BREAST CANCER TREATMENT INFORMATION

This sample is a small example of the complete review you will receive.
Breast Imaging and Intervention
The concepts of the "comprehensive breast center" and "comprehensive cancer center" are recent
innovations whose times have come. I speak with experience as I have been fortunate enough to
receive my radiology residency and fellowship training in such unique environments, and I am
currently directing a breast center located within a comprehensive cancer center.

Allow me to introduce myself. My name is Alanna Harris, M.D. I am a board certified

radiologist with fellowship training in breast imaging and intervention. I am Chief of Breast
Diagnostics at the new Aventura Breast Diagnostic Center, located within the Aventura
Comprehensive Cancer Center. Both are affiliated with Aventura Hospital and Medical Center in
South Florida. The center was built to serve our growing population which was in need of sub
specialized cancer care and state-of-the-art diagnostic breast services.

It is important to realize when scheduling your mammogram that there is a tremendous range in
the quality of breast imaging services at different facilities. Some centers offer only screening
services and refer out their diagnostic cases. Others claim they are fully comprehensive but their
equipment is substandard and unsuitable for diagnostic and procedural purposes. Most general
diagnostic centers do not have dedicated mammographers (radiologists sub-specialized in
reading mammograms) and the radiologist who reads your mammogram is usually not the same
doctor who correlates that exam with your ultrasound.

At a true comprehensive breast center, the radiologists are dedicated mammographers who are
knowledgeable about the latest breakthroughs in breast imaging. Screening mammograms are
usually double-read by two mammographers to improve detection of subtle cancers. For
diagnostic patients, the same radiologist evaluates both the mammographic and sonographic
findings and correlates the studies to arrive at a conclusion. The radiologist should speak to all
diagnostic patients regarding their results.

A comprehensive breast center should offer state-of-the-art biopsy procedures such as

stereotactic core biopsies and sentinel node injections. The mammographers will also be skilled
at needle localization procedures, cyst aspirations, ultrasound guided core biopsies, and
galactography. Should a biopsy reveal a malignancy, the breast center staff will be able to assist
you in choosing a skilled oncologic surgeon who is affiliated with the cancer center. The
mammographer and surgeon will work together to ensure superb treatment.

The benefits of an association with a comprehensive cancer center are also extremely rewarding.
Medical oncologists, surgical oncologists, and radiation oncologists are often located in the same
building. Ancillary services such as psychosocial support groups and lymphedema therapy may
also be available.
I urge all women 40 and over (or younger if you have a family history of breast cancer or a
breast symptom) to have an annual mammogram. However, I caution you to investigate the
facility at which you are scheduled. At minimum, make certain that the center is FDA approved
and ACR accredited, and that a board-certified radiologist will be reading your mammogram.
The best choice you have for early detection of breast cancer is to go to a comprehensive breast
center with a dedicated mammographer.

Dr. Alanna Harris, M.D.

ALTERNATIVE TREATMENTS:-

This review will provide an overview of select alternative treatments. We will describe
alternative treatments, examine dietary support, botanicals and supplements that fight cancer, and
treatments for specifically neutralizing cancer and tumors. There are many more additions to
what we present and we hope that you will take action to win the battle over cancer by contacting
a health professional to help you begin an alternative program, such as the physicians and centers
listed at the end.
Here is an example of the cancer process and its reversal by the person most affected - a woman
with breast cancer with metastases to the bones.
Lisa, aged 44, was a chemist with a lifelong habit of eating high-fat foods and pushing herself to
workaholic extremes. She was a single mother of 3 children and worked full time. When she was
diagnosed with breast cancer, she agreed to the orthodox strategy of surgery and chemotherapy.

After these treatments, she decided to forgo the radiation treatment the surgeon recommended
because the chemotherapy had left her “feeling so weak.” She thought having radiation would be
too much for her system to handle. Three years late, the cancer returned with a vengeance, this
time metastasizing to Lisa’s bones.

A bone scan revealed that cancer had permeated both sides of her rib cage and seemed to be
moving into her spine. Several specialists told her nothing could be done and that she probably
had less than a year of life.

Now she had a difficult decision, whether to receive the same treatments as before and hope for
the best, or should she look for ways to support the self-healing ability of her body through
alternative treatments?

She visited Dr. Keith Block, M.D., mentioned along with other alternative physicians at the end
of the review, the next month and found that his integrated system of nutrition, botanicals,
phytochemicals, tailored exercise, and personalized stress management appealed to her. She was
impressed with the variety of non-invasive and low-invasive methods intended to diminish side
effects and boost effectiveness.

