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Breast Cancer

by Mary Ann Kosir, MD

Breast cancer most often involves glandular breast cells in the ducts or lobules. Most patients present with an asymptomatic mass discovered during examination or screening mammography. Diagnosis is confirmed by biopsy. Treatment usually includes surgical excision, often with radiation therapy, with or without adjuvant chemotherapy, hormonal therapy, or both.

About 232,000 new cases of invasive breast cancer and about 40,000 deaths from it are expected in 2013. In addition, about 64,000 new cases of in situ breast cancer are expected in 2013. Breast cancer is the 2nd leading cause of cancer death in women (after lung cancer). Male breast cancer accounts for < 1% of total cases; in men, manifestations, diagnosis, and management are the same, although men tend to present later.

Risk Factors

In the US, cumulative risk of developing breast cancer is 12% (1 in 8) by age 95, and risk of dying of it is about 4%. Much of the risk is incurred after age 60 ( Breast Cancer Risks). These statistics can be misleading because most people die before age 95, and cumulative risk of developing the cancer in any 20-yr period is considerably lower.

Breast Cancer Risks

Age (yr)

Risk of Being Diagnosed With Breast Cancer (%)

Lifetime Risk of Being Diagnosed With (or Dying of) Breast Cancer (%)

In 10 yr

In 20 yr

In 30 yr

30

0.4 (0.1)

1.9 (0.6)

4.2 (1.2)

12.5 (2.8)

40

1.5 (0.5)

3.8 (1.1)

7.0 (2.0)

12.3 (2.8)

50

2.4 (0.7)

5.7 (1.6)

8.8 (2.6)

11.2 (2.7)

60

3.6 (1.0)

6.9 (2.0)

8.9(2.6)

9.4 (2.4)

70

3.8 (1.2)

6.1 (1.9)

6.7 (2.0)

Based on the cancer.gov web site . Accessed on September 15, 2013.

Factors that may affect breast cancer risk include the following:

  • Family history: Having a 1st-degree relative (mother, sister, daughter) with breast cancer doubles or triples risk of developing the cancer, but breast cancer in more distant relatives increases risk only slightly. When 2 1st-degree relatives have breast cancer, risk may be 5 to 6 times higher.

  • Breast cancer gene: About 5% of women with breast cancer carry a mutation in one of the 2 known breast cancer genes, BRCA1 or BRCA2 . If relatives of such a woman also carry the gene, they have a 50 to 85% lifetime risk of developing breast cancer. Women with BRCA1 mutations also have a 20 to 40% lifetime risk of developing ovarian cancer; risk among women with BRCA2 mutations is increased less. Women without a family history of breast cancer in at least 2 1st-degree relatives are unlikely to carry this gene and thus do not require screening for BRCA1 and BRCA2 mutations. Men who carry a BRCA2 mutation also have an increased risk of developing breast cancer. The genes are more common among Ashkenazi Jews. Women with BRCA1 or BRCA2 mutations may require closer surveillance or preventive measures, such as taking tamoxifen or raloxifene or undergoing double mastectomy.

  • Personal history: Having had in situ or invasive breast cancer increases risk. Risk of developing cancer in the contralateral breast after mastectomy is about 0.5 to 1%/yr of follow-up.

  • Gynecologic history: Early menarche, late menopause, or late first pregnancy increases risk. Women who have a first pregnancy after age 30 are at higher risk than those who are nulliparous.

  • Breast changes: History of a lesion that required a biopsy increases risk slightly. Women with multiple breast masses but no histologic confirmation of a high-risk pattern should not be considered at high risk. Benign lesions that may slightly increase risk of developing invasive breast cancer include complex fibroadenoma, moderate or florid hyperplasia (with or without atypia), sclerosing adenosis, and papilloma. Risk is about 4 or 5 times higher than average in patients with atypical ductal or lobular hyperplasia and about 10 times higher if they also have a family history of invasive breast cancer in a 1st-degree relative. Increased breast density seen on screening mammography is associated with an increased risk of breast cancer.

  • Lobular carcinoma in situ (LCIS) : Having LCIS increases the risk of developing invasive carcinoma in either breast by about 25 times; invasive carcinoma develops in about 1 to 2% of patients with LCIS annually.

  • Use of oral contraceptives: Oral contraceptive use increases risk very slightly (by about 5 more cases per 100,000 women). Risk increases primarily during the years of contraceptive use and tapers off during the 10 yr after stopping. Risk is highest in women who began to use contraceptives before age 20 (although absolute risk is still very low).

