. Radiation can be used to relieve symptoms such as pain from bony metastases. Intravenous bisphosphanates such as Zoledronic Acid can help reduce morbidity of disease that has spread to bone.
 
Breast cancer patients at Weiss also may participate in cancer support groups or clinical trials.

More information about breast cancer can be found at the following Web sites:

For more information
If you would like more information about breast cancer or would like an appointment or a second opinion, please call Lakefront Oncology and Hematology Associates at (773) 564-5030.



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