Introduction:
Breast cancer is the most common cancer afflicting women, with an estimated 290,000 new cases in 2015. The National Cancer Institute estimates that the risk of breast cancer in an average woman’s lifetime is 12.7%. An average woman’s chance of getting breast cancer increases with age: the chance for a 30-39 year old woman developing breast cancer is about 0.43%, (1 in 233) while the chance for a 60-69 year old woman is about 3.65% (1 in 27). This survivorship guide is intended to be the jumping off point for your education, empowerment, and survival of this disease. Together, we will beat this!
After treatment, there are simple things you can do to continue thriving! Increasing physical activity (30 minutes, 3-4 times weekly), lowering your body mass index (BMI) to close to 30, and limiting red meat protein consumption while increasing fruit and vegetable consumption, are just some of the lifestyle modifications patients can do to limit their chance of breast cancer recurrence. Remember, even after 5 years of successful survivorship, you need ongoing follow-up with me for clinical examination and survivorship.

Risk factors for breast cancer:
Scientifically proven risks for the development of breast cancer include: female gender, increasing age, personal or family history of breast cancer (especially younger and first degree relatives), personal history of atypical hyperplasia on prior biopsy, genetic mutations such as BRCA, radiation therapy to the chest prior to age 30, obesity, physical inactivity, early menses, late menopause, no pregnancies or first pregnancy after age 30, long-term hormone replacement therapy, and alcohol consumption. Hormone replacement therapy is a slight risk factor, and breast density remains somewhat debated (ie, is it harder to spot, or is it a true risk factors). There is no conclusive scientific evidence that deodorants or underwire bras increase the risk of breast cancer.
The majority of women “get “breast cancer because of increasing age, female gender, and bad luck (i.e., these are “sporadic” cancers). About 5-10% of breast cancers are inherited from your family. Considerations for inherited breast cancers are diagnosis age under 50, first-degree relatives with breast, pancreas or ovarian cancer (not cervical or uterine), male breast cancer, triple negative breast cancer, and Ashkenazi Jewish ethnicity.

Types of breast cancer:
Ductal carcinoma in situ, also known as DCIS, is a pre-invasive, Stage 0 breast cancer. “Preinvasive” means that the breast cancer has been diagnosed so early it cannot move elsewhere. There is some slight debate in the medical world if we should continue to classify all DCIS as breast cancer, but for now, it remains classified as Stage 0 disease. Invasive breast cancers are typically classified as invasive ductal cancers (IDC) or invasive lobular cancers (ILC). Invasive cancers have POSSIBLY gained the ability to move to lymph nodes or other organs, but the vast majority of invasive cancers DO NOT move elsewhere. Invasive breast cancers are Staged from 1-4.
Inflammatory breast cancer (IBC) does not behave like a typical breast cancer- IBCs often show up suddenly and woman’s breast may be large, red, and inflamed. These Stage 3 breast cancers require a combination of chemotherapy, followed then by surgery and radiation therapy to treat successfully. Less common types of breast cancer, include papillary (typically very unaggressive), malignant phyllodes, angiosarcoma (very aggressive), and lymphoma. Rarely, other types of cancer can move to the breast, including kidney, lymphoma, and lung cancer.

Pathology review:
There are important “receptors” for breast cancer, which determine therapies you may need after surgery. Hormone receptors are Estrogen (ER) and progesterone (PR) receptors. These determine if your cancer will respond to a taking an endocrine pill, after treatment, which will decrease the likelihood of the breast cancer returning. These pills are NOT chemotherapy and most are very well tolerated; common names for these pills are tamoxifen and anastrozole. 80% of breast cancers are hormone positive; however, if a person’s cancer is both ER and PR negative, taking an endocrine pill does not work for their type of breast cancer. The HER2/neu receptor is another receptor we look at; it is positive in about 15-20% of invasive tumors. If a woman is Her2/Neu positive, she will potentially be offered IV targeted therapy after surgery, (trastuzumab or pertuzumab). Tumor grade is also described on your path report, with tumors being reported as low grade (Grade1) to high grade (Grade 3). Lymphovascular invasion (LVI) may also be reported in your tumor; this means the tumor potentially is more quickly dividing, making chemotherapy possibly more likely after surgery.

