Running head: BREAST CANCER WITH CHEMOTHERAPY

Breast Cancer with Chemotherapy

Janet Chow
Tin Hlaine
Evelyn Rocha
Stephanie Wong
Professor Buxton-Pacheco
February 18, 2015
NTRS 415A
Winter Quarter 2014
California State University, Los Angeles

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Pathophysiology of the disease

Breast cancer is a malignant tumor that starts in the cells of the breast and can divide into
the surrounding tissues or spread to other parts of the body. According to the Breast Cancer
Foundation Inc. (2014), breast cancer affects 1 in 8 women in their lifetime. It is mostly found in
women but men can also be diagnosed with breast cancer. It is the second leading cause of death
among women in the United States with lung cancer being the first. Any type of cancer,
including breast cancer, occurs because of damage to the DNA or mutations in the genes
responsible for controlling the growth of cells. The normal cells in the human body help regulate
the growth, maturity, division, and death of the cell cycle. According to the American Cancer
Society (2015) mutations in the cells can either turn on or turn off genes in certain cells that
make it divide out of control forming a tumor. There are two different kinds of tumors, benign
and malignant. Benign tumors are considered to be non-invasive because the cells have the same
appearance as a normal cell. Malignant tumors are cancerous tumors and if left untreated they
can spread to other parts of the body.
The American Cancer Society (2015) also states that breast cancer begins in the cells of
the milk producing glands or ducts. It can also begin in the fatty fibrous connective tissue of the
breast. When cancer begins the cells become mutated and begin reproducing growing in numbers
therefore, becoming a tumor. The cancer cells can then invade nearby healthy breast tissue and
make their way to the lymph nodes of the underarm. If cancer cells reach the lymph nodes of the
underarm they have a secure way to reach other parts of the body.
There are many different types of breast cancers. One type of breast cancer is called
Ductal Carcinoma Situ (DCTS), also called non-invasive breast cancer, and it happens when
abnormal cells start in the lining ducts without growing into other tissues of the breast. A second

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type of cancer is Invasive Ductal Carcinoma (IDC), which is the most common form of breast
cancer. This cancer starts when abnormal cells in the lining duct cross through the wall of the
duct and spread into a nearby breast tissue making it possible for the cells to spread to the lymph
nodes or other parts of the body. A third form of breast cancer is called Invasive Lobular
Carcinoma and it starts in the cells lining the milk glands. They can grow through the wall of the
lobules and spread to the lymph nodes nearby. The fourth type of breast cancer is called
Inflammatory Breast Cancer (IBC) and it is a rare form of cancer. This cancer shows no signs of
a lump or tumor rather it makes the skin of the breast look red, warm, thick, and pitted.
Breast cancer is classified into four different stages. These stages state the severity and
progress of the cancer. Breast cancer in stage 0 states that cancer cells have not spread to the
surrounding breast tissue. In stage 1 the cancerous tumor is no more than 2cm in size and has not
spread beyond the breast. In stage II the cancerous tumor has spread to the lymph nodes of the
underarms but the tumor is less than 2cm or the tumor has not spread to the lymph nodes of the
underarms and it is greater than 5 cm is size. In stage III the tumor is greater than 5cm in size and
has spread to the lymph nodes of the underarm. In stage IV the cancer has spread to other parts
of the body.
The signs and symptoms of breast cancer vary widely though, when breast cancer is in its
early stages it does not show any signs nor symptoms. Some of the symptoms of breast cancer
include a lump in the breast or underarms that persist after a womans menstrual period, swelling
in the armpits, pain or tenderness in the breast, flattening or indentation of the breast, any change
in size, contour, texture, or temperature in the breast, and a change in the nipple such as nipple
retraction, itching, and burning sensation. Having a reddish pitted surface like an orange can also
be a sign of having an advance stage of cancer.