Within days of beginning Dr. Block’s program, Lisa began to feel more energized and
enthusiastic. Ten months into the program, her bone cancer was markedly reduced. For several
months she continued to take an anti-estrogen drug (Tamoxifen), but later discontinued it with
Dr. Block’s approval due to harsh side effects.
Lisa followed his dietary and lifestyle advice, attending his intensive health education seminars
in nutrition, cooking, therapeutic fitness, medicinal herbs, stress reduction, along with training
sessions in nutrition, detoxification, meditation, imagery, cognitive restructuring, and personally
tailored fitness techniques to strengthen her immune system.

Exercise and relaxation were vital aspects of her recovery. She practiced a series of slow,
contemplative movements; which Dr. Block taught her, and she regularly walked and bicycled.
She states that these were very relaxing to her and she did them frequently.

Lisa’s efforts paid off in a huge way.

After 16 months on the Block program, new CT and bone scans revealed that all of Lisa’s cancer
had disappeared. More than 13 years later, she feels better that ever and she says her life feels
much more balanced.

Therapies and Vaccines To Combat Breast Cancer

T/Tn Antigen Breast Cancer Vaccine

Georg Springer, M.D., showed that 2 antigens, called T and Tn, play a vital role in the immune
system's ability to respond to cancer and are present in 90% of all cancers. Through the use of a
specially developed vaccine, Dr. Springer demonstrated that the immune system's reaction to T
and Tn antigens results in strong cancer cell killing activity.

Cancer cells have proteins, or antigens, on their surfaces that can be recognized by the immune
system. The identification of certain cancer-related antigens forms the basis for the exciting
approach embraced by Georg Springer, M.D. Dr. Springer is an immunologist who founded the
Heather Bligh Cancer Research Laboratories at the Chicago Medical School. This pioneering
German scientist-physician has shown that 2 antigens, called T and Tn, play a vital role in the
immune system's ability to respond to cancer. Since the early 1980's, Dr. Springer has repeatedly
shown that the immune system's reaction to T and Tn antigens results in strong cancer cell killing
activity in both animal and human studies.

Using various biochemical tests, Dr. Springer has detected the T and Tn antigens in over 90% of
all cancers. The less aggressive cancer (meaning they are well differentiated) produce a higher
proportion of the T antigen, while the Tn antigen predominates in the more aggressive cancers
(meaning they are poorly differentiated). The overall concentrations of the T and Tn antigens
correlate with the aggressiveness of breast cancer,

DRS REVIEW:-

Natural History and Routes of Spread:

Breast CA is a systemic disease w/ exception of early presentation.
Untreated Breast CA survival 6% at 10 years.
Approx. 85% of women with a history of breast CA will have disease present at autopsy.
First evident spread is usually to axillary L.N. Risk varies by size of primary lesion:
<1 cm 10-20%
 1-2 cm 30%
2-3 cm 50%
> 3 cm 50-70%
Inflammatory 90%

Axillary nodes (about 50) in each axilla are divided into 3 anatomical areas:
Level I Inf. and Lat. to Pectoralis minor
Level II Beneath pec. minor
Level III Superior and medial to pec. minor (aka apex)

In clinically negative axillas, 43% will be found positive at surgery (i.e. 43% false -).
In clinically positive axillas, 28% will be found negative at surgery (i.e. 28% false +).

Internal Mammary node spread: rarely occurs in absence of axillary node involvement.
-With positive axilla: inner quadrant 70%+
central breast 50%+
outer quadrant 20%+
-With negative axilla: inner quadrant 15%+
other areas only 5%+

Some locally advanced breast cancer pts. present with Haagenson’s “Grave Signs”
-Large tumors (>5 cm)
-More than 4 positive axillary nodes
-Skin involvement
-Angiolymphatic invasion
These patients have 15-30% chance for recurrance after mastectomy if adjuvant XRT is not,
given!

Breast Cancer spread is by contiguity, lymphatic channels, and hemotogenous metastasis. Spread
may become evident many years after initial diagnosis!

Breast Cancer may spread to:

Regional lymph nodes (intramammary, axillary, internal mammary, supraclavicular)
Bone--most common distant site— lytic lesions
Brain, Liver, Lung, Skin, Orbit, Spinal epidural space.

Staging of Breast Cancer (AJCC)

-T1 up to 2 cm (subdivided into “a=<0.5 cm, b=0.5-1.0 cm, c= 1.0-2.0 cm”)
-T2 between 2 cm and 5 cm
-T3 greater than 5 cm
-T4 subdivided into a, b, c ,d (a=chest wall, b=skin, c=chest wall + skin, d=inflammatory)

-N1 Movable clinically + axillary nodes

-N2 Fixed clinically + axillary nodes
-N3 Internal Mammary +nodes
M0 = No distant mets. M1 = distant mets. (+ supraclavicular nodes = M1)
Groupings:

Stage 0 Tis, N0 includes Paget’s (5 year surv. = 98%)

Stage I T1, N0 (5 year surv. = 95%)

Stage IIA T1, N1 or T2, NO (5 year surv. = 80%)

Stage IIB T2, N1 or T3, NO (5 year surv. = 65%)

Stage IIIA T1-T3, N2 or T3, N1 (5 year surv. = 50%)

Stage IIIB any T4 or N3 (5 year surv. = 45%)

Stage IV any M1 (5 year surv. = 20%)

If Multiple simultaneous ipsilateral primary cancers, use largest primary to classify T-stage If
Bilateral simultaneous breast cancers, each is staged separately.