Preoperative work-up:
Preoperatively, I will be able to clinically stage your cancer based on imaging; this sometimes can change after surgery depending on your final pathology. Your breast cancer stage is based on estimated tumor size and presence or absence of disease in your lymph nodes. Women diagnosed with Stage 0-2 breast cancer need just blood tests and a chest x-ray preoperatively to ensure the cancer has not spread elsewhere. It is highly unlikely to find anything on these studies. More extensive staging is only recommended for women with Stage 3 cancer, or if you have a specific symptom. For most patients, surgery is the first step of breast cancer treatment, followed if needed by radiation therapy or chemotherapy. Some women may benefit from chemotherapy prior to surgery (neoadjuvant therapy). Depending on certain patient and breast-specific factors, I may recommend a breast MRI for additional imaging prior to surgery. Preop breast MRI is NOT necessary for all women. Genetic testing is recommended for young women diagnosed with breast cancer, and in patients with strong family histories of breast, ovarian, or pancreas cancers.
Your breast cancer team consists of myself, as your surgical oncologist, your oncology nurse navigator (ONN), and if necessary, a medical oncologist, a radiation oncologist, a physical therapist, a nutritionist, a social worker, and a genetic counselor. This team coordinates your care to provide you the best possible outcome. Every one of my patients is presented at a Multidisciplinary Breast Conference prior to treatment to ensure highest quality care. My office arranges all of your post-operative referrals so that your care is coordinated. If you prefer to meet with other physicians preoperatively, please let me know; however, in most circumstances, other physicians cannot make additional treatment recommendations until after I complete your surgery.

Surgical decision making:
Most women have two main treatment options for their breast cancer, and there are pros and cons to each choice. Breast cancer surgery is a PERSONAL decision. Mastectomy involves removal of the entire breast, while lumpectomy means removing the breast cancer and a rim of normal tissue. The majority of women under age 70 who desire lumpectomy must have radiation therapy after surgery. Patients who choose mastectomy usually do not need radiation after surgery. Some women may have the false belief that mastectomy is “better” than lumpectomy, but this is certainly not true!! Lumpectomy and mastectomy provide EQUAL survival for breast cancer. Also, choosing a mastectomy does NOT make chemotherapy less likely after surgery.
The main difference between the lumpectomy and mastectomy is the risk of “local recurrence”. If breast cancer returns at the breast it is called a local recurrence. Local recurrence is NOT the same as systemic reccurrence, which means the breast cancer has come back somewhere else (typically in the bones, liver, or lung). For most women, the risk of local recurrence after lumpectomy and radiation is low, less than 10%. The risk of systemic recurrence is inherent to your type of cancer and stage, not your surgery. The factors that increase the risk of systemic recurrence include later stage, and cancers that are hormone negative or Her2/neu positive. We decrease the risk of systemic recurrence with chemotherapy, not more extensive surgery.
A mastectomy is medically necessary if you have several areas of cancer in the breast, do not want radiation or have already had breast radiation (and you need radiation now), or a if you have very large cancer we can’t shrink down with preoperative therapy. The majority of women choose to have a mastectomy for personal reasons, but didn’t necessarily have to. If that is your decision, it remains absolutely respected in my practice! Radiation is not routinely necessary after mastectomy, unless you have a big tumor or multiple lymph nodes with cancer. After a mastectomy, a woman has the option of reconstructive surgery. Your insurance is federally mandated to cover reconstruction for breast cancer, so if you are interested in this, you will be referred to a board-certified plastic surgeon that will perform your reconstruction. If you choose not to have reconstruction, you can be fitted for mastectomy bra and breast prosthesis about 4-6 weeks after surgery.
Most mastectomies with reconstruction are are called “skin-sparing”- I save the majority of your skin for the plastic surgeon to reconstruct your breast. Some highly selected women may qualify for a nipple-sparing mastectomy. Most women choose implant-based reconstruction, done in two stages. For this, stage 1 of reconstruction is completed at the time of your mastectomy, with a tissue expander. A second stage is completed several months later to switch out the expander for your permanent implant. If you have interest in reconstruction, your plastic surgeon will discuss your reconstructive options, and will work closely with me to optimize your cosmetic goals.
Most women are candidates for lumpectomy for treatment of their breast cancer, even women with initially large breast cancers. Women under age 70 routinely need radiation after lumpectomy; over age 70, SOME women may eliminate radiation without decreasing their survival. Radiation therapy for breast cancer does not cause nausea or hair loss; fatigue sometimes occurs. Side effects of breast radiation include skin darkening, thickening, and sometimes a burn; these effects are temporary during treatment, and improve with time. Some women have permanent but mild skin changes and breast achiness. Rare complications include lung scarring, heart disease, and other cancers years later.
There are two main types of radiation for breast cancer. Many women receive whole breast radiation (WBRT). WBRT involves office visits 5 days a week, for 4-6 weeks. WBRT treats the entire breast and part of the armpit. Some women qualify for a shorter 4 week treatment called hypofractionation; the radiation oncologist will tell you if you need 4 or 6 weeks of treatment based on your breast size and final pathology. A second type of radiation is called brachytherapy (APBI). Only some women qualify for this type of therapy, and it involves me placing catheter at the lumpectomy site. A woman receives focal radiation only to the lumpectomy through this catheter, twice daily for 5 days. This radiation has been FDA approved since 2002 and is also covered by insurance. Intraoperative radiation and proton radiation remain investigational, and are not typical radiation treatments for breast cancer at this time.