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There is no definite answer as to what causes breast cancer but certain risk factors are
related to the disease. According to the National Breast Cancer Foundation Inc. (2014), some
risks factors related to the disease include gender, inherited genetic risk factors, family history,
personal history of breast cancer, race, having menstrual periods early in age or beginning
menopause late. Also, using hormone therapy after menopause can increase a womans chance of
developing breast cancer. Drinking alcohol and being overweight or obese can also be risk
factors for developing this disease. Some of these risk factors can be change by having a person
make changes in their lifestyle and that in turn can reduce their chances of developing breast
cancer.
Pertinent laboratory findings (include serum, chemistry, hematology, urinalysis, etc.)
When someone is diagnosed with breast cancer the doctor usually orders the patient to
get additional lab testing done, asides from the regular procedures, to help with their prognosis.
According to the National Breast Care Foundation. Inc. (2012), the two most common lab tests
are the hormone receptor test and the HER2/neu test. Results from these tests can help indicate
which cancer treatment is most effective for the patient.
In the hormone receptor test, many breast cancer tumors contain hormone receptors that
can fuel the growth of the cancer. The receptors involved are estrogen and progesterone and the
test typically uses a specialized staining process on the breast tissue sample to see if the hormone
receptors are present. Moreover, according to National Breast Care Foundation, Inc. (2012), If
the cancer is deemed estrogen-receptor-positive (ER+), its cells have receptors for the estrogen
hormone and that indicates the cancer cells likely receive signals from estrogen to promote
growth. The same applies to progesterone, where If the cancer is progesterone-receptorpositive (PR+), its cells have receptors for the progesterone (National Breast Care Foundation,

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Inc., 2012). Breast cancer patients who test positive for both estrogen receptors and progesterone
receptors usually have a better chance of survival and complete recovery compared to those who
do not have any receptors present.
Additionally, the second test is the HER2/NEU test, which also looks for a specific
receptor that is found in certain types of cancer cells and the gene that produces it. Normally, the
HER2 receptors are proteins that help manage the growth, division, and repair of breast cells.
However, with breast cancer, the HER2 gene does not function properly and the malfunction of
this gene causes the production of too many HER2 receptors. Having too much of these receptors
causes uncontrollable growth and division of breast cancer cells. Moreover, this test can help
detect whether a sample is normal or where it has too much of the HER2/neu protein or too much
of the copies of its gene. National Breast Care Foundation, Inc. (2102), indicates that there are
four tests for HER2 which include: IHC (Immuno-Histo-Chemistry) to look for excess HER2
proteins in cancerous cells and the three other tests consist of FISH test (Fluorescence In Situ
Hybridization), SPoT-Light HER2 CISH test (Subtraction Probe Technology Chromogenic In
Situ Hybridization), and Inform HER2 Dual ISH test (Inform Dual In Situ Hybridization) to look
for excess of copies of the HER2 gene. The IHC test have results of 0 or 1+ which indicates there
is no excess, 2+ for borderline, and 3+ for positive test in for HER2 protein overexpression. For
the other three tests, they have the results of either positive for HER2 gene amplification or
negative for amount of HER2 gene is not excessive. Therefore, breast cancers with HER2 protein
overexpression and HER2 gene amplification are HER2 positive and cause the cancer to grow
faster and spread to other areas compared to a negative test.

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Common diagnostic test or procedures with a brief description of what each test evaluates
There are a variety of ways to diagnose breast cancer depending on the presentation or
sign and symptom the patient have. Screening methods such as mammogram are used for women
starting from the age of 50, and then annually or every 2 years depending on the risk (example,
family history). For women with history of breast lump/mass or with a strong family history
(example, history of breast cancer in a first degree relative) of breast cancer would need earlier
check-up and self-breast examination. Physical examination done by a medical personnel or a
physician can also detect abnormal breast lump, cyst, abnormal skin changes, nipple discharge,
or lymph node enlargement. Mammograms, ultrasound of breast, MRI of breast, biopsy of breast
lump, lymph node biopsy, ductal lavage, and nipple discharge exams are the diagnostic
procedures commonly used to diagnose breast cancer.
A mammogram is an x-ray picture of the breast. Screening mammograms are used to
check for breast cancer in women who have no signs or symptoms of the disease. Diagnostic
mammograms are used to check for breast cancer after a lump or other sign or symptom of the
disease has been found. Another procedure commonly used is USG (ultrasound) of breast tissue.
It is a safe and painless procedure. It produces pictures of the interior part of the breast using
sound waves. Ultrasound imaging is also called ultrasound scanning or sonography, and it
involves the use of a small transducer (probe) and ultrasound gel placed directly on the skin.
Furthermore, another imaging study call MRI (magnetic resonance imaging) is used for
diagnosis of breast cancer. This is a noninvasive medical procedure used for screening of breast
cancer, determining the extent of cancer to see if there are any metastases (spread of cancer to
other areas of the body), and following the chemotherapy treatment of breast cancer.