Prognostic Factors:
Includes stage, grade, and ER/PR status (This is all according to Borgelt MSKCC)
Stage info, above--
If axilla negative, 5 yr. surv = 80% 10 yr. surv. = 65%
If l-3nodes+ 5yr. surv.= 65% 10yr.surv. = 40%
If 4 or more nodes + 5 yr. surv = 30% 10 yr. surv.= 15%

Tumor Size--
If <1 cm. 10 yr. surv. = 80%
If 3 - 4cm. l0 yr.surv. = 60%
If 5-8 cm. 10 yr. surv. = 40%
Grade is Bloom-Richardson I-III. This system considers nuclear grade, mitosis and attempt at
tubule formation, assigns each a score and takes an average.
ER/PR status- need >0.5 cubic cm. of tissue to quantitate. ER is + in 60% of women under age
50 and 75% of women over age 50.
Positive PR but negative ER conveys better prognosis than vice-versa. Even if pt. is both ER/PR
+ still only 80% respond to hormonal Rx.
But even if pt. is both ER/PR negative about 12% will respond to hormonal Rx. There is a better
chance of responding is ER-/PR+ than vice versa. ER/PR concentrations are in fentomoles/mg
cytosol protein and response rate increases with increasing concentration, range usally <5 units
considered ER negative, 5-80 positive, >80 strongly positive.

Other factors are felt (by some) to convey prognostic significance. These include:

DNA activity measures-- use flow cytometry, labeling index to quantitate proliferative activity of
breast CA. The more rapid cellular division, the more aggressive the CA is thought to be, and the
higher likelihood of lymph node mets.
Aneuploid vs. Diploid tumors show probability of 5 yr. survival 76% c/w 89%
High S-Phase (>4-7%) shows poorer outcome for diploid tumors (70% vs. 90% 5 yr. surv)
Cathepsin D-- a high level of this lysosomal enzyme correlates with higher percentage of
positive nodes. Also may imply decreased DFS is pts. with negative nodes at presentation.

Oncogenes increased amplification of HER-2/neu and erb-B2 correlates with increased nodal
positivity and tumor aggressiveness. However, HER-2/neu amplification does not correlate with
negative outcome for N0 pts!
Poor response to treatment, short remission duration are obviously bad.

Treatment:
Breast Cancer is often a systemic disease at presentation. Halstead believed that the more
aggressive the surgical approach, the better the outcome but this was found to be untrue. He
routinely performed radical mastectomies (taking the pectoralis major and minor muscles along
with all breast tissue and axillary contents) achieving a 20% 5-year survival rate.

In the 1950’s, extended radical mastectomy (radical mastectomy + internal mammary dissection)
likewise failed to improve long-term survival. Utilization of multimodality therapy including
surgery, chemotherapy and radiotherapy and hormonal manipulation are now conventional
treatment for various stages of breast CA. Bone marrow transplant and immunotherapy are
investigative approaches. We will sequentially consider treatment from DCIS and early invasive
breast cancer through locally advanced and inflammatory presentations.

CLINICAL TRIALS:-

Role of detection method in predicting breast cancer survival: analysis of randomized screening
trials.

Shen Y, Yang Y, Inoue LY, Munsell MF, Miller AB, Berry DA.

Department of Biostatistics and Applied Mathematics, The University of Texas M. D. Anderson

Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA.

BACKGROUND: Screening mammography detects breast cancers earlier than those detected
symptomatically, and so mammographically detected breast cancers tend to have better
prognoses. The so-called stage shift that results from screen detection is subject to lead-time and
length biases, and so earlier detection may not translate into longer survival. We used data from
three large breast cancer screening trials--Health Insurance Plan (HIP) of New York and two
Canadian National Breast Cancer Screening Studies (CNBSS)--to investigate survival benefits of
breast cancer screening beyond stage shift. We also address whether method of detection is an
independent prognostic factor in breast cancer. METHODS: The HIP trial randomly assigned
approximately 62,000 women to screening and control groups. The two CNBSS trial cohorts
CNBSS-1 and CNBSS-2 included a total of 44,970 women in the screening group and 44,961 in
the control group. After adjusting for stage and other tumor characteristics in a Cox proportional
hazards model, survival distributions were compared by method of breast cancer detection with
both univariate and multivariable analyses.

