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Q: Breast Cancer - treatment options ( Answered,   0 Comments )
Subject: Breast Cancer - treatment options
Category: Health > Conditions and Diseases
Asked by: bselltiz-ga
List Price: $50.00
Posted: 22 Sep 2006 19:35 PDT
Expires: 22 Oct 2006 19:35 PDT
Question ID: 767724
My sister-in-law was recently diagnosed with breast cancer. She is in
stage 2, has 2 tumors in one of her breasts - one is 2.5cm and one is
1.7cm. One of her lymph nodes also seems to be affected. She is 40
years old in good overall health with her only mentionable medical
condition other than the cancer being a slight case of anemia.
While getting a second opinion one doctor informed her that she did
have the option of foregoing the surgery in favor of
radiation/chemotherapy only. Telling her that she could try the
treatment first to see if that alone would eliminate the tumors and if
not then she would have the surgery afterwards.
Now she is left with uncertainty as far as which direction to head.
She is leaning toward surgery but still wants to know more. I suppose
knowing the following would help her:
The advantage/disadvantage to treatment only without the surgery?
	Will the chances of the surgery being successful decrease if she has 
        done the treatment first? 
	Will she be worn down and unable to heal as easily if surgery is 
        necessary after treatment?
	Are there any recent statistics that might help her decide between the 
        two paths?
Is the removal of all the lymph nodes a bad thing since they are in
fact filters for the body? Is removing only the affected lymph nodes
the way to go?

Opinions and or experience will also be valuable here if there is no
hard data to address my questions.

Thank you very much.
Subject: Re: Breast Cancer - treatment options
Answered By: crabcakes-ga on 22 Sep 2006 22:58 PDT
Hello Bselltiz,

   I?ve gathered numerous opinions and recommendations from various
reliable medical sites. Because of copyright restrictions, I can post
only a limited amount here, so be sure and read each site for complete

 Of course having surgery or not is a decision to be made by your
sister-in-law and her physicians, and this answer is not intended to
recommend one therapy over another.

Lumpectomy vs. Mastectomy
   ?In 2006, more than 200,000 women in the U.S. will be diagnosed
with breast cancer. Experts agree that for most early-stage breast
cancer (stage 0, 1 or 2), lumpectomy (which removes just the cancer
and the breast tissue around it) is just as safe as mastectomy (which
removes the entire breast), if the lumpectomy is followed by radiation
treatment.1 Half of the women that experts deem eligible for
lumpectomy, however, will undergo mastectomy instead. Why are so many
women undergoing medically unnecessary mastectomies?

 At a 1990 Conference sponsored by the National Institutes of Health,
experts agreed that since survival rates were the same, lumpectomy
followed by radiation is the preferable treatment for most women with
early-stage breast cancer.

 But even today, more than 15 years later, many women eligible for
breast-conserving surgery are getting mastectomies. Studies have found
that some women are not even told that lumpectomies are an option.?

?One factor is fear. Some women are very afraid of recurrence and
choose mastectomy because the chances of recurrence in the same breast
are reduced when the breast is removed. Some women are afraid of
radiation therapy. Radiation therapy does cause side effects, but they
are usually relatively mild, such as fatigue or skin irritation. Only
very infrequently does radiation therapy cause long-lasting problems.?

   ?The procedure is often performed on women with small or localized
breast cancers and can be an attractive surgical treatment option for
breast cancer because it allows women to maintain most of their breast
after surgery. Several studies have shown that women with small breast
tumors have an equal chance of surviving breast cancer regardless of
whether they have a lumpectomy, followed by a full course of radiation
therapy, or mastectomy (complete breast removal, which generally does
not require post-operative radiation treatment).?

