Breast Cancer Screening & Treatment

with Tom Zukowski, M.D., medical oncologist with Columbia St. Mary’s

Last Updated: Aug. 1, 2003

Breast cancer is the most common female malignancy, causing almost one-third of cancers in women. This year alone approximately 200,000 new breast cancers will be diagnosed in the United States. Fortunately, with screening programs and early detection plus treatment advances, the survival rate for breast cancer is now over 90% in women whose cancer is detected in the earliest stages.

Tom Zukowski, M.D., medical oncologist with Columbia St. Mary’s "An obligation I have to my patients is to explain to them their diagnosis and their options, so that they can actively participate in the best therapy for them. Important in this is good communication regarding symptoms, so as to address these issues early and to avoid preventable disease complications."

Screening
Patients should confer with their primary physician regarding the age-appropriate screening recommendations as well as any new findings on the recommended monthly patient self-breast exam. Breast cancer is often first detected during a mammogram ordered either as part of a routine screening physical or because a new lump has been discovered.

“The accuracy rate of mammograms can vary depending on the type and quality of imaging equipment used and the skill of the interpreting radiologist. That is why it is important for women to choose a facility with state-of-the-art equipment and a skilled staff,” said Dr. Thomas Zukowski, a medical oncologist with Columbia St. Mary’s.

Biopsy
If a lump appears suspicious, a biopsy (sometimes preceded by ultrasound) will be done. If the biopsy is benign (noncancerous), women will usually be referred back to the primary care physician for ongoing follow-up. The majority of breast lumps are this type.

If the biopsy shows a cancerous change, a surgeon is consulted to perform the appropriate surgery for the tumor type, size, and location. In this situation, a sentinel lymph node biopsy also may be performed.

After a cancer diagnosis, the patient is usually referred to a medical oncologist. Some patients also need consultation with a radiation oncologist. The medical oncologist will meet with the patient to explain the cancer diagnosis, discuss the role of postoperative medications (if any are warranted), and will make recommendations for follow-up after treatment.

“Communication is very important because a woman needs to understand her options so that she can actively participate in the treatment that will give her the best chance of being cured,” the doctor said.

Treatment
Post-operative treatment will depend on the extent of surgery performed, the menopausal status of the patient (pre- vs. post-menopausal), the exact type of breast cancer (with ductal carcinoma being the most common), the size of the tumor mass, whether it has negative surgical margins (a rim of healthy tissue around the cancer), and whether it has spread to tissue-draining lymph nodes or further.

Also, some special characteristics of the tumor have prognostic and therapeutic importance. These characteristics include expression of the estrogen and progesterone receptors on the cancer cells and whether the cancer displays the Her-2-Neu gene mutation.

Due to improved screening and diagnostic technology, many women are now found sooner with pre-invasive cancer (also called in situ carcinoma) or small (early) invasive cancer (example, less than 1 cm in diameter). Depending on the exact tissue diagnosis and type of intervention required, surgery and radiation usually eradicate the tumor, but oral medication therapy with the drug Tamoxifen is sometimes recommended by the oncologist for five years to decrease disease recurrence risk.

For those women with invasive cancer larger than 1 cm or that has spread (for example, to lymph nodes), additional therapy will be recommended based again on the patient’s menopausal status, the tumor characteristics, and other potentially complicating medical conditions.

The rationale for chemotherapy would be to decrease the risk of relapse. Chemotherapy is given on a prescribed schedule including days of actual chemotherapy infusion plus days after for rest and management or monitoring of side effects. Some women receive chemotherapy once every three weeks, for example, over a period of four to six months depending on the situation.

One of the most promising new developments toward the treatment of breast cancer is the recent identification of the Her-2-Neu genetic mutation and the development of a specific treatment for it. This mutation, different from hereditary forms of breast cancer, is present in up to 30% of breast cancers. “Literature suggests it indicates a more aggressive cancer with higher rate of relapse,” Dr. Zukowski explained.

Recently, researchers discovered a biological therapy called Herceptin (Trastuzumab) that targets these cancer cells with this mutation. In the past, Herceptin was given to women after relapse.

Clinical trials
Now there is a clinical trial underway in which Herceptin is used along with chemotherapy in women with Stage II Her-2-Neu positive breast cancer to determine if this lessens their relapse rate. It is just one of many clinical research trials underway looking for new treatment advances in breast cancer. “These trials will challenge what is currently held to be the best standard treatment, leading to potential treatment modifications and improved therapeutic outcomes,” Dr. Zukowski said.

Columbia St. Mary’s offers patients opportunities to participate in this trial and other important clinical trials. “No matter where they are being treated, however, all patients with cancer should ask their oncologist if they are a candidate for a pertinent clinical trial and to have this reviewed along with all the treatment options,” Dr. Zukowski said.

Breast cancer symptoms
Early breast cancer usually does not cause pain. In fact, when breast cancer first develops, there may be no symptoms at all. But as the cancer grows, it can cause changes that women should watch for:

• A lump or thickening in or near the breast or in the underarm area
• A change in the size or shape of the breast
• Nipple discharge or tenderness, or the nipple pulled back (inverted) into the breast
• Ridges or pitting of the breast (the skin looks like the skin of an orange)
• A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red, or scaly)

A woman should see her doctor about any symptoms like these. Most often, they are not cancer, but it’s important to check with the doctor so that any problems can be diagnosed and treated as early as possible.

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