All P values are two-sided. RESULTS: Breast cancers detected by screening mammography had
a shift in stage distribution to earlier stages (for HIP, P < .001; for CNBSS-1, P = .03; and for
CNBSS-2, P < .001). After adjusting for tumor size, lymph node status, and disease stage in a
Cox proportional hazards model, method of detection was a statistically significant independent
predictor of disease-specific survival. Patients with interval cancers had a 53% (95% confidence
interval [CI] = 17% to 100%) greater hazard of death from breast cancer than patients with
screen-detected cancers, and patients with cancer in the control groups had a 36% (95% CI =
10% to 68%) greater hazard of death than patients with screen-detected cancer. CONCLUSION:
There was an apparent survival benefit beyond stage shift for patients with screen-detected breast
cancers compared with patients with breast cancers detected otherwise. Method of detection
appears to be an important prognostic factor, even after adjusting for known tumor
characteristics. This finding suggests that clinical trialists should routinely collect information
about method of detection.

Neoadjuvant Chemotherapy with Myocet/Taxotere/Herceptin for HER2 Positive Breast Cancer

Patients.
Open-label study to assess efficacy and tolerability of the combination
Myocet®/Taxotere®/Herceptin® as primary treatment for HER2 positive breast cancer patients.
HER2 status will be confirmed centrally by FISH.
Phase I: initial doses will be:
Myocet: 50-60 mg/m² day 1 every 3 weeks; Taxotere 60-75 mg/m² day 1 every 3 weeks;
Herceptin (4) 2 mg/kg weekly.
Sample size will depend on number of patients recruited during dose escalation. 3 patients must
be recruited in each dose level. If one out of three experiences a Dose Limiting Toxicity (DLT), 3
more patients must be recruited in the same dose level. Considering that there are 4 dose levels to
be tested, estimated number of patients is 9 to 24. Patients receiving the Recommended Dose
(RD) will be incorporated to phase II of the study.
Phase II: Average pathological complete response rate reported in other trials is around 11%. We
expect to achieve an increase of 14% on this rate, that is, we expect a pathological response rate
of 25%. With a= 0,05 and β=0,2, 18 patients are initially needed. If al least 3 pathological
complete responses are achieved, recruitment will continue up to 53 patients. At least 10
pathological complete responses are needed top probe the hypothesis. Considering a 10% post-
randomization drop-out rate, a total of 59 patients must be recruited in the trial.
Spanish Breast Cancer Research Group (GEICAM), San Sebastián de los Reyes, Madrid,
28700, Spain; Recruiting Esther Mahillo, PhD +34916592870 emahillo@geicam.org

Maintenance Treatment with Liposomal Doxorubicin (Caelyx) in Metastatic Breast Cancer.

This is a randomized, prospective and multicenter phase IV clinical trial, which has been
designed as a phase III study. One hundred fifty-four women (77 per treatment arm) will be
recruited in the study.

Spanish Breast Cancer Research Group (GEICAM), San Sebastián de los Reyes, Madrid,
28700, Spain; Recruiting Esther Mahillo, PhD +34916592870 emahillo@geicam.org and
Emilio Alba, MD., PhD. +34916592870 oncologia98@yahoo.com

CONVENTIONAL REVIEW:-
Latest News - Breast cancer subtypes and survival in patients with brain metastases.

Nam BH, Kim SY, Han HS, Kwon Y, Lee KS, Kim TH, Ro J.

ABSTRACT: INTRODUCTION: Brain metastases (BM) occur in up to one third of patients

with metastatic breast cancer (MBC), whose incidences and prognoses by breast cancer subtypes
in BM have not been well delineated. METHODS: Retrospective survival analyses were
performed in 126 BM patients from 805 MBC patients treated at the National Cancer Center
between August 2001 and April 2006, according to clinical characteristics, breast cancer
subtypes, and receipt of trastuzumab. Estrogen receptor (ER), progesterone receptor (PR), and
human epidermal growth receptor-2 (HER2) statuses were tested by immunohistochemical (IHC)
staining, and HER2 FISH analysis conducted for IHC 2+. RESULTS: The proportion of
HER2+/ER- (29% vs 16%) and triple-negative (37% vs 25%) tumors was higher in the 126 BM
patients than those without BM. While median survival after recurrence was longer in patients
with luminal A disease (median survival of luminal A vs luminal B vs HER2+/ER- vs triple-
negative: p = 0.0246; 39.6 vs 27.4 vs 20.9 vs 15.5 months), survival was shorter from BM to
death in luminal A and triple negatives (median survival: p = 0.0113; 4.0 vs 9.2 vs 5.0 vs 3.4
months).

