Cancer

Sometimes in lonely nights I wonder why there aren't more starsigns named after deadly illnesses, but then after I while the fact occurs to me, that nobody died of cancer when they named them back then. Nobody was old enough in those days.

I'd still love to hear women approach each other, asking for their signs. »I'm multiple sklerosis and my friend is alzheimers« – »Oh, that's like so terrible, you just don't match«.

I tend to think, it would be a better world. And I'm not even a Cancer.

All breast cancer results from changes in genes, but not all changes in the genes
are inherited. In fact, only about 5 to 10 percent of breast cancers are thought to
be caused by inheritance. Scientists have identified some of the genetic
alterations, or mutations, that are responsible. In particular, women with
mutations in genes called BRCA 1 or BRCA 2 (for breast cancer 1 or 2) are in
greater danger of breast cancer. Statistics indicate that about 50 to 60 percent of
women with a mutation in either gene will develop breast cancer by the age of 70.
These mutations also increase a womans risk of ovarian cancer, and possibly of
colon cancer. And they tend to promote development of breast cancer at a
younger than average age.

Women with an abnormal AT (ataxia telangiectasia) gene are also thought to be
at increased risk of breast cancer. Likewise, abnormalities in the p53 tumor
suppressor gene can increase a womans risk. Theres also some evidence that
women of Ashkenazi Jewish descent may be at higher risk of carrying a genetic
mutation associated with breast cancer.

Its important to remember that a case of breast cancer in your family does not
automatically mean that you carry a gene associated with the disease. After all,
breast cancer is relatively common in women without a genetic mutation. A family
history of both breast and ovarian cancer increases the likelihood that you carry
such a mutation, but does not guarantee it.

You can find out whether you have the BRCA 1 or BRCA 2 mutation by getting
a blood test. If you have a family history of breast cancer, theres good reason to
be tested, but there are pluses and minuses to knowing for sure. Confirmation of
the abnormality can alert you to the need for lifestyle changes you might otherwise
have dismissed. It can also weigh heavily in the decision to undergo drug therapy
or a mastectomy to reduce the risk of breast cancer (see chapter 37 for more
details). On the other hand, a positive reading could result in loss of health
insurance, inability to obtain insurance, or an increase in premiums to an
unaffordable level.

Radiation therapy involves beaming x-rays at the site of the tumor to kill the
growing cancer cells. X-rays may sterilize the tissue around the tumor site – and
possibly under the arm – and keep the cancer from spreading or returning.

Radiation is always given after breast conservation surgery (lumpectomy or a
partial/segmental mastectomy). It may also be given after a full mastectomy,
especially to women with large tumors or those with evidence of tumor cells at
the edge of the tissue that is removed. Radiation is used in both early and
advanced stage cancer, as well as in cancer that recurs in the chest wall after
mastectomy. Radiation is also used to shrink an especially large tumor prior to
surgery or to slow the growth of inoperable tumors.

There are two types of radiation. The doctor may beam a concentrated booster
dose at the original tumor site or implant radioactive materials within the breast.

Some women undergoing radiation develop a skin reaction similar to a sunburn
and complain of itchy or peeling skin. However, the skin usually regains its normal
appearance as soon as treatment ends. Radiation therapy may also cause a
temporary decrease in the bloods disease-fighting white cells and increase the
risk of developing an infection.

Follow-up Treatment

In the past few years, physicians have recognized that adjuvant (additional)
treatment may improve the survival rate in early-stage breast cancer.

Since there is no way to be sure who is likely to have a recurrence, the National
Cancer Institute now strongly recommends follow-up treatment with drugs
(chemotherapy) or hormones to improve the odds of beating breast cancer.
Doctors regard this »extra treatment« as an insurance policy, hopefully ridding the
system of any hidden cancer that may remain and preventing or at least delaying
any return of the disease.