?Lumpectomy is often a suitable treatment option for patients with the
following breast cancers:
?	Ductal carcinoma in situ (DCIS) 
?	Stage I
?	Stage II
?	Stage III 
?After the lumpectomy is performed, the pathologist will check to make
sure the surgeon removed the entire cancerous tumor by seeing if the
tissue margins are "clear" (in other words, if there is no cancer
present in the outermost edges of the breast tissue sample). A
preliminary check of the tissue margins may be performed while the
patient is still in the operating room and may allow the surgeon to
obtain "clear margins" during the same operation. However, this is
only a preliminary reading, and the final results, available over the
course of a few days, may reveal residual cancer cells (known as a
"positive" margin). If the margins of the removed breast tissue do
contain cancer cells, then additional surgery (re-excision) is usually
necessary to attempt to remove the remaining cancer. If it is not
possible to clear the margins on re-excision, then a mastectomy is
usually offered as an alternative.?

   ?Stage II breast cancers are curable with current multi-modality
treatment consisting of surgery, chemotherapy, radiation therapy and
hormonal therapy.
Effective treatment of stage II breast cancer requires both local and
systemic therapy. Local therapy consists of surgery and/or radiation
and is directed at destroying any cancer cells in or near the breast.
Systemic therapy is directed at destroying cancer cells throughout the
body, and may include chemotherapy, targeted therapy, or hormonal
therapy . Systemic therapy is often administered as adjuvant therapy ,
which means treatment after surgery.?

?Surgery: Surgery for stage II breast cancers may consist of
mastectomy or lumpectomy. A mastectomy involves removal of the entire
breast, whereas a lumpectomy involves removal of the cancer and a
portion of surrounding tissue. Because a lumpectomy alone is
associated with a higher rate of cancer recurrence than mastectomy,
patients who elect to have a lumpectomy are also treated with
radiation therapy. This combination of lumpectomy and radiation
therapy is called breast-conserving therapy . Clinical studies have
shown that breast conserving therapy is associated with a lower risk
of local cancer recurrence compared to lumpectomy alone.

Mastectomy and breast-conserving therapy are the current standard of
care for the local treatment of stage II breast cancers and both are
considered acceptable options. Furthermore, breast conserving therapy
and mastectomy have been shown to produce identical long-term survival

?Surgery for early stage breast cancer may also involve the evaluation
of axillary (underarm) lymph nodes in order to determine whether
cancer has spread outside the breast and establish the stage of the
cancer. This is important to determine whether additional treatments
beyond local therapies, such as chemotherapy, are required. For over
30 years, the standard of practice for breast cancer staging has
included the removal of approximately 10-25 axillary lymph nodes to
help determine whether the cancer has spread. This procedure, called
an axillary lymph node dissection, can be associated with chronic side
effects, including pain, limited shoulder motion, numbness, and

A new approach for evaluating whether cancer has spread to the lymph
nodes is a sentinel lymph node biopsy . The advantage to this
procedure is that it involves the removal of a single lymph node,
called the sentinel node, which is the first lymph node to collect
excess fluid surrounding the cancer. Prior to surgery, blue dye is
injected near the cancer. The dye drains from the area containing the
cancer into the nearby lymph nodes, through the sentinel node. The
node containing the dye is removed during surgery and evaluated under
a microscope to determine whether cancer has spread. Sentinel lymph
node biopsy is becoming the standard approach for determining whether
cancer has spread to the axillary lymph nodes.

Research now indicates that sentinel node biopsy appears to be just as
effective in determining cancer spread to axillary lymph nodes as an
axillary lymph node dissection and results in fewer side effects in
patients with early stage breast cancer.?

   ??your first instinct may be: "The more treatment, the better." For
this reason, when it comes to surgery, you may think that mastectomy
is better than lumpectomy plus radiation. But when you and your doctor
evaluate the options, you may find out?depending on the type of cancer
you have?that more radical treatment is unlikely to offer any extra

?As a result of these studies, in the past 20 years many women with
small cancers (less than four centimeters) that are at an early stage
(Stage I or II) have been able to choose lumpectomy plus radiation
instead of mastectomy.?

   According to the following web site, identical results were
obtained with Modified Radical Mastectomy and lumpectomy with sentinel
lymphadenectomy and  radiation, along with clear margins.

