Breast Cancer

i wanted to be able to videotape thetalk that i normally give patients when you first come see me with adiagnosis of breast cancer there's so many, so much information ineed to convey and so many decisions that need to be had uh made, it's really nice if you wouldhave a resource to be able to go back to. so really what i'm going to do is justgo through this speel that i normally do with my patients. when i given this speel i ask themto hold their questions till the very end because most the time

by the time i get to the end of this speel i have answered almost all of their questions. so first of all, the first and verymost important thing to understand is that breast cancer is a really reallycommon disease. almost 200,000 women were diagnosed withbreast cancer in the united states alone last year. the other good news, although i can't say it's necessarily good news, but the good news is most women go onto survive their breast cancer. so wenever want the treatment to be worse

than the disease. we do know that the rate a breast cancer has finally startedto decrease and that probably has something to do with women really stopping hormone replacementtherapy at a older ages. so there'd haven't been exposed to it for a long time but they're still i breast cancer in theunited states. so just first a little bit about breastcancer biology it's really important to understand the breast cancers arerelatively slow-growing cancer so

and it works by doubling time so goesfrom one cell to two cells, two cells to four cells eg cetera and so by the time we can detect abreast cancer mammographicly it's usually about five millimeters at aminimum and that means it's probably been growing for about five years. by that time we can pick one up that wecan feel which is usually about one centimeter or ten millimeters it's probably been growing for about 10years. now i don't tell patients this to get them upset that they should havepicked this up last year five years ago

or ten years ago. i tell them this so they understand thatthere's really not a huge rush in fact is somebody tells you you have breastcancer you need both breasts cut off tomorrow they just don't understand the biologyof the disease and i really want you to understand both the biology of thedisease in all your treatment options have some time to think about thatbefore you make your decisions about which way you want to go. so let's talk a little bit about riskfactors for breast cancer, first of all

the two biggest risk factors for breastcancer are being a woman and getting older, neither which we can really change and most patients those are there onlytwo risk factors. the other things that we talk about certainly there's geneticrisk that accounts for only about five percent thebreast cancers that we see united states there are also things like familyhistory, early time that you started your period,early age or late menopause. but once you have breastcancer obviously all those are moot points. we do

use some of those - especially familyhistory to assess and helping your treatment planning. but they really aren't things that onceyou're diagnosed with breast cancer that help us much. when we talk about breast cancer i liketo try and divide it into treating the local disease which is usually treatedwith surgery and radiation and then treating the disease that might be beyond local disease so i call thatsystemic disease and that or use drugs like chemotherapythe stuff to make your hair fall out

makes you sick to your stomach and hormonal therapy usually a pill thatdoesn't really help don't really have many side effects. what's the most important thing from mystandpoint as a surgeon to understand is that your long-term survival is based oncharacteristics of the tumor. not on the surgical option that youchoose for your breasts. so those four characteristics that help us determine howgood or bad your cancer are are the following: number one is size ofthe tumor number two is whether or not lymph nodeshave cancer in them

number three is are there hormonereceptors on the cancer cells so those are docking stations for the hormones that your body makes thatwhen your if you have those on your cancer cellsthe estrogen and progesterone that your body makes dock in there and then they stimulate the cells togrow. not all cancers breast cancer cells have those but itdoes give us useful information. and then the fourth thing is grade ofthe tumor so that means what did the tumor cells look like

underneath the microscope. now i like toexplain this because most women that we see with breast cancer have someexperience with teenagers. so i like to explain it like teenagers. so there'sthree grades of breast cancer grade 1 is well differentiated, grade2 is moderately differentiated and grade 3 is poorly differentiated. so i think of it as teenagers. grade 1 isthat you left the house for two or three hours and your teenagers know exactlywhen you're going to get back. so they're probably not gonna try toomuch, they're not terribly aggressive about it.

