The Farber Center: For Radiation Oncology

Men are susceptible to breast cancer, although the disease is much less common among males. Nearly 2,000 men will be diagnosed with breast cancer annually, and 450 men will die.

TYPES OF BREAST CANCER

• Ductal carcinoma is the most common form of breast cancer. Tumors form in the cells of the milk ducts, which convey milk to the nipples. Ductal carcinoma can either be non-invasive, or invasive, with the potential to spread.
• Lobular carcinoma occurs in the lobules, which are the milk-producing glands. Lobular carcinoma can either be non-invasive, or invasive, with the potential to spread.
• Inflammatory breast cancer (IBC) is a rare, aggressive form of breast cancer that affects the dermal lymphatic system. IBC tumors grow in flat sheets that cannot be felt in a breast exam.
• Recurrent breast cancer means that the cancer has returned after being treated and undetected for a period of time. Recurrent cancer can occur in the remaining breast tissue, and also as metastatic disease at other sites of the body, such as the lungs, liver, bones or brain. Even though these tumors are in a new location, they are still called breast cancer.

The Farber Center would like you to know that the symptoms and presentation of breast cancer often vary among women. The most typical sign is a palpable mass,that is either felt by the woman herself, or during a breast exam as part of a routine physical examination.  Symptoms include:

• Lump or mass in your breast
• Breast swelling or change in size and/or shape
• Skin redness or discoloration
• Dimpling, thickening, or puckering of the skin
• Nipple changes, including retraction, or discharge
• Enlarged lymph nodes in the armpit

Breast cancer in men usually presents as a palpable mass or nipple thickening or discharge.

Many breast changes – including lumps – are not cancer, but if you notice one or more of these symptoms for more than two weeks, see your doctor.

There are many risk factors that increase a woman's risk of developing a breast cancer. It is important to realize that these are risk factors only and having a risk factor does not mean one will develop breast cancer, it just means that the risk is higher than if one did not have that risk factor, all other things being equal.

Risk Factors for Breast Cancer:

• Age: As women get older, the risk of developing breast cancer rises. Most cases occur in women 50 or older; it is less common in women 35 or younger.
• Family History: Risk is higher with a family history of breast and/or ovarian cancer. Family history can be a mother, sister, grandmother or any other first or second degree relative. Nearly 75% of women who are diagnosed with breast cancer, however, have no family history at all.
• Hormonal Factors: Early onset of age of your first period, onset of menopause after age 55, never having children (nulliparity) or having your first child after age 30 are all associated with an increase risk of developing breast cancer. The use of hormonal replacement therapy after menopause has also been shown to increase your risk of developing breast cancer.
• Previous Breast Cancer History: If a woman has in the past developed a breast cancer, she is at increased risk of developing a subsequent one, in the other breast for example. Other breast diseases such as atypical hyperplasia, lobular or ductal carcinoma in situ are risk factors, as well.
• Education / Socioeconomic Status: Women with a higher socioeconomic status and/or education tend to have fewer children and start childbearing after age 30 – both of which put them at higher risk.
• Genetic Alterations: In five to 10% of all breast cancer cases there an inherited risk. This inherited susceptibility is a mutation in genes BRCA1 and BRCA2. Family members with these gene mutations have a 60% to 80% risk of developing breast cancer in their lifetimes, as well as possible increase risks of developing other associated malignancies such as ovarian or pancreatic cancers. There are now several genetic tests that can determine whether a woman has a genetic mutation that may increase her chance of developing breast cancer, as well as helping to assess her family's risk of inheritance. These tests are typically performed on women with a diagnosis of breast cancer, to help them make decisions regarding their own treatment and to help guide their daughters or family members who may share these mutations. A genetic counselor is someone that can discuss the details of the testing and its implication, and can assist to help get the test performed.
• Environmental factors: Oral contraceptive use, obesity and weight gain after menopause, alcohol intake, a diet high in saturated fats, and physical activity are suspected of being associated with an increase risk of developing breast cancer. Previous history of radiation therapy which would have included the breast is also a risk factor.