Chemotherapy

After surgery for early-stage breast cancer, most doctors now prescribe a
combination of drugs to destroy any remaining cancer cells. Some drugs may be
swallowed or injected into a muscle. Others are injected into a vein. These
anticancer »cocktails« are given in cycles, with periods of treatment alternating
with »off therapy,« or recovery, times. The total course of chemotherapy lasts 3 to
6 months, depending on the regimen.

Radiation targets a specific part of the body. Chemotherapy, on the other hand, is
a systemic treatment: The drugs reach every part of body. The strategy is to
attack any remaining cancer cells no matter where the drugs are found.

The problem with this strategy is that the drugs are very strong. They attack many
types of cells and, as a result, can produce debilitating side effects such as
nausea, vomiting, fatigue, and hair loss. Because they can damage healthy cells,
the body is less able to fight infections and other diseases.

Despite the drawbacks, chemotherapy works. Anticancer drug treatment has
been shown to increase the chance of reaching the 10-year survival mark by 34
percent in women with early-stage disease who underwent either a modified
radical or a total mastectomy.

The even better news is that some of the newer drugs cause fewer and less
severe side effects. Some women are lucky and dont have any side effects at all.
Administering certain drugs before chemotherapy can help reduce nausea and
vomiting, too. Regular laboratory tests can alert the doctor to any damaging
effects on the bodys ability to fight infection and other diseases.

Bone Marrow Transplantation

For some cancers, very high doses of drugs are more effective than standard
doses. However, such massive doses also kill the bone marrow, which produces
blood cells. To enable use of such doses, they are followed by »rescue«
maneuvers such as bone marrow transplantation (BMT) or transplantation of
blood stem cells (stem cell support).

BMT is a dangerous and taxing procedure. About 5 percent of those who
undergo it die, even in centers experienced in its use. The procedure used to be
restricted to women whose disease had spread beyond the breast area. More
recently, however, it has been performed in women with very high-risk primary
breast cancer that has spread to multiple lymph nodes but not to other organs. At
least half of women with breast cancer who undergo BMT now fall into this latter
group. However, there is little evidence that high-dose chemotherapy plus BMT
actually improves their chances of survival. Out of five studies done to date, only
one has been positive.

Because the evidence is conflicting at this point, the American Society of Clinical
Oncology has avoided making a recommendation about the use of high-dose
chemotherapy in breast cancer. (This group is the professional organization of
physicians who specialize in treating people with cancer.)

Hormonal Therapy

Because some breast cancers seem to be nourished by the female hormone
estrogen (or sometimes progesterone), doctors often prescribe therapy that
blocks or eliminates a womans natural supply of these hormones. To confirm the
value of this therapy, the tissue removed during breast biopsy is now routinely
tested for the presence of estrogen »receptors.« If the receptors are found, the
tumor is considered a suitable candidate for hormonal therapy. Women whose
cancers contain these receptors have a better overall prognosis.

Anti-estrogen therapy usually involves use of hormone blockers, though in some
relatively rare cases, the ovaries (which make the female hormones) are removed
surgically. Tamoxifen (Nolvadex), the most widely used hormone blocker, has
proved to be very effective. It works by attaching itself to the estrogen receptors
and blocking the estrogen from doing its cancer-promoting damage. The drug is
taken twice a day for up to five years.

Tamoxifen offers a number of benefits. It may suppress recurrence of cancer in
the same breast and prevent breast cancer in the other breast. In postmenopausal
women, it may also help maintain bone density and reduce the risk of heart
disease. On the other hand, it may increase risk of endometrial cancer, and can
cause bone loss among premenopausal women. Tamoxifen has also been linked
to blood clots in the major veins and the lungs.

Raloxifene (Evista), another anti-estrogen agent that is prescribed to prevent
osteoporosis, is being studied for use in treating breast cancer or suppressing its
recurrence. It appears to have a significant preventive effect, though it has not yet
been approved for this purpose. For more information on the role of both
raloxifene and tamoxifen in preventing breast cancer from ever occurring, see
chapter 37, »Your Best Insurance Against Breast Cancer.«

Megestrol acetate (Megace), another hormonal treatment, is usually used in
women with advanced breast cancers that do not respond to tamoxifen. The
doctor may also try treating advanced breast cancer with progestins or
androgens, if other hormonal therapies do not work.