grade 2 which frankly is the most commonrun-of-the-mill breast cancer in women means you left for more than a couple ofhours but that teenagers are pretty sure when you'll be home maybe a leftovernight but they know you're going to be back early saturday morning. great three is you left the teenagersfor a weekend and and they don't really know when you'recoming back so they might be a little bit more prone to try a few things sothat's how i like to explain those grades. so other things that we consider whenwe're trying to determine the treatment

options for breast cancer patients arethe patients age. so really we kind of make a dividingline at age 70 and that's in part becausepatients over age 70 tend not to do so well with they're really harsh treatments andthey don't have as much to gain in long-term survival so if you're seventythe chance of you being alive twenty years from then is a littlebit less than if you're forty when you're diagnosed. we also look at her2/neu that's againa receptor on the cell wall

we used to think if we had, your tumorcells were positive for her2 that was really badbecause it means the cancer is more aggressive. but in the last five years there's a drugthat was developed to treat specifically target that receptor andit's called trastuzumab or herceptin is thetrade name for it and it specifically targets thosereceptors and kills any cells that have those receptors on them. thegood news is it's rare for other cells besides breast cancer cells to have her2 on them. so it's a very effective

treatment. and then we also try to look at yourpredicted life expectancy so most women in their forties aredefinitely living another 20 years if not forty years although there's anoccasional patient in the fifties and sixties that have other diseases that make their lifeexpectancy not so long. so we try to treat the whole patient so once we determine then we see all thecharacteristics of the tumor then we try to think what up all these treatmentsthat we have available will you need for

your breast cancer. so most people need surgery although thereare some exceptions to that there are some people who need radiationtreatment, some people who need chemotherapy, and then some people need hormonaltherapy, and those four characteristics help us determine that. so they are also what help us determinehow what the risk is that you're gonna die from this breast cancer. so chemotherapy is really the thing thatmost people fear

and chemotherapy again is the stuff thatmakes you sick to your stomach although if you take all our good medicines toprevent that you probably won't get sick to your stomach. but it definitely make sure hair fall out. why does thatmake your hair fall out well because chemotherapy targets any fast dividingcells which include the cells that make yourhair grow. that's what makes your stomach upset because the cells that line your gut, yourstomach and things like that turn over very quickly like once a week.

so those those cells get killed and that's what makes you sick to yourstomach and some other things. it also impact your ability to fightinfections cause your blood cells are white and red blood cells turn over veryquickly. but this is these are the general guidelines for chemotherapy soin general we use these four things and your age. so if you're under age 70right now the recommendations are if your tumor is over two centimeters in size thanalmost everybody would recommend you

have chemotherapy no matter what thosethree other characteristics are. if your tumor is between one and twocentimeters than we think you should be considered for chemotherapy andcertainly if you are on the younger side we're gonna push more for chemo. ifyour lymph nodes have tumor in them then almost everybodybelieves if you're under age seventy you should have chemotherapy because that'sa sign that the tumor cells might have gotten outside your breast. if you got hormone receptors on yourcells then we might kinda ease up some theother things why cuz we have lots of

good drugs to treat to either block those receptors orkeep your body for making the hormone so having the hormone receptors on yourcells is a good thing. and then we use a grade again with thoseother things that if you're on the borderline for chemotherapy and yourtumor looks like it's the well-behaved teenagers then we might be a little less likely tosend you on to chemotherapy. so we use all those. now people get confused and they saywell if i have a mastectomy then i don't

need chemotherapy right? wrong. chemotherapy is something toprolong your long-term survival we users four characteristics: size, lymphnode status, hormone status and grade to help us determine if you needchemotherapy and again we treat the whole patient so if you're older youhave a lot of medical problems we might change some of those recommendations. now radiation therapy in general is usedto treat the local disease and we'll get into that more when we talk about thesurgical options. but over the years we've expanded theuse of radiation therapy.