If any one of the signs or symptoms is noted, there are several procedures that can be used to diagnose breast cancer. Not every patient undergoes every procedure and evaluation is based upon the physical findings and the physician recommendations. The next step is usually a mammogram and ultrasound (also known as a sonogram). If the mammogram was the original detecting test, or if there is a palpable lesion, the next step is often a biopsy. Biopsies can be performed by either an interventional radiologist under ultrasound, mammographic, or MRI guidance, as well as by a breast surgeon. The tissue obtained is examined under a microscope for diagnostic purposes.

Tissue Sampling and Types of Biopsies:

• Surgical biopsy: Surgeons locate the tumor by palpation or with the guidance of images obtained from an ultrasound or mammogram or MRI. In an excisional biopsy, the entire mass is removed, whereas in an incisional biopsy, only a portion of the tumor is removed.
• Fine Needle Aspiration (FNA): A very thin, hollow needle is inserted into the breast to the tumor, and fluid and cells are extracted to help determine if a tumor is present. Additional biopsies may be needed if cancer is noted.
• Core biopsy: A thicker needle is used to remove one or more cylindrical tissue samples. It may help to provide additional information not obtainable in a fine needle aspiration.
• Sentinel lymph node biopsy: If a diagnosis of invasive breast cancer is made, the surgeon may recommend a biopsy of the lymph nodes within the axilla (armpit area). Lymph nodes are glands which are part of a system that circulates lymph fluid throughout the body. This lymphatic may also be responsible for carrying cancer cells from the original tumor site to other areas of the body. In patients with breast cancer, the first nodes to be affected are under the arm.
  
  In a sentinel lymph node biopsy, the surgeon injects a radioactive tracer into the designated area. The surgeon then injects a blue dye near the tumor site, which may show up in lymph nodes involved with. The lymph node containing the highest amount of tracer or blue dye is known as the "sentinel" node.  The surgeon removes all nodes with blue dye, thereby sparing removal of unaffected or healthy lymph nodes. This results in fewer side-effects such as lymphedema, or swelling, of the arm. 

Staging of Breast Cancer
Source: The American Joint Committee on Cancer (AJCC) staging system. This system provides a strategy for grouping patients with respect to prognosis. By knowing the extent of disease doctors can determine the best treatment for each patient. Treatment decisions are made according to staging categories but also individual information regarding tumor size, lymph node status, estrogen-receptor and progesterone-receptor levels in the tumor tissue, human epidermal growth factor receptor 2 (HER2/neu) status, menopausal status, and the general health of the patient factor in as well.

Stage 0 (Carcinoma in Situ)
Cancer has not spread from the site of origin.

There are 2 types of breast carcinoma in situ:

Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast.
Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer; however, having lobular carcinoma in situ in one breast increases the risk of developing breast cancer in either breast.

Stage I
The tumor is 2 centimeters or smaller and has not spread outside the breast.

Stage IIA

• No tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or
• The tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or
• The tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.

Stage IIB

• The tumor is larger than 2 centimeters but not larger than 5 centimeters and has spread to the axillary lymph nodes; or
• The tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.

Stage IIIA

• No tumor is found in the breast. Cancer is found in axillary lymph nodes that are attached to each other or to other structures, or cancer may be found in lymph nodes near the breastbone; or
• The tumor is 2 centimeters or smaller. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
• The tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
• The tumor is larger than 5 centimeters. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.

Stage IIIB

The tumor may be any size and cancer:

• Has spread to the chest wall and/or the skin of the breast; and
• May have spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.

Stage IIIC

The tumor may be any size and may have spread to the chest wall and/or the skin of the breast. Also, cancer:

• Has spread to lymph nodes above the collarbone (supraclavicular lymph nodes) or below the collarbone (infraclavicular lymph nodes); and
• May have spread to 10 or more axillary lymph nodes; or
• May have spread to lymph nodes near the breastbone (internal mammary lymph nodes).