  • Hormonal therapy: Postmenopausal hormone (estrogen plus a progestin) therapy appears to increase risk modestly after only 3 yr of use (see also Hormone therapy). After 5 yr of use, the increased risk is about 7 or 8 more cases per 10,000 women for each year of use (about a 24% increase in relative risk). Use of estrogen alone does not appear to increase risk of breast cancer. Selective estrogen -receptor modulators (eg, raloxifene) reduce the risk of developing breast cancer.

  • Radiation therapy: Exposure to radiation therapy before age 30 increases risk. Mantle-field radiation therapy for Hodgkin lymphoma about quadruples risk of breast cancer over the next 20 to 30 yr.

  • Diet: Diet may contribute to development or growth of breast cancers, but conclusive evidence about the effect of a particular diet (eg, one high in fats) is lacking. Obese postmenopausal women are at increased risk, but there is no evidence that dietary modification reduces risk. For obese women who are menstruating later than normal, risk may be decreased.

Pathology

Most breast cancers are epithelial tumors that develop from cells lining ducts or lobules; less common are nonepithelial cancers of the supporting stroma (eg, angiosarcoma, primary stromal sarcomas, phyllodes tumor). Cancers are divided into carcinoma in situ and invasive cancer.

Carcinoma in situ is proliferation of cancer cells within ducts or lobules and without invasion of stromal tissue. There are 2 types:

  • Ductal carcinoma in situ (DCIS): About 85% of carcinoma in situ are this type. DCIS is usually detected only by mammography. It may involve a small or wide area of the breast; if a wide area is involved, microscopic invasive foci may develop over time.

  • Lobular carcinoma in situ (LCIS): This nonpalpable lesion is usually detected via biopsy; it is rarely visualized with mammography. LCIS is often multifocal and bilateral. It is not malignant but increases risk of developing invasive carcinoma in either breast.

Invasive carcinoma is primarily adenocarcinoma. About 80% is the infiltrating ductal type; most of the remaining cases are infiltrating lobular. Rare types include medullary, mucinous, and tubular carcinomas. Mucinous carcinoma tends to develop in older women and to be slow growing. Women with these types of breast cancer have a much better prognosis than women with other types of invasive breast cancer.

Inflammatory breast cancer is a fast-growing, often fatal cancer. Cancer cells block the lymphatic vessels in breast skin, causing the breast to appear inflamed. Usually, inflammatory breast cancer spreads to the lymph nodes in the armpit. The lymph nodes feel like hard lumps. However, often no mass may be felt in the breast itself because this cancer is dispersed throughout the breast.

Paget disease of the nipple (not to be confused with the metabolic bone disease also called Paget disease) is a form of ductal carcinoma in situ that extends into the skin over the nipple and areola, manifesting with a skin lesion (eg, an eczematous or a psoriaform lesion—see Paget Disease of the Nipple). Characteristic malignant cells called Paget cells are present in the epidermis. Women with Paget disease of the nipple often have underlying invasive or in situ cancer.

Pathophysiology

Breast cancer invades locally and spreads through the regional lymph nodes, bloodstream, or both. Metastatic breast cancer may affect almost any organ in the body—most commonly, lungs, liver, bone, brain, and skin.

Most skin metastases occur near the site of breast surgery; scalp metastases are also common. Metastatic breast cancer frequently appears years or decades after initial diagnosis and treatment.

Estrogen and progesterone receptors, present in some breast cancers, are nuclear hormone receptors that promote DNA replication and cell division when the appropriate hormones bind to them. Thus, drugs that block these receptors may be useful in treating tumors with the receptors. About two thirds of postmenopausal patients have an estrogen -receptor positive (ER+) tumor. Incidence of ER+ tumors is lower among premenopausal patients.

Another cellular receptor is human epidermal growth factor receptor 2 (HER2; also called HER2/neu or ErbB2); its presence correlates with a poorer prognosis at any given stage of cancer.

Symptoms and Signs

Many breast cancers are discovered as a mass by the patient or during routine physical examination or mammography. Less commonly, the presenting symptom is breast pain or enlargement or a nondescript thickening in the breast.

Paget disease of the nipple manifests as skin changes, including erythema, crusting, scaling, and discharge; these changes usually appear so benign that the patient ignores them, delaying diagnosis for a year or more. About 50% of patients with Paget disease of the nipple have a palpable mass at presentation.

A few patients with breast cancer present with signs of metastatic disease (eg, pathologic fracture, pulmonary dysfunction).

A common finding during physical examination is asymmetry or a dominant mass—a mass distinctly different from the surrounding breast tissue. Diffuse fibrotic changes in a quadrant of the breast, usually the upper outer quadrant, are more characteristic of benign disorders; a slightly firmer thickening in one breast but not the other may be a sign of cancer.