Monoclonal Antibody Therapy

In September 1998, the FDA approved the first genetically engineered antibody
therapy for advanced breast cancer. The agent, called trastuzumab or Herceptin,
is used for cancers that produce too much of a certain protein (called the
HER-2/nue). When trastuzumab combines with this protein, the cell is unable to
divide and eventually dies. About 25 percent to 30 percent of patients with
metastatic breast cancer have tumor cells that express too much of this protein.
For these women, trastuzumab provides improved response to treatment when
given with other, standard forms of chemotherapy.

There are many different types of surgery for breast cancer. Options include
removing the whole breast and certain other tissues (radical, modified radical, and
total mastectomy) or removing only the lump with or without some tissue around
it (lumpectomy and partial mastectomy). The latter options are known as "breast
conservation» or «breast conserving therapy," as they allow a woman to keep
some of her breast. Breast conserving therapy is followed by radiation therapy; a
full mastectomy may not require it. Long-term cure rates with breast conserving
therapy are identical to those with mastectomy in women who qualify for the less
destructive procedure.

According to guidelines developed by the National Cancer Institute,
approximately 75 percent of women diagnosed with early stage (Stage I or II)
breast cancer are eligible for breast conserving therapy. Mastectomy is more
appropriate in early-stage cancers only for women with large tumors, small breast
size in comparison to tumor size, or multiple tumors in various parts of the breast,
and for those in an early-stage of pregnancy. One study indicates that many
women eligible for breast conserving therapy wind up with a mastectomy, so be
sure to quiz the doctor carefully about the breast conserving option.

In any of these procedures, the surgeon may also remove some – and possibly
all – of the lymph nodes under the arm. The lymph nodes are part of the bodys
lymphatic system, which filters waste from the tissues and carries fluids that help
the body fight infection. The lymphatic system transports fluids very efficiently
and, if invaded by cancer cells, can carry them throughout the body.

Surgeons remove at least a sampling of the lymph nodes near the breast to check
whether the cancer has reached the nodes. The extent of »nodal involvement« --
the number of lymph nodes with cancer – helps the physician determine how
much radiation or chemotherapy a woman needs after surgery. Removal of
underarm lymph nodes also is intended to help prevent cancer from recurring in
the same breast area.

Unfortunately, this procedure often leads to pain, as well as reduced use of the
arm and shoulder, for nearly 3 years after surgery. Investigators are trying to
determine whether removing only one or a few lymph nodes from under the arm
 – a technique known as sentinel node biopsy – is as effective as removing more
nodes. If so, doctors will need to remove just the nodes that cancer cells would
reach first. Only if these nodes show evidence of cancer would others need
removal.

For many years, women went into the hospital for a biopsy not even knowing
whether they even had cancer and often woke up several hours later to find that
their breast was gone. Advocates of this one-step approach to biopsy and
treatment believed that a simple surgical procedure involved less risk than waiting
between biopsy and surgery. Treatment began immediately and the woman had
less stress and anxiety because the ordeal was over much sooner. The one-step
approach was also cheaper and involved only one hospitalization.

Times have changed. Many women and physicians now favor the two-step
approach. This not only allows the doctor time to better evaluate the disease, but
also gives the patient a chance to consider the different treatment possibilities,
obtain a second opinion if she wants, make any necessary arrangements at work
or at home, and get herself mentally and emotionally ready to fight the disease.

The trend toward shortened hospital stays is evident in breast cancer surgery.
Lumpectomy is usually performed in an outpatient surgery center. Women
undergoing a mastectomy and/or removal of underarm lymph nodes generally
stay in the hospital for no more than 1 or 2 nights. Mastectomy patients are
occasionally hospitalized for as long as 5 days, but some may be discharged from
a short-stay observation unit in as little as 23 hours. In this situation, a home care
nurse typically monitors the patient. Many women are now discharged with a
surgical drain in place.