Stage IV

The cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.

SURGERY
is the most common treatment for breast cancer. Surgery is either breast-sparing (lumpectomy, or partial mastectomy) which removes the tumor from the breast, or a mastectomy which involves removal of the entire breast itself.  The type of surgery performed depends on many factors, and is something that is best discussed with a breast surgeon. During a lumpectomy or mastectomy procedure, one or more lymph nodes located near the armpit or axilla, are removed, depending on the certain clinical factors. They are then reviewed microscopically.  These lymph nodes can often be one of the first places that a cancer cell travels to, making them a good predictor of whether or not any cells may have escaped out of the breast.  A sentinel node biopsy has replaced in most cases the more invasive full axillary lymph node dissection as a means of getting this lymph
node information.  Full axillary dissections can have increased risks
such as long-term swelling of the arm (lymphedema).

LUMPECTOMY
is typically followed by radiation therapy which can help treat any cells that may be left behind from breast cancer surgery.  Together, a lumpectomy and radiation is termed Breast Conservation Therapy or BCT.  The goal of BCT (in comparison to a mastectomy), is to preserve the breast while providing an equivalent cure and survival to mastectomy.  Over the past 30 years numerous studies have compared the outcome and survival of women having either a lumpectomy + radiation to that of a mastectomy as their breast cancer treatment. These studies, which were performed at major institutions all around the world, have all confirmed the survival and cure rate equivalence of lumpectomy + radiation to mastectomy. In breast conservation therapy, the surgery and radiation work together. Knowing that radiation will be used to aid in sterilizing the tissue after surgery, often times a surgeon may be able to provide a less disfiguring surgery that allows a woman to retain the cosmesis of her breast without sacrificing curability. 

CHEMOTHERAPY
drug therapy, or hormonal therapy are therapies used by a medical oncologist to treat breast cancer. These treatments are delivered throughout the bloodstream, they are also known as systemic therapy. In breast cancer, chemotherapy is most often used either before or after surgery, or as a primary treatment for cancer that has spread outside the breast at the time of diagnosis. Chemotherapy can be delivered orally or intravenously. Newer tests such as OncoDx can often assist the medical oncologist to determine which patients might benefit even more than others from chemotherapy using specific testing on the cancer cells themselves. Most breast cancer patients will see both a medical oncologist and radiation oncologist to determine their overall treatment strategy.

HORMONE THERAPY
is a form of systemic therapy that is used to prevent normally occurring female hormones such as estrogen, progesterone, and estradiol, from promoting the growth of breast tumors in certain patients. Breast cancer cells are usually tested under a microscope to see if they may be responsive to hormonal treatment. The most well know hormonal therapies include tamoxifen (Nolvaldex), Evista (raloxifene), Arimidex (anastrozole), Aromasin (exemestane), and Femara (letrozole). Typically these medications are taken by mouth. In younger women who have not reached menopause, surgery may be used to remove the ovaries as another type of hormone therapy.

BIOLOGIC THERAPY
is a drug treatment that helps the body's immune system fight cancer. Herceptin® is a type of biologic therapy that targets cells which produce excessive amounts of a protein called HER2. This protein is present in some breast cancer patients. Herceptin binds to the cells, shutting off HER2 production.

RADIATION THERAPY
uses high-energy beams to destroy cancer cells. There are two types of radiation treatment for breast cance offered at The Farber Center for Radiation Oncologyr:

External beam radiation therapy: the beams are aimed at the tumor from outside the body. Patients undergo painless radiation five days a week (Monday through Friday) for typically five to six and a half weeks. Each treatment takes minutes only. Treatment may be only to the breast or include nearby lymph nodes. 3-Dimensional Conformal Radiotherapy (3D-CRT) and intensity modulated radiation therapy (IMRT) are the latest technologies used to deliver very precise radiation to the areas to be treated while sparing the surrounding normal tissue.