More advanced breast cancers are characterized by fixation of the mass to the chest wall or to overlying skin, by satellite nodules or ulcers in the skin, or by exaggeration of the usual skin markings resulting from skin edema caused by invasion of dermal lymphatic vessels (so-called peau d’orange). Matted or fixed axillary lymph nodes suggest tumor spread, as does supraclavicular or infraclavicular lymphadenopathy.

Inflammatory breast cancer is characterized by peau d'orange, erythema, and enlargement of the breast, often without a mass, and has a particularly aggressive course.

Screening

Screening includes mammography, clinical breast examination (CBE) by health care practitioners, MRI (for high-risk patients), and monthly breast self-examination (BSE).

Mammography, done annually, is recommended for women 50; it reduces mortality rate by 25 to 35% in this age group. Mammography is more accurate in older women, partly because with aging, fibroglandular tissue in breasts tends to be replaced with fatty tissue, which can be more easily distinguished from abnormal tissue. However, there is considerable disagreement about screening for women 40 to 50 yr; recommendations include annual mammography (American Cancer Society), mammography every 1 to 2 yr (National Cancer Institute), and no periodic mammography (American College of Physicians). Concerns about screening too soon or too often include increased radiation exposure and overdiagnosis of tumors (eg, DCIS) that may not develop into invasive cancer during the patient’s lifetime. Young age at the time of radiation exposure increases the risk of cancer. On balance, most experts recommend screening mammography every 1 to 2 yr for women aged 40 to 50.

Only about 10 to 15% of abnormalities detected on screening mammography result from cancer, and false-negative results may exceed 15%. Accuracy depends partly on the techniques used and experience of the mammographer. Some centers use computer analysis of digitized mammography images (full-field digital mammography) to help in diagnosis. Such systems may be slightly more sensitive for invasive cancers in women < 50 when results are interpreted by radiologists, but probably not when interpreted primarily via computer detection.

CBE is usually part of routine annual care for women > 35; it can detect 7 to 10% of cancers that cannot be seen on a mammogram. In the US, CBE augments rather than replaces screening mammography. However, in some countries where mammography is considered too expensive, CBE is the sole screen; reports on its effectiveness in this role vary.

MRI is thought to be better than CBE or mammography for screening women with a high (eg, > 15%) risk of breast cancer, such as those with a BRCA gene mutation. For these women, screening should include MRI as well as mammography and CBE. MRI has higher sensitivity but may be less specific. Because specificity is lower, MRI is not considered appropriate for screening women with average or slightly increased risk.

BSE alone has not been shown to reduce mortality rate, but evidence of its usefulness is mixed, and it is widely practiced. Because a negative BSE may tempt some women to forego mammography or CBE, the need for these procedures should be reinforced when BSE is taught. Patients should be instructed to do BSE on the same day each month. For menstruating women, 2 or 3 days after menses ends is recommended because breasts are less likely to be tender and swollen.

Diagnosis

  • Screening by mammography, breast examination, ultrasonography, and/or MRI

  • Biopsy, including analysis for estrogen and progesterone receptors and for HER2 protein

Testing is required to differentiate benign lesions from cancer. Because early detection and treatment of breast cancer improves prognosis, this differentiation must be conclusive before evaluation is terminated.

If advanced cancer is suspected based on physical examination, biopsy should be done first; otherwise, the approach is as for breast mass (see Breast Masses (Breast Lumps) : Evaluation). All lesions that could be cancer should be biopsied. A prebiopsy bilateral mammogram may help delineate other areas that should be biopsied and provides a baseline for future reference. However, mammogram results should not alter the decision to do a biopsy if that decision is based on physical findings.

Biopsy

Percutaneous core biopsy is preferred to surgical biopsy. Core biopsy can be done guided by imaging or palpation (freehand). Routinely, stereotactic biopsy (needle biopsy guided by mammography done in 2 planes and analyzed by computer to produce a 3-dimensional image) or ultrasound-guided biopsy is being used to improve accuracy. Clips are placed at the biopsy site to identify it. If core biopsy is not possible (eg, the lesion is too posterior), surgical biopsy can be done; a guidewire is inserted, using imaging for guidance, to help identify the biopsy site. Any skin taken with the biopsy specimen should be examined because it may show cancer cells in dermal lymphatic vessels.

The excised specimen should be x-rayed, and the x-ray should be compared with the prebiopsy mammogram to determine whether all of the lesion has been removed. Mammography is repeated when the breast is no longer tender, usually 6 to 12 wk after biopsy, to confirm removal of the lesion.