Receipt of trastuzumab after BM was a significant variable for survival in HER2+ patients.
Multivariate analyses identified ER-negative, HER2-negative, or triple-negative, as well as older
age, presence of leptomeningeal disease, and three or more extracranial disease sites, as poor
prognostic factors for survival after BM. CONCLUSIONS: MBC patients who developed BM
had higher proportions of triple-negative and HER2+/ER- tumor status. Triple receptor status is a
useful prognostic marker for predicting survival after BM in metastatic breast cancer patients.

We explore the use of hormonal therapies in breast cancer. It aims to discuss and summarise the
issues and is written for health professionals. It may also be of interest to patients. More
information for patients can be found in our complete breast cancer report.

Since the latest results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial were
announced in December 2004, questions have been asked by patients, patient families and
clinicians about the best hormonal therapy treatment for oestrogen-positive early-stage breast
cancer.
Premenopausal women

For women who are premenopausal, tamoxifen remains the treatment of choice. Tamoxifen is a
SERM (Selective Estrogen Receptor Modulator) with both oestrogenic and anti-oestrogenic
properties. Goserelin (Zoladex), a gonadorelin (LHRH) analogue which works on the pituitary
gland, may also be used. This drug causes a temporary chemical menopause which is reversed
once the drug is stopped.
Postmenopausal women

For post menopausal women, tamoxifen has also been the drug of choice. Following the ATAC
data presented in 2002, it was felt that the standard treatment should continue to be tamoxifen for
five years. However, for women at high risk of thromboembolic disorders or endometrial
abnormalities, or those who could not tolerate tamoxifen, anastrozole could be used instead.
Current evidence suggests that using aromatase inhibitors may be preferable to using tamoxifen.
However, there is still much uncertainty and trials have investigated different aromatase
inhibitors in different ways. These have been

* using aromatase inhibitors directly after surgery

* switching to an aromatase inhibitor after two to three years of tamoxifen or
* using an aromatase inhibitor after five years of tamoxifen.

Our review summarises the current state of knowledge and the criteria for treatment selection.

Background Information-- What Is Breast Cancer?

Any uncontrolled growth of breast tissue cells, which has the capacity to spread, is breast
cancer."Early" breast cancer is confined to the breast and the tumor is not larger than 5 cm (about
2 inches) across. It may also involve the lymph glands under the armpit, called the"axillary
lymph nodes". It has not spread to any distant sites in the body, as far as can be told with todays
technology."Locally Advanced" Breast Cancer is noted by a tumor greater than 5 cm across, or a
fixed lump in the axilla representing cancer, ulceration of the skin from cancer, or involvement of
the deep chest muscles. "Inflammatory Breast Cancer" is a hot, tender breast with skin looking
like an orange peel, called "peau de orange" and almost always has spread to the axilla.
"Metastatic" breast cancer means the disease has spread to other areas of the body, such as the
lung, liver, brain, skin or bone.

Breast cancer, like other cancers, starts in just a single cell. Normally, breast cells divide
infrequently after breast growth is completed; only to replace those cells lost through old age or
injury. The production of new breast cells from pre-existing ones is under tight control by the
genetic code, or "genes", of each cell. When this code becomes damaged, a cell may start
dividing out of control. The breast cancer cell is genetically damaged, but otherwise it looks very
similar to normal body tissue. This is why our immune system may fail to detect it as abnormal.
These cells can pile up to form a local "tumor".

A tumor simply means a swelling; it is not necessarily cancerous. Less than 1/3 of new breast
lumps and bumps are cancer. A tumor which only grows in it's place or origin, and cannot spread
distantly, is called"benign" and is not cancer. However, a tumor which has the capacity to spread
(whether it actually does or not) is called"malignant", this is cancer. The actual process of spread
is called"metastasis". It is this ability to spread to any organ in the body which makes cancers so
dangerous.

How Common is Breast Cancer?

Breast cancer is the most common cancer in women, after skin cancer, with 200,000 new cases
estimated for 2008 in the U.S.A. It causes 48,000 deaths per year, which makes it second leading
cause of cancer death after lung cancer in women. The number of annual deaths from breast
cancer has remained about the same for the past 50 years, although the number of cases is
increasing. This shows the benefits of early detection, which impacts survival. Also, effective
treatment is increasing survival in all breast cancer patients. One in nine women will get breast
cancer in the U.S.A. during their lifetimes.
Two thirds to 75% of cases are "Early Breast Cancer", 20% are "Advanced Breast Cancer"
(including Metastatic), and 5% are the"Inflammatory" subtype. Initial "Early Breast Cancer"
which was thought cured may be detected as the "Advanced Metastatic" type decades after the
initial diagnosis and treatment. Advanced Breast cancer can "smolder" along, slowly growing in
the bone, for many years before detection.

What Causes or Increases the Risk for Breast Cancer?

Like any other cancer, the exact reason why one woman gets breast cancer and another doesn't
remains unknown. However, certain "risk factors" have been identified:

1) Being female (only 1% of cases are in males).