   ?Radiation therapy generally follows breast-sparing surgery, such
as lumpectomy and segmented (or partial) mastectomy. Sometimes,
depending on the size of the tumor and other factors, radiation
therapy is also used after mastectomy. The radiation destroys breast
cancer cells that may remain in the area.

Before surgery, radiation therapy, alone or with chemotherapy or
hormone therapy, is sometimes used to destroy cancer cells and shrink
tumors. This approach is most often used in cases in which the breast
tumor is large or not easily removed by surgery.?

    ?Women with early-stage breast cancer who undergo
breast-conserving surgery with radiation therapy live just as long as
those who undergo mastectomy. Life expectancy is the same regardless
of which choice a woman makes.
When the patient is told that the survival rate for lumpectomy with
radiation is the same as for mastectomy, some women may be surprised
or skeptical.
Why would any woman pick mastectomy if the survival rate is the same? 
Thanks to early detection, between 70 and 75 percent of women
diagnosed with breast cancer today are possible candidates for
lumpectomy or other breast-conserving surgery. Yet, half of these
women undergo mastectomies instead. Some of those women are making a
well-informed choice. Some do not know that they have a choice. And,
because of the costs of health care, some cannot afford to make the
choice they would prefer.

   Unfortunately, cost sometimes prevents women from choosing
breast-conserving surgery. Lumpectomy followed by radiation costs more
in the short-term than mastectomy, and some insurance plans do not
cover all the expenses of the lumpectomy or the radiation therapy.
Reconstruction of the breast after mastectomy adds to the cost, but
the law requires that insurance covers that expense. Despite the
slightly higher cost of lumpectomy and radiation, that choice is
actually less expensive if you look at costs for the five years after
the initial diagnosis. Lumpectomy preserves the breast and there are
few additional costs when the radiation treatment is completed,
whereas breast reconstruction after a mastectomy may require several
surgeries that add to the cost over time. This information may help
women who are concerned about cost to decide what is best for them.?

   ?Chemotherapy is not recommended for most women with early stage
breast cancer. If chemotherapy is recommended, it can improve survival
and decrease the risk of breast cancer recurrence. There are several
different kinds of chemotherapy, and it is sometimes used in
combination with tamoxifen. Chemotherapy is usually given after
surgery, but there are exceptions. For example, a woman with Stage III
breast cancer may undergo chemotherapy before surgery to shrink a
tumor so that she can undergo breast-conserving surgery.?

   ?By summarizing the data reported it is clear that most but not all
women with stage I or II breast cancer benefit from breast-conserving
treatment. Decision-making, particularly on younger women, is complex
and challenging and requires our special consideration with an
in-depth analysis of clinicopathologic criteria and therapeutic
options available.

 As the presence of occult carcinoma detected by modern imaging
techniques may be responsible for a late tumor appearance, despite
whole breast irradiation after breast-conserving surgery, the total
mastectomy option should also be offered to a young woman until new
evidence-based data make clear the biological behavior of these
microscopic lesions. Whether magnetic resonance imaging or positron
emission tomography, in addition to ultrasonography and mammography,
should be incorporated into clinical use for identification of these
lesions is unclear and under investigation. It is clear that surgical
margins free of tumor continue to remain the principal goal of
breast-conserving surgery and re-excision or mastectomy cannot be
replaced by an additional margin-directed boost. Chemotherapy and/or
tamoxifen are effective in reducing risk of local failure in certain

Stage 2 Breast Cancer Therapies
?Like stage I breast cancer, stage II breast cancer in often treated
with lumpectomy and radiation, and in some cases mastectomy may be a
better surgical option or patients choice. Unlike stage I breast
cancer, in stage II breast cancer, if the tumor size is more than 2
inches (5 cms) in size, or if cancer has spread to more than three
lymph nodes, patient will benefit from radiation therapy even if the
surgical choice was mastectomy. Adjuvant chemotherapy is recommended
to all patients unless there is something that suggests that patient
may not tolerate chemotherapy. If the tumor is found to be hormone
receptor positive, adjuvant Hormonal therapy is almost always

   ?One new study has suggested that, at the end of five years of
tamoxifen if another hormonal agent namely letrozole is given for
another 5 years, that would further decrease the risk of breast cancer
from coming back. Also one new study has suggested that if at the end
of 2 to 3 years, if tamoxifen is switched to another hormonal agent
namely exemestane, patient may get more benefit.?