Whatever treatment a woman chooses, she needs to have her physicians support.
Its very important for doctor and patient to discuss the situation thoroughly and
make sure they agree on whats best. The bottom line for most women is to go
with the approach that offers them the best chance for survival. There are many
choices:

Radical Mastectomy

In a radical mastectomy, the surgeon removes the entire breast, both chest
muscles, and all of the lymph nodes under the arm. Also known as the Halsted
radical mastectomy, after the surgeon who developed the procedure in the
1890s, this operation used to be the standard breast cancer treatment.

There were many drawbacks to such extensive surgery. Women sometimes lost
movement in the arm and shoulder and experienced numbness, discomfort, and
swelling of the arm. The surgery was very disfiguring – some called it mutilation.
After the operation, the chest looked hollow and the scar unsightly. Breast
reconstruction was possible, but very difficult.

Over the years, scientific studies have shown that removing the chest muscles
doesnt improve a womans prognosis and isnt necessary if the cancer is found
early. Today, doctors perform radical mastectomies only when the tumor has
spread to the chest muscles.

Modified Radical Mastectomy

The modified radical mastectomy is an updated version of the standard radical
and is the most common surgical procedure performed for breast cancer. The
operation involves removing the breast, the lymph nodes, and the lining that
covers the two chest muscles. The muscles themselves are usually left in place,
although the smaller muscle is sometimes removed.

This operation delivers survival rates for women with early breast cancer that are
just as good as those achieved with a radical mastectomy. The surgery effectively
removes local cancer without causing muscle and nerve damage. Women
experience fewer complications and have more muscle strength in the arm.

The chest also looks a lot better, and this can be a great morale booster. In
addition, breast reconstruction is much easier to perform after a modified radical.

Although many women dont decide to have reconstruction until several months or
even years after their cancer surgery, it is important to discuss the possibility
beforehand so that the surgeon can help prepare the area for eventual operation.
The type of incision used in the mastectomy, for example, can make a big
difference in subsequent reconstructive surgery.

Total or Simple Mastectomy

In this operation, the surgeon removes the breast and maybe a few of the lymph
nodes closest to the breast. Presumably, any invasion of cancer cells will show up
in these lymph nodes first.

The benefits of this approach include a great reduction in swelling, because most
(or all) of the lymph nodes are left alone. The operation also makes breast
reconstruction easier than does more extensive surgery.

Partial or Segmental Mastectomy

With this procedure, the surgeon removes the tumor along with a portion of the
tissue around it. This wedge also includes some skin and the lining of the chest
muscle just below the tumor. The surgeon may also remove some or all of the
lymph nodes. Women who have this type of surgery also receive radiation
therapy.

If the breast is large, this approach leaves most of it intact. However, a woman
with smaller breasts will definitely see a change in breast shape after the surgery.
The amount of postoperative swelling generally depends on the number of lymph
nodes removed. Loss of muscle strength in the arm is not a problem.

Lumpectomy

The popular name for this operation, which involves removing only the tumor, is
somewhat misleading. Many surgeons also take out the lymph nodes through a
second incision in the armpit. Radiation therapy follows the surgery.

Lumpectomy is not without some drawbacks. The resulting scar tissue in the
breast can make follow-up breast examinations difficult. Swelling in the arm is a
possibility whenever lymph nodes are removed.

Women who have a large lump removed from a small breast are likely to notice a
significant change in the shape of the breast. Since the procedure itself can make
it more difficult to correct any resulting »deformities,« many plastic surgeons do
not recommend a lumpectomy for small-breasted women or those whose tumor
is located under the nipple.

On the other hand, many women do not need reconstruction after a lumpectomy.
To make a decision, you really need to discuss the prospects with both a general
surgeon and a plastic surgeon.