2) Family history of breast cancer in mother and aunts; BRCA-1 gene. The BRCA-1 gene stands
for breast cancer, and although the risk is increased with the gene, not all patients with it get
breast cancer. Also, genes for rare diseases like ataxia-telangectasia ("A-T") (lack of repair of
skin to sun damage) associated with breast CA.

3) Getting older-- average age is 60 to get breast cancer.

4) Lots of estrogens-- including start of menstrual periods at a young age completion of

menstrual periods at an old age, no children or first child after age 30, being obese (fat cells
produce estrogen).

5) Low dose radiation exposure-- can take 10 to 50 years afterward to develop breast cancer,
among others. About 6 per 1 million women are estimated to get breast cancer from the
mammogram radiation, but this is believed worthwhile owing to the many early cancers found.

6) High fat in the diet. This many also be related to obesity above.

**Tobacco smoking, alcohol or birth control pills do NOT seem to increase risk!

Is Breast Cancer Preventable?

Most of the risk factors for getting Breast Cancer are not in a woman's control. In the past,
women with a very high risk sometimes had both breasts removed as a preventative measure,
called"prophylactic mastectomy". This is very infrequent today, given the earlier detection and
better treatment of breast cancer. Reducing fat in the diet, getting pregnant in her early 20's, and
appropriate screening and prompt treatment can reduce cancer deaths.

How is Breast Cancer Screened For?

There are two common ways of screening for breast cancer. Every woman can do a Breast Self
Exam" one week after her menstrual period each month, feeling for lumps. After menopause, it
can be done at any standard time each month. This should also be done if a patient with a history
of breast cancer has kept a breast. The American Cancer Society recommends a"baseline"
mammogram at age 35 - 40 with an "every other year" mammogram from ages 40 to 50. After
age 50, women should get a mammogram every year. Women at higher risk may get this test
more frequently, as should women who have had breast cancer but kept their breast. In spite of
the recent controversy for how often to get mammograms, the main point is to get them on a
regular basis, especially as a women gets older than age 40.

What are the Symptoms of Breast Cancer?

Breast cancer usually has no symptoms, but is picked up with screening tests. It is important to
note that most new breast lumps are not cancer, but it must be "ruled out" anyway. The first
symptom is usually a new lump or bump in the breast, which is of "dominant" character. This
means that it is single, hard, non-movable, non-tender, and in only one breast. Occasionally (3%)
breast cancer results in a nipple discharge, while 50% of watery discharges are from cancer, only
1% of milky or pussy discharges are cancerous. In more advanced breast cancer, the breast may
have a large tumor, or have a lump in the armpit.

Inflammatory breast cancer looks like an infection, being red and painful, and may be confused
with the much more common "mastitis", which is a simple breast infection. Breast cancer spread
to bones can cause pain and fractures, and to the brain can result in symptoms of imbalance,
confusion, headache and local weakness or numbness. Rarely, it spreads to the eyes to cause
blindness. Most commonly, however, it stays localized in the breast for many years. If it spreads,
it is most commonly to bone where it may remain unapparent for many years. About 5% of
patients develop cancers in both breasts, called"bilateral" breast cancer.

How Does Breast Cancer Spread?

It generally starts inside the milk ducts of the breast, then invades through the wall of the breast.
If it invades, then it grows locally to form a tumor, and the first spread is to the lymph glands in
same sided armpit (called the "axilla" ). When the tumor is 1 inch across, there is a 30% chance
that it has spread to the axillary lymph glands; when it is 2 inches across, the chance of the axilla
being involved, or"positive" is about 60%. Once the axilla is involved, the cancer is
considered"systemic", that is likely to have spread to other areas of the body through the
bloodstream. The most common places for it to spread, in order, are the bones, liver, lung, skin
and brain.

What are the Types of Breast Cancer?

The most common type is called"Invasive Ductal Carcinoma", that is, the cancer starts in the
milk duct and invades through it. This accounts for 70% of breast cancers,and is the only type
found in men. It accounts for most of the locally advanced and inflammatory cancer too. The
next most common type is called "Invasive Lobular Carcinoma", it arises from the lobules in the
breast and accounts for 10% of cases. Alternatively, the either the "Ductal" or the "Lobular" type
of cancers may not invade, but stay locally within the ducts or lobules and grow to a large size
there. "Non-invasive" or "in Situ" disease accounts for about 10% of breast cancer, it does not
spread to the axilla or elsewhere, and in general patients do better than with invasive disease.