Hormone Therapy
?After a breast cancer is removed, the cancer cells are tested to see
if they have hormone receptors. If either estrogen or progesterone
receptors are present, a response to hormonal therapy is very
possible. The more estrogen or progesterone receptors present on those
cells, the more likely that hormonal therapy will work against the
particular cancer. If high levels of both estrogen and progesterone
receptors are present, an even greater response to hormonal therapy is
?About 75% of breast cancers are estrogen-receptor-positive
("ER-positive" or "ER+").?

??  If both estrogen and progesterone receptors are present (ER+/PR+),
your chance of responding to hormonal therapy is about 70%.
?  If you are estrogen-receptor-positive only (ER+/PR?) OR
progesterone-receptor-positive only (ER?/PR+), you have about a 33%
chance of responding.
?  If the receptor status is unknown, there is about an overall 10%
chance of responding.?

   ?Hormone therapy is another form of adjuvant systemic therapy. The
hormone estrogen is produced mainly by a woman's ovaries until
menopause. After menopause it is made mostly in the body?s fat tissue,
where a testosterone-like hormone made by the adrenal gland is
converted into estrogen. Estrogen promotes the growth of about two
thirds of breast cancers (those containing estrogen or progesterone
receptors and called hormone receptor positive cancers). Because of
this, several approaches to blocking the effect of estrogen or
lowering estrogen levels are used to treat breast cancer.?

The Lymphatic System
    Your sister-in-law will not have all of her lymph nodes removed?
only the affected ones. Lymph nodes are located all through the body,
and other modes will continue to work as ?filters?. The doctor may
advise her not to have injections, have blood drawn, or have her blood
pressure taken from the affected side for several years, to avoid
introducing bacteria into her system on that side.
?The lymphatic system consists of various glands, organs and ducts
connected throughout the body. It removes lymph (fluid containing
white blood cells, plasma and other substances) from the tissues and
returns it to the bloodstream. The lymphatic system is an important
part of the immune defense system. In addition to extracting lymph
fluid from tissues, the lymphatic system produces and stores some of
the cells needed by the body to fight infections and diseases,
including cancer.?

??  Following a lymph node dissection, don't avoid using your arm, but
don't exercise it until your first post-operative visit. Please review
"Protecting Your Arm" on page 15 of the California State Guide "A
Woman's Guide to Breast Cancer Diagnosis and Treatment" for prevention
of infection and lymphedema (swelling of the arm).
?  You will be given exercises to regain movement and flexibility (on
the surgical side). You may be referred to Physical Therapy for
additional rehabilitation if it is needed.
?  Most people return to work within 3 to 6 weeks. Return to work
varies with your type of work, your overall health and personal
preferences. Discuss returning to work with your physician or nurse.?


   The tumors your sister-in-law has are smaller than  5cm, which is
good news! After her lumpectomy, the tissue will be tested for hormone
receptors. The majority of women with breast cancer are
estrogen-receptor positive, which is another plus ? your sister-in-law
had a 75% chance of being positive for estrogen-receptors!

   ?A survival rate is a statistical index, which summarizes the
probable frequency of a specific outcome for a group of patients at a
particular point in time. Different methods may be used to compute
rates so they are not directly comparable with each other. Depending
on the source used the time frame and numbers could be different.
Five-year survival rate for Stage 2A or 2B cancer based on our source
is noted at approximately 65%. This is a number based on a group of
patients, and does not translate literally to the individual. These
and other statistics are helpful when used generally to make
recommendations and decisions regarding treatment, but how an
individual will respond to treatment is influenced by many factors
that are not captured by the statistic.?