Evaluation after cancer diagnosis

After cancer is diagnosed, evaluation is usually done in consultation with an oncologist, who helps determine which of the many possible tests are needed for a specific patient.

Part of a positive biopsy specimen should be analyzed for estrogen and progesterone receptors and for HER2 protein.

WBCs should be tested for BRCA1 and BRCA2 genes when

  • Family history includes multiple cases of early-onset breast cancer.

  • Ovarian cancer develops in patients with a family history of breast or ovarian cancer.

  • Breast and ovarian cancers occur in the same patient.

  • Patients have an Ashkenazi Jewish heritage.

  • Family history includes a single case of male breast cancer.

  • Breast cancer develops at age < 45.

  • The cancer does not have estrogen or progesterone receptors or overexpression of HER2 protein (triple negative breast cancer).

Chest x-ray, CBC, liver function tests, and serum Ca measurement should be done to check for metastatic disease.

An oncologist should be consulted to determine whether to measure serum carcinoembryonic antigen (CEA), cancer antigen (CA) 15-3, or CA 27-29 and whether bone scanning should be done. Some common indications for bone scanning include the following:

  • Tumors > 2 cm

  • Bone pain

  • Lymph node involvement

  • Elevated serum alkaline phosphatase or Ca levels

Abdominal CT is done if patients have any of the following:

  • Abnormal liver function results

  • Hepatomegaly

  • Locally advanced cancer with or without axillary lymph node involvement

MRI is often used by surgeons for preoperative planning; it can accurately determine tumor size, chest wall involvement, and number of tumors.


Grading and staging

Grading is based on histologic examination of the tissue taken during biopsy.

Staging follows the TNM (tumor, node, metastasis) classification ( Staging of Breast Cancer). Because clinical examination and imaging have poor sensitivity for nodal involvement, staging is refined during surgery, when regional lymph nodes can be evaluated. However, if patients have palpably abnormal axillary nodes, preoperative ultrasonography-guided fine needle aspiration or core biopsy may be done. If results are positive, axillary lymph node dissection is typically done during the definitive surgical procedure. If results are negative, a sentinel lymph node biopsy, a less aggressive procedure, may be done instead.

Staging of Breast Cancer

Stage

Tumor

Regional Lymph Node/Distant Metastasis

0

Tis

N0/M0

IA

T1*

N0/M0

IB

T0

N1mi/M0

T1 *

N1mi/M0

IIA

T0

N1 /M0

T1*

N1 /M0

T2

N0/M0

IIB

T2

N1/M0

T3

N0/M0

IIIA

T0

N2/M0

TI*

N2/M0

T2

N2/M0

T3

N1/M0

T3

N2/M0

IIIB

T4

N0/M0

T4

N1/M0

T4

N2/M0

IIIC

Any T

N3/M0

IV

Any T

Any N/M1

T1 includes T1mi.

Here, N1 excludes N1mi.

Tis = carcinoma in situ or Paget disease of the nipple with no tumor (Paget disease with a tumor is classified by tumor size); T1 = tumor 2 cm; T1mi = 0.1 cm; T2 = tumor > 2 but < 5 cm; T3 = tumor > 5 cm; T4 = any size with extension to chest wall or skin and with ulceration or skin nodules or inflammatory cancer. Larger tumors are more likely to be node-positive, but they also confer a worse prognosis independent of nodal status.

NX = Nearby nodes not assessable (for example, because removed previously); N0 = no spread to nearby nodes; N1 = spread to 1–3 movable, low or midaxillary nodes; N1mi = N1 nodes with micrometastases (> 0.2 mm and/or 200 cells, but none > 2 mm); N2 = any of the following:

  • Spread to low or midaxillary nodes that are fixed or matted

  • Spread to internal mammary nodes but not axillary nodes as detected by clinical examination or imaging

N3 = any of the following:

  • Spread to internal mammary nodes plus axillary nodes as detected by clinical examination or imaging

  • Spread to infraclavicular nodes

  • Spread to supraclavicular nodes

M0 = no metastases; M1 = metastases present.

Adapted from the American Joint Committee on Cancer, AJCC Cancer Staging Manual, Seventh Edition (2010) . Springer New York, Inc.


Prognosis

Long-term prognosis depends on tumor stage ( Staging of Breast Cancer). Nodal status (including number and location of nodes) correlates with disease-free and overall survival better than any other prognostic factor.

The 5-yr survival rate (from the National Cancer Center Data Base) depends on cancer stage:

  • Stage 0: 93%

  • Stages IA and IB: 88%

  • Stage IIA: 81%

  • Stage IIB: 74%

  • Stage IIIA: 67%

  • Stage IIIB: 41%

  • Stage IIIC: 49%

  • Stage IV: 15%

Poor prognosis is associated with the following other factors:

  • Young age: Prognosis appears worse for patients diagnosed with breast cancer during their 20s and 30s than for patients diagnosed during middle age.