Lymph node surgery and lymphedema:
Lymph node surgery is necessary for women with Stage 1 and 2 disease to determine if the cancer had spread to the lymph nodes. Lymph node spread is typically the first factor a medical oncologist uses to determine a woman’s need for chemotherapy after surgery. An axillary node dissection is when I have to remove all of your lymph nodes in the armpit. This procedure is now NOT necessary for the majority of women diagnosed with early stage breast cancer when they undergo a lumpectomy. Most women undergo only a sentinel lymph node biopsy (SLNB) to determine if her lymph nodes contain cancer. This involves removing only the lymph nodes to which the cancer could spread first, if cancer has moved from the breast. SLNs are found during your breast surgery by using a nuclear medicine and a blue dye that we inject into your breast. These travel through the breast to the lymph nodes in the armpit. Lymph nodes that pick up these medicines are removed during surgery to ensure there is no cancer there. Many women with Stage 0 cancer do not need even a SLNB.
Why is it important to discuss lymph node surgery? The development of lymphedema (swelling and pain in the arm) is hypothesized to be caused by both patient-specific risk factors and the extent of axillary surgery. However, we still really do not know what “causes” lymphedema. Obesity, extensive axillary surgery, radiation, and chemotherapy are risk factors for developing lymphedema. Women undergoing only SLNB report lower rates of lymphedema (about 5-10%, versus 10-40%) than women who undergo ALND. For some women with more aggressive cancers, ALND remains necessary. If a woman must undergo this procedure, she will be referred to lymphedema education classes for prevention techniques and to lymphedema physical therapy for treatment if she develops lymphedema. Lymphedema typically will not develop until 18-36 months after surgery, so it’s important to be diligent afterwards.

Genetics:
About 5-10% of breast cancers are inherited from your parents, most commonly due to a MUTATION in the BRCA 1 or BRCA 2 gene (there are other gene mutations that can cause breast cancer, but these are more rare). All people have BRCA genes, but a mutation in the BRCA 1 or 2 gene can place a patient at a higher risk for developing breast, ovarian, and pancreas cancer. I will refer you for genetic counseling/testing if you have certain risk factors: age of diagnosis under 50, prior history of breast cancer, a first-degree young relative with breast cancer, a family history of ovarian (not uterine or cervical) or male breast cancer, Ashkenazi Jewish ancestry, or triple negative cancer breast cancer under age 60. If you meet your insurance’s criteria for testing, the geneticist will counsel you about implications for testing and future management for you and your family. Importantly, many women diagnosed with breast cancer do not need genetic testing (because their cancer was sporadic), and even if a woman needs tested, most will test NEGATIVE. Genetic testing results typically take less than 2 weeks; I often will wait for these results for surgery, to ensure your surgical decision would not be altered by a positive result (ie, converting from lumpectomy to mastectomy, or adding on prophylactic ovarian removal).

Evidence-based web resources
1) NCCN Guidelines (National breast cancer guidelines):
http://www.nccn.org/patients/guidelines/cancers.aspx#breast
2) Data on improved survival lumpectomy vs. mastectomy:
http://www.generalsurgerynews.com/In-the-News/Article/01-16/More-Evidence-Supports-Breast-Conservation-Over-Mastectomy/34816
2) Breast cancer, lumpectomy vs. mastectomy:
http://www.breastcancer.org/treatment/surgery/mast_vs_lump
3) Z11 study (eliminating ALND after lumpectomy):
http://www.ncbi.nlm.nih.gov/pubmed/21304082
4) CALGB 9343 study (eliminating radiation in women >70):
http://www.ncbi.nlm.nih.gov/pubmed/23690420
5) Radiation guidelines for brachytherapy and hypofractionation:
https://www.astro.org/Clinical-Practice/Guidelines/Breast-Cancers.aspgx
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