Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Dr. Balentine received his undergraduate degree from McDaniel College in Westminster, Maryland. He attended medical school at the Philadelphia College of Osteopathic Medicine graduating in1983. He completed his internship at St. Joseph's Hospital in Philadelphia and his Emergency Medicine residency at Lincoln Medical and Mental Health Center in the Bronx, where he served as chief resident.
Many women have treatment in addition to surgery, which may include radiation
therapy, chemotherapy, or hormonal therapy. The decision about which additional
treatments are needed is based upon the stage and type of cancer, the presence
of hormonal and/or HER-2/neu receptors, and patient health and preferences.
Radiation therapy is used to kill tumor cells if there are any left after
surgery.
Radiation is a local treatment and therefore works only on tumor
cells that are directly in its beam.
Radiation is used most often in people
who have undergone conservative surgery such as lumpectomy. Conservative surgery
is designed to leave as much of the breast tissue in place as possible.
Radiation therapy is usually given five days a week over five to six weeks. Each
treatment takes only a few minutes.
Radiation therapy is painless and has
relatively few side effects. However, it can irritate the skin or cause a burn
similar to a bad sunburn in the area.
Radiation therapy in breast cancer is usually external beam radiation, where the radiation is pointed at a specific area of the breast from the outside. Rarely internal radiation therapy is used, where radioactive pellets are implanted close to the cancer.
Chemotherapy consists of the
administration of medications that kill cancer cells or stop them from growing.
In breast cancer, three different chemotherapy strategies may be used:
1.
Adjuvant chemotherapy is given to people who have had curative treatment for
their breast cancer, such as surgery and radiation. It is given to reduce the
possibility that the cancer will return.
2. Presurgical chemotherapy (known as neoadjuvant chemotherapy) is given to shrink a large tumor and/or to kill
stray cancer cells. This increases the chances that surgery will get rid of the
cancer completely.
3. Therapeutic chemotherapy is routinely administered to women with breast
cancer that has spread beyond the confines of the breast or local area.
Most
chemotherapy agents are given through an IV line, but some are given as pills.
Chemotherapy is usually given in "cycles." Each cycle includes a period of
intensive treatment lasting a few days or weeks followed by a week or two of
recovery. Most people with breast cancer receive at least two, more often four,
cycles of chemotherapy to begin with. Tests are then repeated to see what effect
the therapy has had on the cancer.
Chemotherapy differs from radiation in that
it treats the entire body and thus may target stray tumor cells that may have
migrated from the breast area.
The side effects of chemotherapy are well
known. Side effects depend on which drugs are used. Many of these drugs have
side effects that include loss of hair, nausea and vomiting, loss of appetite,
fatigue, and low blood cell counts. Low blood counts may cause patients to be
more susceptible to infections, to feel sick and tired, or to bleed more easily
than usual. Medications are available to treat or prevent many of these side
effects.
Hormonal therapy may be given because breast cancers (especially those
that have ample estrogen or progesterone receptors) are frequently sensitive to
changes in hormones. Hormonal therapy may be given to prevent recurrence of a
tumor or for treatment of existing disease.
In some cases, it is beneficial to
suppress a woman's natural hormones with drugs; in others, it is beneficial to
add hormones.
In premenopausal women, ovarian ablation (removal of the hormonal effects
of the ovary) may be useful. This can be accomplished with medications that
block the ovaries' ability to produce estrogens or by surgically removing the
ovaries, or less commonly with radiation.
Until recently, tamoxifen (Nolvadex), an antiestrogen (a drug that blocks
the effect of estrogen), has been the most commonly prescribed hormone
treatment. It is used both for breast cancer prevention and for treatment.
Fulvestrant (Faslodex) is another drug that acts via the estrogen receptor,
but instead of blocking it, this drug eliminates it. It can be effective if the
breast cancer is no longer responding to tamoxifen. Fulvestrant is only given to
women who are already in menopause and is approved for use in women with
advanced breast cancer.
Toremifene (Fareston) is another anti-estrogen drug closely related to
tamoxifen.
Aromatase inhibitors, which block the effect of a key hormone affecting the
tumor, may be more effective than tamoxifen in the adjuvant setting. The drugs
anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara) have a
different set of side effects and risks than tamoxifen.
Aromatase inhibitors are rapidly moving into first-line hormonal therapy
regimens. In addition, they are frequently used after two or more years of
tamoxifen therapy.
Megace (megestrolacetate) is a drug similar to progesterone which may also
be used as hormonal therapy.
Targeted therapy is a type of treatment that has been developed to directly work against some of the cellular changes that have been identified in breast cancers. Examples of targeted therapies include monoclonal antibodies against cancer cell-specific proteins.
Monoclonal antibodies are antibodies against
proteins in or around a cancer cell. Antibodies recognize an "invader"
-- in this
case, a cancer cell -- and attack it.
Trastuzumab (Herceptin) is an antibody
against the HER-2 protein, a protein responsible for cancer cell growth in many
women with breast cancer (about 15%-25% of breast cancers). Adding treatment with
trastuzumab to chemotherapy given after surgery has been shown to lower the
recurrence rate and death rate in women with HER2/neu-positive early breast
cancers. Using trastuzumab along with chemotherapy has become standard adjuvant
treatment for these women.
Lapatinib (Tykerb) is another drug that targets the HER2/neu protein and
may be given combined with chemotherapy. It is used in women with HER2-positive
breast cancer that is no longer helped by chemotherapy and trastuzumab.
Another monoclonal antibody,
Bevacizumab (Avastin) has been shown to have
activity in the treatment of breast cancer and is used in combination with
chemotherapy. This drug targets the ability of cancer cells to form new blood
vessels. However, the U.S. FDA revoked its approval of this drug in November 2011, noting that those taking Avastin faced potentially life-threatening side effects without proof that the drug provided benefits in slowing tumor growth or improving longevity or quality of life.
Surgery
Surgery is generally the first step after the diagnosis of breast
cancer. The type of surgery is dependent upon the size and type of tumor and the
patient's health and preferences. The choice of procedures should be discussed with your health-care team as any approach has advantages and disadvantages.
Lumpectomy involves removal of the cancerous
tissue and a surrounding area of normal tissue. This is not considered curative
and should almost always be done in association with other therapy such as
radiation therapy with or without chemotherapy or hormonal therapy.
At the time of lumpectomy, the axillary lymph nodes (the glands in the
armpit) need to be evaluated for the spread of cancer. This can be done by
either removing the lymph nodes or by sentinel node biopsy (biopsy of the
closest lymph node to the tumor).
If a sentinel node biopsy is done at the time of lumpectomy, it may allow
the surgeon to remove only some of the lymph nodes. In this procedure, a dye is
injected into the area of the tumor. The path of the substance is then followed
as it travels to the lymph nodes. The first node reached is the sentinel node.
This node is considered most important to biopsy when evaluating the spread of
the tumor.
If the sentinel node biopsy is positive, the surgeon will usually remove of
all of the lymph nodes found in the axilla (armpit).
Simple mastectomy removes the entire breast but no other structures. If the
cancer is invasive, this surgery alone will not cure it. It is a common
treatment for DCIS, a noninvasive type of breast cancer.
Modified radical mastectomy removes the breast and the axillary (underarm)
lymph nodes but does not remove the underlying muscle of the chest wall.
Although additional chemotherapy or hormonal therapy is almost always offered,
surgery alone is considered adequate to control the disease if it has not
metastasized.
Radical mastectomy involves removal of the breast and the underlying chest
wall muscles, as well as the underarm contents. This surgery is no longer done
because current therapies are less disfiguring and have fewer complications.