  • Larger primary tumor: Larger tumors are more likely to be node-positive, but they also confer a worse prognosis independent of nodal status.

  • High-grade tumor: Patients with poorly differentiated tumors have a worse prognosis.

  • Absence of estrogen and progesterone receptors: Patients with ER+ tumors have a somewhat better prognosis and are more likely to benefit from hormone therapy. Patients with progesterone receptors on a tumor may also have a better prognosis. Patients with both estrogen and progesterone receptors on a tumor may have a better prognosis than those who have only one of these receptors, but this benefit is not clear.

  • Presence of HER2 protein: When the HER2 gene ( HER2/neu [ erb-b2 ]) is amplified, HER2 is overexpressed, increasing cell growth and reproduction and often resulting in more aggressive tumor cells. Overexpression of HER2 is an independent risk factor for a poor prognosis; it may also be associated with high histologic grade, ER− tumors, greater proliferation, and larger tumor size, which are all poor prognostic factors.

  • Presence of BRCA genes: For any given stage, patients with the BRCA1 gene appear to have a worse prognosis than those with sporadic tumors, perhaps because they have a higher proportion of high-grade, hormone receptor–negative cancers. Patients with the BRCA2 gene probably have the same prognosis as those without the genes if the tumors have similar characteristics. With either gene, risk of a 2nd cancer in remaining breast tissue is increased (to perhaps as high as 40%).

Treatment

  • Surgery

  • Usually radiation therapy

  • Systemic therapy: Hormone therapy, chemotherapy, or both

For most types of breast cancer, treatment involves surgery, radiation therapy, and systemic therapy. Choice of treatment depends on tumor and patient characteristics. ( Treatment by Cancer Type). Recommendations for surgery are evolving.

Treatment by Cancer Type

Type

Possible Treatments

DCIS

Mastectomy

Wide excision with or without* radiation therapy

LCIS

Observation with regular examinations and mammograms

Tamoxifen or, for some postmenopausal women, raloxifene to reduce risk of invasive cancer

Bilateral prophylactic mastectomy (rarely)

Stages I and II (early-stage) cancer

Preoperative chemotherapy if tumor is > 5 cm or fixed to the chest wall

Breast-conserving surgery to remove the tumor and some surrounding tissue, followed by radiation therapy

Sometimes mastectomy with breast reconstruction

Postoperative chemotherapy, hormonal therapy, trastuzumab, or a combination, except in some postmenopausal women with tumors < 1 cm

Stage III (locally advanced) cancer, including inflammatory breast cancer

Preoperative systemic therapy, usually chemotherapy

Breast-conserving surgery or mastectomy if tumor is resectable after preoperative therapy

Mastectomy for inflammatory breast cancer

Usually, postoperative radiation therapy

Sometimes postoperative chemotherapy, hormonal therapy, or both

Stage IV (metastatic) cancer

If cancer is symptomatic and multifocal, hormone therapy, ovarian ablation therapy, or chemotherapy

If HER2 is overexpressed, trastuzumab

For brain metastases, local skin recurrences, or isolated, symptomatic bone metastases, radiation therapy

For bone metastases, IV bisphosphonates to reduce bone loss and bone pain

Paget disease of the nipple

Usually, the same as for other types

Occasionally, local excision only

Locally recurrent breast cancer

Mastectomy, sometimes preceded by chemotherapy or hormone therapy

Phyllodes tumors if malignant

Wide excision

Mastectomy if the mass is large or histology suggests cancer

*Wide excision may be used alone, especially if the lesion is < 2.5 cm and histologic characteristics are favorable, or with radiation therapy if size and histologic characteristics are less favorable.

DCIS = ductal carcinoma in situ; LCIS = lobular carcinoma in situ.

Surgery

For patients with invasive cancer, survival rates do not differ significantly whether mastectomy or breast-conserving surgery plus radiation therapy is used. Breast-conserving surgery includes lumpectomy, wide excision, and quadrantectomy (see Figure: Surgery for breast cancer). Thus, patient preference can guide choice of treatment within limits. The main advantage of breast-conserving surgery plus radiation therapy is less extensive surgery and opportunity to keep the breast. In 15% of patients thus treated, cosmetic results are excellent. However, the need for total removal of the tumor with a tumor-free margin overrides cosmetic considerations.