It is also important because local recurrence of breast cancer (after breast conservation therapy)
may be of this "non-invasive" type and so less dangerous."Ductal Carcinoma in Situ", or "DCIS
" for short, is becoming more common since it often can only be detected with a mammogram.
Interestingly,"Lobular Carcinoma in Situ", or "LCIS" for short, is a "marker" for the
development of later invasive ductal cancer, which happens in 30% of patients. Uncommon types
of breast cancer include "medullary", "mucinous" and"tubular" forms, which all tend to occur in
older women and are less aggressive, and "Paget's Disease of the Nipple", which appears as a
scaly irritation but has an underlying lump in the breast 70% of the time. Rarely, cancer may
arise from the sweat glands of the breast ("apocrine") from the immune cells in the breast
("lymphoma") or from the muscle ("sarcoma"). The treatment for these cancers is different that
the typical ductal or lobular types, and discussed in other transcripts. There may be a mixture of
types 10% of cases.

How is Breast Cancer Detected and Evaluated?

Monthly breast "self-exam" by women can pick up about 30% of breast cancers, both new ones
and recurrences after breast conservation therapy. Others are too small to be felt, or "palpated",
but 85% of breast cancers can be detected with a mammogram. The radiation dose from a
modern mammogram is 0.2 centiGray, about the same as an ordinary chest X-ray. Worrisome
findings on a mammogram include lots of little calcium deposits, called "microcalcifications",
especially in irregular or "starburst" patterns. About 1/3 of these will represent cancer.
Sometimes, a "dominant" mass may be felt in the breast, but the mammogram doesn't show
anything. ANY DOMINANT MASS MUST BE BIOPSIED (SAMPLED) TO RULE OUT
CANCER! That's because 15% of even large cancers will remain invisible on a mammogram.

If a suspicious area is found, either on exam or mammogram, the National Cancer Institute
recommends a "2 part approach". Firstly, a biopsy (sampling procedure) is done to confirm or
deny cancer, then secondly, a surgery is performed to remove any cancer detected. The quickest,
easiest way to sample a suspicious area is called a "fine needle aspiration" in which a thin needle
is placed into the tumor using radiographic guidance. Some cells are sucked up, or "aspirated",
and sent to a "pathologist", that is a doctor who specializes in making diagnoses from tissue
specimens.

This test is over 90% accurate at detecting cancer. If it is"positive" (that means cancer is found)
then surgery is done. Either the entire breast is removed (called amastectomy ), or just the area of
the tumor with a surrounding safety margin (called a lumpectomy ).

The cancer removed is submitted for various tests, to classify it and see how likely it is to be
aggressive. These include the following"Prognostic Factors" :

1) Grading the tumor -- the pathologist looks at the cells in the tumor to see just how closely they
resemble normal breast cells. He assigns a grade, called the "Bloom-Richardson" grade, from 1
to 3. A grade of 1 means that the tumor closely resembles normal breast, that is"well-
differentiated", and probably isn't very aggressive while a grade of 3 means the tumor looks very
cancerous, that is"poorly differentiated" and is likely aggressive. A grade of 2 means "moderately
differentiated" so is of intermediate behavior.

2) Estrogen and Progesterone Receptor Studies ("ER" and"PR" for short) look to see how likely
the tumor is to respond to these female hormones. The chances of them being positive increases
with the age of the patient. If both"ER" and "PR" are positive, the tumor is less aggressive and
has an 80% chance of responding to "anti-estrogen" drugs like tamoxifen. If both are negative,
their is only a 10% chance of response Positive"PR" with Negative"ER" is better than vice-versa.

3 ) The "DNA activity measurements" of"S-phase" (which tells how quickly the cells are
dividing-- higher "S-phase" is more aggressive ) and "Ploidy" which also tells how similar the
cancer cells are genetically to normal breast cells. "Diploid" is normal and is better
than"aneuploid" which is more cancerous.

4) Cathepsin D -- is a cellular "enzyme", a high level suggests positive lymph glands.

5) "Oncogenes" look genetically at the tumor, if the "Breast Cancer" ("BCA-1") o a gene
called"HER-2/neu" are increased, these tumors are more aggressive.

6) The size of the tumor - If it's less than 1 cm. across, 10 year survival is over 80% while if it's
more than 7 cm. across, average 10 year survival is only 40%. The larger the cancer grows
locally (the higher the"tumor burden" ) , the more chance it has to spread to lymph nodes and to
distant body areas. The pathologist also looks at the type of breast cells to classify the cancer
as"ductal or"lobular", and to see if it invades through these ducts or lobules. If the cancer invades
(90% of them do) then it becomes necessary to do a second small operation, called an "axillary
lymph node sampling", which is not a therapeutic procedure, but merelydiagnostic. There
procedure isn't done if the cancer isn't invasive (i.e. "DCIS" or "LCIS"). If the axilla's lymph
glands are "negative" (not involved) then 10 year survival is over 75%, while if more than 4
lymph nodes are"positive" (involved) 10 year average survival drops to only 25%. The main
point of checking the axilla is to see if chemotherapy will be necessary, if it is involved, this
suggests that the cancer cells may have spread through the body, and chemotherapy will be
necessary.For any Locally Advanced or Inflammatory cancer, chemotherapy is essential.