so we now, sometimes will recommendradiation therapy even beyond local treatment. but againi'll get into that. so let's go into the surgical therapy.let's start first with lymph nodes. now the reason i wanna start first with thatis because that's not always as much of a choice. we're gonna push you one way orthe other. so first of all in my practice if i candetermine that you have tumor cells in your lymph nodes prior to your surgery then you go directly to anaxillary node dissection. so that means a lymph node in your armpit, you probablyhaven't we were clear

everything out you probably have sixtylymph nodes underneath your arm we're gonna try with an axillary lymphnode dissection to get ten or fifteen. that's not all of them but why ten orfifteen because we think that would get adequate staging. the act of taking lymph nodes out from underneath your arm does not provide you a survival benefit. so to me why takes, you know, do more surgerywhen it doesn't impact your long-term survival. so i have two goals for taking outlymph nodes from underneath the arm if if we know there's tumorcells in there.

one is to get at least 10 lymph nodes sowe can be sure we've got an adequate sampling of those 60. and two is any lymph node that isgrossly positive for tumors. so what do i mean by that? well i've done alot of these operations and we know that lymph nodes that are normal are generally kidney bean shaped, they're brown and they're soft. lymph nodes is one placewhere in general size and breast cancer size doesn't really matter but theirconsistency in their color seems seem to be more predictive. so if i'moperating on someone and i know they

have tumor in their lymph nodes, i'm gonna feelfor any hard ones and take those out. why? cuz i wanna provide local control sothat they don't end up with tumor growing to their skin later on. so ten to fifteen lymph node andcertainly anything that feels positive. so if you if we can't prove that youhave tumor in your lymph nodes to begin with which is most patients withbreast cancer. most patients with breast cancer it's picked up very early, it'shighly treatable. then we do something called the sentinellymph node biopsy. now you remember i said just a littlewhile ago that the act of taking lymph

nodes out from underneath the arm doesnot improve survival. so we find, we've looked at this inbig clinical trials to see could we get by with taking out fewer lymphnodes and the answer seems to be yes. if we can target the exact right lymph nodes to get so that's what the sentinel lymph node technology does. i inject a dye into the breast on the dayof surgery it's a radio labeled dye some people also add in a blue dye and then that helps me find the firstcouple lymph nodes that the breast drains to.

we know that if you're going to havecancer in any of the lymph node underneath your arm ninety-six percent the time it'll be inone of those sentinel lymph nodes. now let's not get confused just becausei can find a sentinel node doesn't mean you have cancer in it. in fact it just means we found thesentinel node. then we look at it very carefully to be sure it does or does nothave cancer in it. so for most patients we do that what'scalled the sentinel lymph node biopsy and i take out the first few lymph nodesthat the breast drains to. i have a little

hand-held geiger counter in theoperating room that helps me find those lymph nodes. we send those off to the pathologist. theydo a frozen section so our still in the operating room they look to see is theircancer in this lymph node. if there's cancer in the lymph node andwe need to take out to get about 10 lymph nodes out. if there's not cancer in the lymph nodewe stop. the average number of lymph nodes we take out for sentinel lymph node biopsyis between two to three and they could range from one to six butwe really try to only get that

first few that we need for that. so mostpatients unless you're really old and we don't think we're gonna change ourtreatment based on that. what's really old? well have to be careful because youknow as i get older my parents get older it really old is not bad at all but in general if you're over age about 75 or if your health if you're younger thanage 75 in your health is not so good then and we won't look at lymph nodesbut if you're under age 75 then we probably will. okay. so that's a lymph node status thenwe have to talk about what to do about

for local treatment for the cancer thatin your breast. now i am going to emphasize this again cuz it's a really really importantconcept, what surgery you use for your breast doesnot impact your long-term survival. cuz that's impacted by the fourcharacteristic: size, lymph node status grade, and hormone status. so we knowfrom big randomized trials that were conducted 25-30 years ago now and wehave published 25-year follow-up data on those ladies that no matter what yoursurgery you choose for your breast your long-term survival is dependent on thecharacter of the tumor, not what you do to your breasts. those survival curves

completely overlap. so what's differentis what you might think is different is that the less you do to the breast thehigher the risk of local recurrence, so in the breast. so really there aretheoretically three options: one is lumpectomy, for what to do withthe cancer that in your breast, one is lumpectomy alone. so that means remove the tumor and arim of normal tissue around it. that rim needs to be about two millimetersor know like an eighth of an inch and then no other local treatment to thebreast. the second option is lumpectomy followed by radiation treatments

and the third option is a mastectomywith or without reconstruction. so again we know from these big studiesno difference in long-term survival. so what's the difference? well if you do a lumpectomy alone and noother local treatments to your breast you risk having recurrence in that breast is 30 to 40 percent at twenty years. andso for most of our women unless you're in your mid 70's and above, you know you're still going to be alivetwenty years from now so that's too high recurrence rate to put up with.