With both types of surgery, axillary lymph nodes are typically evaluated. Methods include axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB). ALND is a fairly extensive procedure that involves removal of as many axillary nodes as possible; adverse effects, particularly lymphedema, are common. ALND is part of mastectomy procedures. However, in breast-conserving surgery, most clinicians now first do SLNB unless biopsy of clinically suspect nodes detected cancer. Routine use of ALND is not justified because the main value of lymph node removal is diagnostic, not therapeutic, and SLNB has 95% sensitivity for axillary node involvement. For SLNB, blue dye and/or radioactive colloid is injected around the breast, and a gamma probe (and when dye is used, direct inspection) is used to locate the nodes the substance drains into. Because these nodes are the first to receive the tracers, they are considered the most likely to receive any metastatic cells and are thus are called sentinel nodes. If any of the sentinel nodes contain cancer cells, ALND may be necessary, based on numerous factors such as tumor stage, hormone receptor status, number of involved nodes, and patient characteristics. Some surgeons do frozen section analysis during SLNB and get prior agreement for ALND in case nodes are positive; others await standard pathology results and do ALND as a 2nd procedure if needed.

Surgery for breast cancer

Surgery for breast cancer consists of 2 main options:

  • Breast-conserving surgery , which includes lumpectomy (removal of a small amount of surrounding normal tissue), wide excision or partial mastectomy (removal of a somewhat larger amount of the surrounding normal tissue), and quadrantectomy (removal of 1/4 of the breast)

  • Mastectomy (removal of all breast tissue)

Some physicians use preoperative chemotherapy to shrink the tumor before removing it and applying radiation therapy; thus, some patients who might otherwise have required mastectomy can have breast-conserving surgery. Early data suggest that this approach does not affect survival.

Radiation therapy after mastectomy significantly reduces incidence of local recurrence on the chest wall and in regional lymph nodes and may improve overall survival in patients with primary tumors >5 cm or with involvement of 4 axillary nodes. Adverse effects of radiation therapy (eg, fatigue, skin changes) are usually transient and mild. Late adverse effects (eg, lymphedema, brachial plexopathy, radiation pneumonitis, rib damage, secondary cancers, cardiac toxicity) are less common.

Impaired lymphatic drainage of the ipsilateral arm often occurs after axillary node removal (ALND or SLNB) or radiation therapy, sometimes resulting in substantial swelling due to lymphedema. Magnitude of the effect is roughly proportional to the number of nodes removed; thus, SLNB causes less lymphedema than ALND. However, even with SLNB, there is a 6% lifetime risk for lymphedema. To reduce risk of lymphedema, practitioners usually avoid giving IV infusions. Avoiding ipsilateral BP measurement and venipuncture is sometimes also recommended, even though supporting evidence is minimal.

If lymphedema develops, a specially trained therapist must treat it. Special massage techniques used once or twice daily may help drain fluid from congested areas toward functioning lymph basins; low-stretch bandaging is applied immediately after manual drainage, and patients should exercise daily as prescribed. After the lymphedema lessens, typically in 1 to 4 wk, patients continue daily exercise and overnight bandaging of the affected limb indefinitely.

Reconstructive procedures include

  • Use of a tissue expander with delayed placement of a silicone or saline implant

  • Muscle flap transfer using the latissimus dorsi or the lower rectus abdominis

  • Creation of a free flap by anastomosing the gluteus maximus to the internal mammary vessels


Adjuvant systemic therapy

Patients with LCIS are often treated with daily oral tamoxifen. For postmenopausal women, raloxifene is an alternative.

For patients with invasive cancer, chemotherapy or hormone therapy is usually begun soon after surgery and continued for months or years; these therapies delay or prevent recurrence in almost all patients and prolong survival in some. However, some experts believe that these therapies are not necessary for many tumors < 1 cm with no lymph node involvement (particularly in postmenopausal patients) because the prognosis is already excellent. If tumors are > 5 cm, adjuvant systemic therapy may be started before surgery.

Relative reduction in risk of recurrence and death with chemotherapy or hormone therapy is the same regardless of the clinical-pathologic stage of the cancer. Thus, absolute benefit is greater for patients with a greater risk of recurrence or death (ie, a 20% relative risk reduction reduces a 10% recurrence rate to 8% but a 50% rate to 40%). Adjuvant chemotherapy reduces annual odds of death (relative risk) on average by 25 to 35% for premenopausal patients; for postmenopausal patients, the reduction is about half of that (9 to 19%), and the absolute benefit in 10-yr survival is much smaller.

Postmenopausal patients with ER– tumors benefit the most from adjuvant chemotherapy ( Preferred Breast Cancer Adjuvant Systemic Therapy*). For ER+ and node-negative invasive tumors, predictive genomic testing of the primary breast cancer is being used increasingly to determine whether combination chemotherapy or hormone therapy alone is indicated.