Other Standard Tests: Include"bone-scan" where a small quantity of radioactive dye is injected
into a vein, and a special X-ray is then taken to see if the cancer has gone to bone. Breast cancer
has a predilection to go to bone, where it may lie dormant for many years. A "baseline" scan is
obtained for any invasive cancer, to make later scans easier to compare and interpret. If
"something" is seen on a bone scan, it may or may not be cancer. Old fractures, inflammation, or
infections can make bone scans"light up" in those areas.

The 2 ways of seeing if cancer is causing the increased "uptake" is to do a bone biopsy, or do
another bone scan several months later to see if the area has"progressed". In practice, bone
biopsy is difficult and may still miss an area of cancer spread, giving a false sense of security.
Repeat scans, and the expertise of the radiologist in determining whether cancer is causing the
abnormal bone scan are relied upon. Chest X-ray and Chest and Abdominal CT scans
("Computerized Axial Tomography"). Acontrast solution may be injected into an arm vein, which
helps highlight blood vessels in a CT scan. Insist upon"omnipaque" brand or equivalent contrast;
it is more expensive but also more comfortable and less likely to cause allergic reactions or
kidney failure. These scans are obtained to help rule out spread, or "metastasis" of cancer to the
lungs and liver. CT scan of the Brain orBone Marrow Biopsy are only done if their is suspicion
that the cancer has spread to these organs, or if a bone-marrow transplant is considered. Routine
blood tests of "complete blood count" (CBC ) and "chemistry panel" (SMA ) are obtained prior
to any therapy.

How is the Extensiveness of Breast Cancer Gauged?

Like any cancer, the extensiveness of Breast Cancer is given by the"Stage". The American Joint
Cancer Committee ("AJCC") has stages given by Roman numerals:

"Stage 0" means the cancer does not invade, such as "DCIS" or "LCIS"
"Stage I" means the cancer is less than 1 inch across, and is invasive.
"Stage II" means the cancer is between 1 and 3 inches across, or the lymph glands in the axilla
are involved (or both).
"Stage III" means that the cancer is greater than 3 inches across and the lymph glands in the
axilla are involved and may even be hard and "fixed".
"Stage IV" means that the cancer has spread to other organs, like bone or brain. This may be as
little as a single lymph node involved above the collarbone ("supraclavicular node") or as much
as massive cancer spread ("dissemination") throughout the body.

What is the Survival of Breast Cancer?

This depends upon many factors, including the cancer type, grade and stage, the general
condition of the patient, and the treatment(s) selected. The textbook figures are:

Stage 5-year Survival 10-year Survival

0 100% 98%
I 90% 80%
II 80% 70%
III 50% 30%
IV 20% 5%

*** It is crucial to note that many patients live many productive years with their cancer! The
figures given above include death from all causes, including heart attack, accidents, or a different
cancer. Many patients with breast cancer are elderly and have other serious medical problems
("comorbid conditions") leading to their demise.

What are the types of Later Breast Cancer?

There are 3 basic types:"Locally Advanced Breast Cancer" involves the local area of the breast
and the axilla, and refers to a large but localized cancer. "Inflammatory Breast Cancer" means
that the drainage channels in the skin, called the "dermal lymphatics", are obstructed by tumor--
this causes the breast to be hot, red and tender, and have a characteristic "peau de orange"
(orange peel) texture."Metastatic Breast Cancer" means that the disease has spread to other body
sites, such as the bone, liver, lung and brain.

What is the Conventional Treatment for Breast Cancer?

Treatment has historically consisted of surgery, radiation, chemotherapy, and hormones. The
combination and sequence of these treatments has been refined over the past 2 decades. Specifics
of each of them is now discussed in turn, with their historic results, followed by the latest,
effective combination treatments and results.
While breast cancer used to be a death sentence, today this is not necessarily so if proper
treatment is obtained. We have made tremendous strides in learning how to help the patient with
later breast cancer. Choosing the correct treatment can literally make the difference between life
and death.

It is critical to get the proper which the gives peace-of-mind of knowing that everything possible
has been done to help ensure a happy outcome.

CancerGroup's material explains, in Plain English, the historic and latest effective treatment for
later breast cancer, including results. We describe surgery, radiation treatments and
chemotherapy, as well as hormone therapy and bone marrow transplant options. We tell you
everything you need to know to help you make the right choices today.

This is just an excerpt of CancerGroup's report on Breast Cancer Treatment. Much more,
including latest can be sent to you by e-mail when you order the complete Breast Cancer
Treatment transcript at a nominal cost. Thank you for using CancerGroup.com as your
information resource.