   ?The chance of recovery (prognosis) and choice of treatment depend
on the stage of the cancer (whether it is just in the breast or has
spread to other places in the body), the type of breast cancer,
certain characteristics of the cancer cells, and whether the cancer is
found in the other breast. A woman's age,weight, menopausal status
(whether or not a woman is still having menstrual periods), and
general health can also affect the prognosis and choice of treatment.?

?Stage IIA is defined by either of the following:
The cancer is no larger than 2 centimeters but has spread to the lymph
nodes under the arm (the axillary lymph nodes).
The cancer is between 2 and 5 centimeters (from 1 to 2 inches), but
has not spread to the lymph nodes under the arm.?

?Lymphedema is a swelling condition that sometimes occurs following
surgical removal of lymph nodes. Early treatment of this swelling
helps to reduce the amount of therapy needed with the least amount of
lifestyle changes.
The treatment of lymphedema is carried out by a physical therapist
certified in its treatment. Lymphedema treatment consists of complete
decongestive therapy, including manual lymphatic drainage, short
stretch compression bandaging, exercise, and skin care. Long-term
independent management of lymphedema is encouraged with the use of
compression garments, self-bandaging, and patient education.?

?Lymphedema can occur immediately after an operation, within a few
months, a couple of years, or even 20 or more years after cancer
therapy. With proper education and care, lymphedema can be avoided or,
if it develops, kept under control.?

   ?Estimates vary greatly in the literature and in practice
ranging from 6%* to 49%** LE occurrence after breast cancer.

Discrepancies due to:
? Inconsistent definitions of lymphedema
? Subjective and Objective Measurement
? Procedures (Node, Radiation & Surgery) not always
accounted for
? Varying periods of follow-up
Page 8

Additional information on hormone therapy:

   It certainly appears, from this research, and previous research I
have done in this area, that in your sister-in-law?s case, lumpectomy
surgery, followed by hormone receptor testing and hormone therapy,
and/or  radiation seems like a logical path to follow. Her tumors are
small, and she is young. However, this is just a recommendation. Only
your sister-in-law?s physician knows the best course of treatment ?
based on her tests, pathologies, location and exact type of cancer.
The outcome looks good for her. Anecdotally, if it were me, I would
opt for a sentinel lymph node biopsy, then lumpectomy first, followed
by whatever is best ? hormone therapy and/or radiation, based on the
post-surgical pathologies and tests.

   If I may interject some unsolicited advice? be sure and help your
sister-in-law to keep a positive attitude towards her cancer. All
research indicates she has a very good prognosis.

I hope this answer has helped you out, and I wish your sister-in-law the best! 

If anything is unclear. Please request an Answer Clarification, and
allow me to respond, before you rate this answer.

Sincerely, Crabcakes

Search Terms
stage 2A breast cancer + lumpectomy
Stage 2A  breast cancer + mastectomy
therapies  + Stage 2A  breast cancer
Hormone therapy + Stage 2A breast cancer
Lumpectomy vs mastectomy + stage 2A
Survival rates + Stage 2A  breast cancer
Prognosis + Stage 2A  breast cancer
occurrence of lymphedema lumpectomy

Request for Answer Clarification by bselltiz-ga on 25 Sep 2006 11:46 PDT
Thank you for the detailed answer. One of the links was unavailable -

Clarification of Answer by crabcakes-ga on 25 Sep 2006 12:40 PDT
I am SO sorry! That link worked when I posted it, but such is the
nature of the internet-everchanging.

 I am posting a cached page (a saved page) so you can read the
information. I doubt if the illustrations will be present. If you find
any information on the cached page useful, please print it out ASAP,
as it is unknown how long the cached page will last!

  If you have further questions, don't hesitate to request another
clarification, and allow me to respond, before you rate this answer.

Sincerely, Crabcakes

Request for Answer Clarification by bselltiz-ga on 26 Sep 2006 06:09 PDT
"I am posting a cached page"

How do I access it?


Clarification of Answer by crabcakes-ga on 26 Sep 2006 08:07 PDT
Oh my! The only way you can access it would be for  me to post it! And I did not!
Please forgive me. Here is the link:

Again, I apologize for the ommission.

Sincerely, Crabcakes
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