Preferred Breast Cancer Adjuvant Systemic Therapy*

Axillary Lymph Node

Premenopausal

Postmenopausal

ER+

ER−

ER+

ER−

Negative

Tamoxifen with or without chemotherapy

Chemotherapy

An aromatase inhibitor or tamoxifen (or raloxifene) with or without chemotherapy

Chemotherapy

Positive

Chemotherapy (with or without a taxane) plus tamoxifen

Chemotherapy (including a taxane)

Chemotherapy (with or without a taxane) plus an aromatase inhibitor or tamoxifen (or raloxifene)

Chemotherapy (including a taxane)

*For all protocols involving chemotherapy, enrollment in a clinical trial is often considered.

Treatment of node-negative tumors also depends on tumor size and grade.

ER = estrogen receptor.

Combination chemotherapy regimens are more effective than a single drug. Dose-dense regimens given for 4 to 6 mo are preferred; in dose-dense regimens, the time between doses is shorter than that in standard-dose regimens. There are many regimens: a commonly used one is ACT (doxorubicin plus cyclophosphamide followed by paclitaxel). Acute adverse effects depend on the regimen but usually include nausea, vomiting, mucositis, fatigue, alopecia, myelosuppression, and thrombocytopenia. Growth factors that stimulate bone marrow (eg, filgrastim, pegfilgrastim) are commonly used to reduce risk of fever and infection due to chemotherapy. Long-term adverse effects are infrequent with most regimens; death due to infection or bleeding is rare (< 0.2%).

High-dose chemotherapy plus bone marrow or stem cell transplantation offers no therapeutic advantage over standard therapy and should not be used.

If tumors overexpress HER2 (HER2+), adding the humanized monoclonal antibody trastuzumab to chemotherapy provides substantial benefit. Trastuzumab is usually continued for a year, although the optimal duration of therapy is unknown. A serious potential adverse effect is a decreased cardiac ejection fraction.

With hormone therapy (eg, tamoxifen, raloxifene, aromatase inhibitors), benefit is greatest when tumors have estrogen and progesterone receptors, nearly as great when they have only estrogen receptors, minimal when they have only progesterone receptors, and absent when they have neither receptor. In patients with ER+ tumors, particularly low-risk tumors, hormone therapy may be used instead of chemotherapy.

  • Tamoxifen: This drug competitively binds with estrogen receptors. Adjuvant tamoxifen for 5 yr reduces annual odds of death by about 25% in premenopausal and postmenopausal women regardless of axillary lymph node involvement; treatment for 2 yr is not as effective. If tumors have estrogen receptors, treatment for 10 yr appears to prolong survival and reduce recurrence risk compared with 5 yr of treatment. Tamoxifen can induce or exacerbate menopausal symptoms but reduces incidence of contralateral breast cancer and lowers serum cholesterol. Tamoxifen increases bone density in postmenopausal women and may reduce risk of fractures and ischemic heart disease. However, it significantly increases risk of developing endometrial cancer; reported incidence is 1% in postmenopausal women after 5 yr of use. Thus, if such women have spotting or bleeding, they must be evaluated for endometrial cancer (see Endometrial Cancer). Nonetheless, the improved survival for women with breast cancer far outweighs increased risk of death due to endometrial cancer. Risk of thromboembolism is also increased. Raloxifene, although indicated for prevention, is not indicated for treatment.

  • Aromatase inhibitors: These drugs (anastrozole, exemestane, letrozole) block peripheral production of estrogen in postmenopausal women. More effective than tamoxifen, these drugs are becoming the preferred treatment for early-stage hormone receptor–positive cancer in postmenopausal patients. Letrozole may be used in postmenopausal women who have completed tamoxifen treatment. Optimal duration of aromatase inhibitor therapy is uncertain.


Metastatic disease

Any indication of metastases should prompt immediate evaluation. Treatment of metastases increases median survival by 6 mo or longer. These treatments (eg, chemotherapy), although relatively toxic, may palliate symptoms and improve quality of life. Thus, the decision to be treated may be highly personal.

Choice of therapy depends on the following:

  • Hormone-receptor status of the tumor

  • Length of the disease-free interval (from remission to manifestation of metastases)

  • Number of metastatic sites and organs affected

  • Patient’s menopausal status

Systemic hormone therapy or chemotherapy is usually used to treat symptomatic metastatic disease. Initially, patients with multiple metastatic sites outside the CNS should be given systemic therapy. If metastases are asymptomatic, there is no proof that treatment substantially increases survival, and it may reduce quality of life.