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There are more invasive measures such as biopsy of breast tissue or breast lump. Biopsy
of breast tissue involves the removal of tissues from a breast lump or mass. The biopsied tissues
are examined under a microscope to check for breast cancer cells. A biopsy is the only way to
determine if a breast lump or mass is benign or malignant (cancerous). Biopsies can be taken
from sites other than breast, for example from lymph node. Lymph node biopsy is taken from the
sentinel node which is usually the axillary nodes (under the arm). The sentinel nodes are the first
place that cancer is likely to spread. Sentinel node biopsy pinpoints the first few lymph nodes
into which a tumor drains (known as the "sentinel" node). This is also useful in staging (how
much the cancer has spread) of breast cancer in a patient.
FISH test (Fluorescence In Situ Hybridization) is a relatively newer genetic testing for
breast cancer. FISH testing is done on biopsied tissue to see if the cells have extra copies of the
HER2 gene. This means that these cells have more HER2 receptors. These HER2 receptors
receive signals that stimulate the growth of breast cancer cells. FISH test results will show
whether the cancer is either positive or negative for HER2 receptor. HER2 receptor positive
breast cancer are more likely to respond to a certain chemotherapy medication (example with
trastuzumab) that blocks the ability of HER2 receptors to receive growth signals. FISH test is
expensive and not widely available.
A procedure called ductal lavage can be done to detect cancerous cells from breast tissue.
It is also a screening tool used to detect precancerous and cancerous breast cell changes in
women who are at high-risk to develop breast cancer (those with multiple breast cancer risk
factors such as strong family history). A small cannula is placed into the milk duct, and then fluid
is washed into the duct to rinse out cells. This fluid is then pulled back out of the nipple, and
evaluated under the microscope.

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In addition, discharge fluid can be examine for presence of cancerous cells. Some patients
with breast cancer have bloody or serous (clear fluid) nipple discharge. For those patient with
nipple discharge, this fluid may be collected and examined under a microscope to see if any
cancer cells are detected.
Medical or surgical treatments for the disease
Furthermore, chemotherapy or chemo is a common form of treatment for breast cancer.
According to American Cancer Society (2015), the chemotherapy treatment consists of cancerkilling drugs that can be injected in the veins or taken by the mouth. The drugs travel through the
bloodstream to reach the cancer cells in throughout the body and chemo is given in different
cycles, where each period of treatment is followed by a recovery period. Chemo is most effective
when a combination of more than one drug are used. Treatment typically lasts for several
months. It is also the main treatment for the advanced stage of breast cancer.
Moreover, there are two different types of chemotherapy: adjuvant chemotherapy and
neoadjuvant chemotherapy. Adjuvant chemotherapy (after surgery) is therapy used when there is
no evidence of cancer after surgery. Surgery is typically used to remove all of the cancer that can
be seen, but adjuvant chemotherapy is used to kill any cancer cells that may have been left
behind or spread that is not as visible. This form of therapy is used after breast-conserving
surgery or mastectomy to reduce the risk of the breast cancer coming back. Radiation, chemo,
targeted therapy, and hormone therapy are other forms of adjuvant chemotherapy. In addition, for
neoadjuvant chemotherapy (before surgery), it consists of treatment before surgery instead of
after surgery. There are two benefits to neoadjuvant chemotherapy: one benefit is that chemo
may shrink the tumor so that it can be removed with a less extensive surgery and the other
benefit consists of giving chemo before the tumor is removed, allows doctors a better perspective

