Breast Cancer:
Diagnosis, Treatment and Recovery
Dr. Susan B. Winchester is familiar with the disease that strikes 175,000 women in
this country each year. She estimates that 85 percent of her practice deals with women who have a potential problem with their breasts,
and she knows that if diagnosed in its early stages, breast cancer is very treatable.
Dr. Winchester, a general surgeon at St. Vincent’s
Hospital, said mammography is critical for early detection, but pointed out that, while an abnormal mammogram causes a great deal
of anxiety for the patient, it indicates cancer only 15 to 20 percent of the time. And a mammogram is only one component of what Dr.
Winchester views as a woman’s personal responsibility for her own health.
Women, she said, should perform monthly self-examinations
in order to become familiar with their breasts, and they should contact their doctor if any change in the breast persists through
two or three monthly cycles. If women are vigilant regarding their breast exams, they will often be the first to detect a change and,
if that change is cancer, it may be at an earlier stage. Women should also be aware of their risk factors concerning breast cancer
and should follow a recommended schedule for mammograms.
On average, breast cancer has an incidence rate of one-to-nine, which means
that one out of nine women will develop the disease during her lifetime. However, if a woman’s mother had breast cancer, her incidence
rate more than doubles; if both her mother and sister had it, risk increases more than 13 times that for the general population. And
if breast cancer develops in one breast, there’s a one-percent-per-year risk that it will develop in the other breast.
Along with
hereditary concerns, there are other known and suspected risk factors, such as: prolonged menstrual activity (menstruation begins
early in life and ends late), a history of ovarian or endometrial cancer, having no children (conversely, an early pregnancy actually
decreases the risk), having a first child after age 35, obesity, and a relatively high socioeconomic status. Although unproven, Dr.
Winchester said it’s believed that high levels of dietary fat may promote breast cancer, but this is probably a factor in less than
25 percent of breast cancers.
Age is also a factor, with an incidence peak between the ages of 40 and 45, and an increase again after
age 55. Fibrocystic changes in the breast are not considered a risk factor, but can create lumps or obscure cancer, thus making detection
difficult.
Major risk factors that require very close surveillance include unusual cells detected on a biopsy, or a history of noninvasive
breast cancer, where the cancer is confined to the breast lobules, which make milk, or the breast ducts that carry the milk.
"Breast
cancer is a multi-factorial disease; many factors are involved," she said. "And it’s important to remember that some 70 percent of
women who develop breast cancer do not have a family history of the disease."
Dr. Winchester said that women with a family history
of breast cancer should have an initial mammogram when their age is five years younger than the age of their closest relative when
breast cancer developed. If there is no family history, the guidelines established by the American Cancer Society should be followed:
a base-line mammogram at age 35 to 40, followed by a test every two years until age 50, and then an annual mammogram after that.
"But
this test should not replace a woman’s self-exam or the physician’s exam," she cautioned. "Cancer is not detected on mammography 15
to 20 percent of the time. If the breast tissue is very dense, or contains many cysts, it can conceal a cancer. These patients may
require ultrasound to evaluate a palpable abnormality."
There are many diagnostic options if a woman has an abnormality noted on her
exam, or detected by mammography or ultrasound. If a mass is noted on examination in the office, a tissue sample can be taken with
a needle biopsy at that time. An abnormality found on a mammogram or ultrasound can also be sampled with a needle biopsy to determine
its nature. Fortunately, only 10 to 20 percent of these abnormalities turn out to represent a breast cancer, she said.
"The needle
biopsy can save eight out of ten women from having surgery, along with associated costs of hospitalization and recovery," she said.
Dr. Winchester has performed more than 150 mammographically directed needle biopsies. A biopsy entails from 45 to 60 minutes of time,
a tiny incision, and at least seven needle biopsies of the abnormality. Usually, the patient can then drive home and continue her
daily activities.
"Women are increasingly seeking such conservative alternatives to traditional excisional biopsies," she said.
If,
however, there is a high likelihood of cancer, or if with mammographic surveillance the abnormality progresses, it would be necessary
to perform surgical excision for diagnosis. Once a breast cancer has been diagnosed, Dr. Winchester advocates a two-step treatment
approach: local treatment, which requires the surgical removal of all breast cancer, and systemic (whole body) treatment to halt any
microscopic forms of the cancer that may have invaded other areas of the body, particularly the bones, lungs and liver.
According
to Dr. Winchester, the surgical treatment includes either a lumpectomy or a mastectomy. A lumpectomy removes the cancerous lump, along
with an adequate margin of surrounding tissue to ensure all cancer cells have been taken. At the same time, samples of the lymph nodes
under the arm are taken to determine if the cancer has spread to the lymph system. This is followed by radiation therapy of the breast.
A mastectomy requires removal of the breast and lymph nodes. She noted, however, that modified mastectomies are now performed which,
unlike a radical mastectomy, removes the breast tissue, but not the breast muscle.
The surgical treatment used, according to Dr. Winchester,
depends on the size of the tumor, the size of the breast, the location and number of malignancies present within the breast, and the
type of breast cancer whether or not the cancer involves the breast lobules or the breast ducts, and if the cancer is confined within
the lobule or the duct.
"Breast cancer is a chronic disease," she said, explaining that most breast cancer grows slowly, with the
cancer cell doubling every 100 days.
"It typically takes years of growth for the cancer to be detected by mammography, or for a lump
to be felt. When it’s discovered, it’s been in the body, microscopically, for a long time. Consequently, breast cancer must frequently
be treated both as a local disease of the breast, and as a disease that may have microscopically spread to other parts of the body."
She said systemic treatment is necessary, either with chemotherapy or hormonal therapy, when breast cancer has had ample opportunity
to spread. And Dr. Winchester works closely with the
She
also advocates breast reconstruction at the time of mastectomy, noting that without it, about one-third of breast cancer patients
develop clinical depression within a year. In fact, she often plans for breast reconstruction when scheduling surgery for her patients.
During surgery, a tissue expander can be placed below the breast muscle to slowly create a pocket, which will later hold a saline
implant. Or, a more complex procedure called a TRAM reconstruction, which utilizes an abdominal muscle swung upward to create the
breast, can be performed. Dr. Winchester said the TRAM procedure provides a very natural looking breast and profile, but should be
delayed if the patient has advanced, aggressive cancer that will require immediate chemotherapy.
"But reconstruction is a very viable
alternative for most patients," she said.
Regardless of the many medical advanced and options in diagnosis, treatment and recovery,
Dr. Winchester still returns to the importance of the individual’s responsibility for breast health.
"Early detection is the key,
vigilance is the answer," she said. "Every woman should perform monthly breast self-examinations, schedule regular physician exams,
and have mammography as indicated."