Hormone therapy is preferred over chemotherapy for patients with ER+ tumors, a disease-free interval of > 2 yr, or disease that is not immediately life threatening. In premenopausal women, tamoxifen is often used first. Reasonable alternatives include ovarian ablation by surgery, radiation therapy, and use of a luteinizing-releasing hormone agonist (eg, buserelin, goserelin, leuprolide). Some experts combine ovarian ablation with tamoxifen or an aromatase inhibitor. In postmenopausal women, aromatase inhibitors are being increasingly used as primary hormone therapy. If the cancer initially responds to hormone therapy but progresses months or years later, additional forms of hormone therapy (eg, progestins, the antiestrogen fulvestrant) may be used sequentially until no further response occurs.

The most effective chemotherapy drugs are capecitabine, doxorubicin (including its liposomal formulation), gemcitabine, the taxanes paclitaxel and docetaxel, and vinorelbine. Response rate to a combination of drugs is higher than that to a single drug, but survival is not improved and toxicity is increased. Thus, some oncologists use single drugs sequentially.

For tumors that overexpress HER2, trastuzumab is effective in treating and controlling visceral metastatic sites. It is used alone or with hormone therapy or chemotherapy. Lapatinib is being used increasingly. Its role is evolving.

Radiation therapy alone may be used to treat isolated, symptomatic bone lesions or local skin recurrences not amenable to surgical resection. Radiation therapy is the most effective treatment for brain metastases, occasionally providing long-term control.

IV bisphosphonates (eg, pamidronate, zoledronate) decrease bone pain and bone loss and prevent or delay skeletal complications due to bone metastases. About 10% of patients with bone metastases eventually develop hypercalcemia, which can also be treated with IV bisphosphonates.


Prevention

Chemoprevention with tamoxifen or raloxifene is indicated for women with the following:

  • Age> 60

  • Age > 35 and previous LCIS

  • Presence of BRCA1 or BRCA2 mutations

  • 5-yr risk of developing breast cancer > 1.66% based on the multivariable Gail model, which includes the women’s current age, age at menarche, age at first live childbirth, number of 1st-degree relatives with breast cancer, and results of prior breast biopsies

A computer program to calculate breast cancer risk by the Gail model is available from the NCI at 1-800-4CANCER and online at http://www.cancer.gov/bcrisktool/ . Recommendations of the U. S. Preventive Services Task Force (USPSTF), Chemoprevention of breast cancer, are available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrpv.htm .

Patients should be informed of risks before beginning chemoprevention. Risks of tamoxifen include uterine cancer, thromboembolic complications, cataracts, and possibly stroke. Risks are higher for older women. Raloxifene appears to be about as effective as tamoxifen in postmenopausal women and to have a lower risk of thromboembolic complications and cataracts. Raloxifene, like tamoxifen, may also increase bone density. Raloxifene should be considered as an alternative to tamoxifen for chemoprevention in postmenopausal women.

Key Points

  • Breast cancer is the 2nd leading cause of cancer death in women; cumulative risk of developing breast cancer by age 95 is 12%.

  • Factors that greatly increase risk include breast cancer in close relatives (particularly if a BRCA gene mutation is present), atypical ductal or lobular hyperplasia, lobular carcinoma in situ, and significant exposure to chest radiation therapy before age 30.

  • Screen women by doing clinical breast examination, mammography (beginning at age 50 and often at age 40), and, for women at high risk, MRI.

  • Factors suggesting a poorer prognosis include younger age, absence of estrogen and progesterone receptors, and presence of HER2 protein or BRCA genes.

  • For most women, treatment requires surgical removal, lymph node sampling, systemic therapy (hormone therapy or chemotherapy), and radiation therapy.

  • Treat with hormone therapy (eg, tamoxifen, an aromatase inhibitor) if tumors have hormone receptors.

  • Consider treating metastatic disease to relieve symptoms (eg, with chemotherapy, hormone therapy, or, for bone metastases, radiation therapy or bisphosphonates), even though survival is unlikely to be prolonged.

  • Consider chemoprevention with tamoxifen or raloxifene for women at high risk.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • NOLVADEX
  • EVISTA
  • CRINONE
  • HERCEPTIN
  • CYTOXAN (LYOPHILIZED)
  • NEUPOGEN
  • ARIMIDEX
  • TAXOL
  • NEULASTA
  • AROMASIN
  • FEMARA
  • GEMZAR
  • No US brand name
  • TYKERB
  • ZOLADEX
  • XELODA
  • LUPRON
  • NAVELBINE
  • FASLODEX
  • TAXOTERE
  • AREDIA

* This is a professional Version *