now if your 85 when your breast cancers detectedit's probably fine. ok. lumpectomy followed by radiationtreatments whenever we've added radiation treatments into local treatment for breast cancer it reducesthe recurrence rate by about half if not more. so that meansif you have a lumpectomy followed by radiation treatment your risk of havinga local recurrence in your breast is about 15 to 20 percent. turn thosenumbers around, look at the glass is half-full instead of half-empty, that's an80 to 85 percent chance it won't come back in breast.

those are pretty reasonable odds foralmost everyone. alright. so and in the trial that i am quoting these numbers out of was the american trial and they allowedwomen into that trial with tumors up to four centimeters so i'm saying this but you know four centimeters are about that big. inthe european trial that was done at the same time they only allowed women in with tumorsup to two centimeters and their risk of local recurrence at twenty years was about eight to 15 percent so for mypatients with the smaller tumor to

two centimeter or less, i like to quotethem those numbers. so those again are very a reasonable rate.eighty-five to 90 percent chance you won't have cancer back in your breast. that is a pretty good numbers. if you have amastectomy whether or not you have reconstruction, you think well doesn'tthat take away my risk of local recurrence totally cuz you removed mybreast. not really. so it's about a five percentrisk a recurrence at twenty years. so you have a chance of it coming backon the chest wall, in the skin, or in the scar.

and do we see that happen at about 5percent? yeah we do. and so there's no way to really assureyourself that it's never coming back. so for a lotof women weighing the risk of a 5 percent chance a recurrence verses 10percent local recurrence, no difference in overall survival, that really puts thedecision up lumpectomy versus mastectomy in their court. so thenwe can take because we know that outcomes are nodifferent than we can take other things into account. what's the breast gonna look like if we do alumpectomy? what would be your outcomes

if you had a mastectomy with or withoutreconstruction and we can explore all those options. i never assume what someone'srelationship is with their own breast. it's very easyto say well if i ever had breast cancer i would do abc. well actually once you get breast cancerit becomes a little different because the breast is a body part and do we do youreally want to lose your breast if you don'thave to. most people say no but it's a very personal decision and iam not the one to make that.

now if there's a medical reason that ishould make it like there's tumor in more than onequadrant then we might push for mastectomy or let's say it's a tumor,they're still cancers we can't detect on mammogram or on ultrasound. and so if it's one that we had troubledetecting then i might push more towards a mastectomy. why? because then i i would have trouble detecting arecurrence probably. so there are certain situations where we push you that way. the otherthing is if you have a large tumor

compared to the size of your breast i'm not going to be able to leave youwith a very nice looking breast and so for cosmetic reasons i might push ittowards a mastectomy. but still it's usually the woman's decision. ok? now i use to say if you do a mastectomy you won't need radiation. remember wetalked about radiation a little bit ago? but there are three reasons why youwould get post mastectomy, so after mastectomy radiation. the two long-standing ones are if you havea tumor more than five centimeters we

give radiation after mastectomy because therisk of having a local failure or a tumor coming back on the chest wall ispretty high once you get up to tumors bigger than five centimeters. number two is if you have a close marginthat's in a place where we can take more tissue like muscle or skin, then we recommend radiationafterwards. and then the third thing that came aboutin the late 1990s with the publication of two randomizedtrials in different parts of the world

that radomized trial look atpre-menopausal women with breast cancer who who had four or more positive lymphnodes, they randomized them so flipped a coin. you either put them in to rate postmastectomy radiation or not all the women that chemotherapy and whatthey found in both the trials was that the womenwho got radiation had in improved long-term survival. so if you have positive lymph nodes eventhough the trials were done with lots of positive lymph nodes, we pretty muchthink