Brachytherapy: means "close" therapy and breast brachytherapy involves placing a small radiation source into the breast, close to the tissue at risk.  This method allows for shortening the treatments to just one week, with treatment given twice a day. This form of radiation is called "balloon brachytherapy," and delivers radiation internally, to the part of the breast where the tumor was located.  Breast brachytherapy is also known as Breast HDR, since is involves the use of a specialized machine called a High Dose Rate remote afterloader unit, or "HDR" device.  Since this type of treatment delivers radiation only to the area in and around where the tumor was, and not to the entire breast, it is also known Partial Breast Irradiation, or PBI.  Because the treatment time is faster it is called Accelerated Partial Breast Irradiation, or APBI.

During treatment, the radiation source stays in a specialized catheter (Contura or MammoSite) for a brief period of several minutes while delivering radiation in and around the site of surgery.  There is a "balloon" filled with saline water that occupies the space of the lumpectomy cavity where the tumor once was. The source is sent out mechanically from the HDR unit under control of the physician and computer through a transfer tube, and then into the catheter of the balloon device, where it stays at one or more different positions for a set amount of time. The position of the balloon is verified before each treatment with an X-ray, ultrasound, or CT scan. As the source is contained within the balloon, at no time does it ever make contact with any tissue. 

SAVI: addresses two key issues in radiation treatment: length of treatment and exposure to healthy tissue. For women who would face hurdles completing an extended treatment schedule, SAVI reduces treatment time from several weeks to just 5 days. Many women consider this accelerated schedule to be a significant benefit.

In addition, the device's unique multi-catheter design provides physicians with the greatest control over radiation delivery. It is the only single-entry device that can sculpt the dose to the patient's specific anatomy, which enables physicians to precisely target radiation where cancer is most likely to recur while minimizing exposure to healthy tissue. Clinical studies show this increased flexibility leads to better outcomes and makes the benefits of Breast Conservation Therapy available to the widest array of women.

AccuBoost: The Farber Center for Radiation Oncology is one of the only centers in NYC to offer AccuBoost to Breast Cancer patients http://www.accuboost.com. The vital role of radiation therapy to maximize cancer-free survival for the women who choose breast conservation therapy (BCT), is well known. The most important decision for patients who qualify for BCT is to seek the advice of their physicians to choose a radiation oncology center and radiation delivery system that are capable of targeting the dose consistently, reliably and reproducibly – every time. The AccuBoost system is designed to take the guess work out of "daily patient positioning" and "dose targeting" for the boost phase of the procedure. By using real-time image guided radiation therapy (IGRT), the AccuBoost system provides a simple, accurate method for accurate boost dose targeting. Furthermore, by sharing the same platform for imaging (by IGRT) and applicator positioning, the AccuBoost system targets the dose precisely to where it needs to go and minimizes side effects of radiation.

RADIATION THERAPY FOR BREAST CANCER AFTER MASTECTOMY
Radiation may be used after a mastectomy in certain cases where the risk of microscopic disease in the chest wall or lymph node regions remains high after the surgery.  Typically, if the initial tumor was larger than 4-5 cm, if lymph nodes were involved, or if was tumor noted in the edge or surrounding tissue following the mastectomy, the patient should be referred to the radiation oncologist to discuss the benefits of radiation in the post-mastectomy setting. 

Techniques such as IMRT can help to reduce the dose of radiation to the underlying normal tissue such as the lungs and the heart.

If a woman has had a breast reconstruction following a mastectomy, radiation therapy may still be used safely in this situation if needed.  Likewise, if breast reconstruction is anticipated following radiation therapy, it can still be performed safely. As with all treatment a complete plan should be discussed ahead of time with the surgeon, radiation oncologist, medical oncologist, and plastic surgeon.