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on how the cancer responds. The first benefit allows the treatment of cancers that are too big to
be surgically removed at the time and diagnosis, while the second benefit allows the use of other
drugs if the first set of drugs do not work.
In addition, there are various side effects to the chemo drugs and side effects depend on
the type of drug, the amount taken, and length of treatment. According to the American Cancer
Society (2015), common side effects of chemo drugs include hair loss and nail changes, mouth
sores, loss of appetite or increased appetite, nausea and vomiting, and low blood cell counts.
Chemotherapy can also affect the bone forming cells of the bone marrow and that can lead to
increased chance of infection from the low white blood cell counts, easy bruising or bleeding
from low platelet counts, and fatigue from low red blood cell counts. The side of effects of
chemotherapy usually are short term and tend to diminish once treatment is finished.
Besides chemotherapy, there are other forms of treatment for breast cancer and they
include surgery, radiation therapy, hormone therapy, targeted therapy, and bone-directed therapy.
According to American Cancer Society (2015), surgery is used to remove the breast tumor and
the breast can be reconstructed at the same time or later on. Surgery is also used to check the
lymph nodes under the arm to see if the cancer spread. The different options of surgery include
breast-conserving surgery, mastectomy, sentinel lymph node biopsy, and axillary lymph node
dissection. Moreover, radiation therapy uses high-energy rays or particles to destroy the cancer
cells and is often used after breast-conserving surgery to reduce the chance of the cancer
returning. Radiation therapy consists of two different forms of external beam radiation and
brachytherapy. Then for hormone therapy, American Cancer Society (2015) state that estrogen
promotes the growth of cancer cells that are hormone receptor-positive and most breast cancers
are hormone receptor-positive. The hormone therapy involves lowering estrogen levels or

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preventing estrogen from acting on breast cancer cells. For targeted therapy, specific drugs are
used to target the gene changes in cells that cause cancer and American Cancer Society (2015)
state that these drugs have less severe side effects than chemo drugs. Finally for the bonedirected therapy, it is used when the cancer spreads to the bones and there are drugs used to
reduce problems of the cancer causing pain in the bones and bone fractures. Bisphosphonates
and denosumab are the two common drugs used in bone-directed therapy. Thus, there are many
forms of treatment for breast cancer.
Commonly prescribed drugs (include drug classifications and indications for use)
Finally, chemotherapy treatment for breast cancer uses medicine to weaken and destroy
cancer cells in the breast. There are six commonly prescribed drugs used to help treat breast
cancer. These drugs are usually given in 2 to 4 week cycles, but some can be used on a daily
basis. Most chemotherapy drugs are given in combinations of two or more drugs because it is
more effective. Chemotherapy drugs are classified into different groups based on factors such as
their relation to other drugs, how they work, and their chemical structure. The two most common
groups of chemotherapy drug used for early stages of breast cancer are anthracyclines and
taxanes.
Anthracyclines are a type of antibiotic used to kill cancer cells by interfering and
damaging the genetic material of cancer cells. Some commonly prescribed anthracyclines are
doxorubicin and epirubicin. Both doxorubicin and epirubicin are given intravenously to a patient
for around 15 minutes, the dosage and time depends on blood counts, how the liver is working,
and frame size. Taxanes are used to interfere with cell division, which stops the cells from
dividing causing it to die. Paclitaxel and docetaxel are taxane chemotherapy drugs that disrupt
the function of microtubule, which interferes with cell division (Moreno-Aspitia).