you should be considered for radiation.so we take all that into account when we talk about what we're gonna do. so if i know, if i'm pretty sure yougonna be able to skip radiation with the mastectomy i'll tell you that but idon't ever promise it anymore cuz there are many reasons why you might getthat. so um, i wanna talk a little bit now about reconstruction options and not goin-depth into that but to to make the point that we believestrongly from data that are out there that animmediate breast reconstruction is

oncologically safe. meaning it doesn't increase your risk of recurrence orincrease your risk of dying from your breast cancer and we believe stronglythat anyone woman who want reconstruction weshould offer that to her. no matter whether they're gonna needradiation after mastectomy or not. now because there are so many women whoend up in a post mastectomy radiation group we do frequently, in fact i would say 95percent of the time say if your gonna have an immediate reconstructionwe're gonna do a temporary one

first. so in case there something thatchanges things and you do need radiation after mastectomy we radiate you with the expander in, thetemporary reconstruction there rather than other types ofreconstruction because we feel that outcomes are better. so that's kinda the overview forinvasive breast cancer there's also a pre-invasive cancerthat's called duct carcinoma in situ. and pre-invasive cancer is treated a lotlike invasive cancer of the breast except for the most part minus the lymphnodes

so pre-invasive cancer means that youhave cancer cells within the ducts so the ducts that drain the milk.but that we don't have any evidence that they've broken outthrough the ducts. so if we think you only have pre-invasive cancer then we treat it as if it were invasivecancer as far as local treatment. so your options again are lumpectomy usually followed byradiation treatments or mastectomy with or without reconstruction. if you go the lumpectomy route with preinvasive cancer we don't check your lymph

nodes. the reason is there should be nochance that you have tumor in your lymph nodes. and the risk of doing the lymph node biopsy is higher than the chance thatyou would have any bad news in there. if however you end up having amastectomy for your pre invasive cancer we do a sentinel lymph node biopsy at thetime of the mastectomy. the reason for that is is that usuallythe reason you're getting it a mastectomy for pre invasive cancer isbecause you have a lot of it. and it's possible that there is somelittle invasive cancer hiding amongst

all of that pre invasive cancer. if we find that out after your breast isremoved then we don't have any way to do the sentinel lymph node biopsyand then we're in a quandary, cuz were like, well that thisteeny tiny one millimeter invasive cancer. do we really need to take out tenlymph nodes when we're pretty sure there's not going to be anything in there? so wedo that ahead of time. again just for that maybe 10 percentchance that you have a small invasive cancer in there with your pre invasive cancer. so

take home messages cuz i know it's hardto incorporate all this information and i'm really and what i tell the patients andpart of the reason we wanna do this video is it takes my residents and medicalstudents hearing this talk many times before they actually get it. so i want youto be able to come back, we have a whole book we give you. but sometimes it's justbetter to hear it again and so important take-home messages is number one is the characteristics ofthe tumor that help us determine how good or bad your cancer is

and whether how much treatment you gonnaneed whether that would involve chemotherapy. the second take-home message is whatyou choose to do your breast has no impact on your long-term survival.there's only one caveat to that and that is if we wentand took every woman's breasts off at age twenty we could probably prevent breast cancerbut to me that seems a bit radical so i don't recommend that. if you have, if you have a strong familyhistory we'll usually recommend that you

go to genetic counseling and possibly getgenetic tested. because the room that general overview i've given heredoes not include patients to have a genetic mutation as a cause fortheir cancer. in those patients they have much higher risk ofgetting another breast cancer so we tend to funnel them off towards a either more aggressive screening or ieven bilateral mastectomy so that's almost like a whole another talk. but ingeneral we want you know it's the characteristic of the

off the tumor that impact yourlong-term survival. what you do your breast is almost alwaysup to you and unless some anatomic reason we need to do it and theonly other thing is if you are one of those people. those few people who recorded theirbreast cancer after lumpectomy and radiation the standard treatment at that time asmastectomy so at this point i'm usually happy toanswer any questions