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Works Cited
American Cancer Society. (2015). How is breast cancer treated?. Retrieved from
http://www.cancer.org/cancer/breastcancer/detailedguide/bre?ast-cancer-treating-general-info
American Cancer Society. (2015). What is breast cancer?. Retrieved from
http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-what-is-breast-cancer
Breast Cancer Tests: Screening, Diagnosis, and Monitoring. (n.d.). Retrieved February 9, 2015,
from http://www.breastcancer.org/symptoms/testing/types
Diagnostic tests for breast conditions. (n.d.). Retrieved February 9, 2015, from
http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/forwome
nfacingabreastbiopsy/breast-biopsy-diagnostic-tests-used
Moreno-Aspitia, A., & Perez, E. A. (2009). Treatment Options for Breast Cancer Resistant to
Anthracycline and Taxane. Mayo Clinic Proceedings, 84, 533545. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688627/
National Breast Cancer Foundation, Inc. (2012). Lab Tests. Retrieved from
http://www.nationalbreastcancer.org/breast-cancer-lab-tests
National Breast Cancer Foundation, Inc. (2012). What is Cancer?. Retrieved from
http://www.nationalbreastcancer.org/what-is-cancer
WebMd. (2014). Understanding Breast Cancer-Symptoms. Retrieved from
http://www.webmd.com/breast-cancer/guide/understanding-breast-cancer-symptoms

Stephanie Wong, Tin Hlaine, Evelyn Rocha, and Janet Chow

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Breast Cancer with Chemotherapy Summary Handout

What is Breast Cancer?
Breast cancer occurs when breast cells become abnormal and grow faster than normal
cells. These extra cells can form a tumor, where some are either benign or not
cancerous or malignant or cancerous. The malignant cells disrupt normal function
and can spread to other parts of the body.
Signs/symptoms
A new lump in the breast, a lump that has changed, change in size or shape of breast, pain
in breast or nipple that does not go away, flaky, red, or swollen skin anywhere on the
breast, a nipple that is very tender or that suddenly turns inward, and blood or any other
type of fluid coming from the nipple that is not milk when nursing.
Causes/ risk factors
Older age, family history of breast cancer or other breast diseases, noting children or
having first child later in life, starting first menstrual period at early age, beginning
menopause late, drinking alcohol, using hormonal replacement therapy for a long time,
being physically inactive, being overweight after menopause, having genetic condition,
and using oral contraceptives.
Pathophysiology
Breast cancer begins in the cells of the milk producing glands or ducts. It can also begin
in the fatty fibrous connective tissue of the breast. The cells become mutated because of
damage done to the DNA of the cell. They then start reproducing in growing numbers
turning into a cancerous tumor. Once the cells become cancerous they can invade other

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breast tissue and make their way up into the lymph nodes of the underarm. Once the
cancer reaches the lymph nodes it can then spread to other parts of the body.
Laboratory findings
Hormone receptor test: test positive or negative for either estrogen receptors or progesterone
receptors or both types of receptors
HER2/neu test (4 tests):
IHC test: 0 or 1+ = no excess; 2+ = borderline; 3+ = positive for HER2 protein overexpression
FISH, SPot-Light HER2 CISH, Inform HER2 Dual ISH: positive or negative for HER2 gene
amplification
Diagnostic test and procedures
Self-Breast examination, physical examination, mammograms, ultrasound of breast, MRI
of breast, biopsy of breast tissue or lump, lymph node biopsy, Fluorescence In Situ
Hybridization (FISH) test, ductal lavage, and nipple discharge exams are the common
diagnostic procedures to detect breast cancer.
Medical treatments
Chemotherapy treatment consists of using cancer-killing drugs that are injected by into
the veins or taken orally. The two types of chemotherapy are adjuvant and neoadjuvant.
Commonly prescribed drugs
Anthracyclines and taxanes are two classes of drugs that are commonly prescribed to
breast cancer patients. Anthracyclines are antibiotics that interfere and damage genetic
material of the cancer cells. Both doxorubicin and epirubicin are anthracyclines that are
given to patients intravenously. Taxanes are used to stop the cancer cells from dividing,
paclitaxel and docetaxel are two common taxane drugs used to treat breast cancer.