Treatment For Stage 4 Breast Cancer
Typically, treatment for stage 4 breast cancer includes a combination of chemotherapy, radiation therapy, and hormone therapy .
Targeted therapy is a treatment that targets the protein that allows cancer cells to grow and this type of therapy may also be an option for people with stage 4 breast cancer.
Sometimes, surgeons will operate to try and remove tumors though this is not usually the first option for treatment.
Doctors, however, may recommend surgery to help with pain relief by treating some of the issues that may develop as a result of having stage 4 breast cancer. These include spinal cord compression, removing single masses caused by metastasis, and fixing any broken bones.
A doctor may also prescribe medication to treat related symptoms such as:
- antidepressants to help mood
- anticonvulsants to manage pain or neurologic conditions
- local anesthetics to manage pain
New treatments and therapies are emerging all the time, and anyone who has breast cancer at any stage can volunteer to try out these new treatments. People considering this should talk to their doctor to see whether any trials are available in their area.
Trials for a new treatment called immunotherapy are currently taking place. Immunotherapy works by raising the bodys natural ability to fight off cancer and has fewer side effects than chemotherapy.
As well as numbers, a zero or an X often follow the letters T, N, and M. According to the AJCC, the meanings are as follows:
How Can I Protect Myself From Breast Cancer
Follow these three steps for early detection:
- Get a mammogram. The American Cancer Society recommends having a baseline mammogram at age 35, and a screening mammogram every year after age 40. Mammograms are an important part of your health history. Recently, the US Preventive Services Task Force came out with new recommendations regarding when and how often one should have mammograms. These include starting at age 50 and having them every two years. We do not agree with this, but we are in agreement with the American Cancer Society and have not changed our guidelines, which recommend yearly mammograms starting at age 40.
- Examine your breasts each month after age 20. You will become familiar with the contours and feel of your breasts and will be more alert to changes.
- Have your breast examined by a healthcare provider at least once every three years after age 20, and every year after age 40. Clinical breast exams can detect lumps that may not be detected by mammogram.
What Are The Stages Of Breast Cancer
There are two different staging systems for breast cancer. One is called anatomic staging while the other is prognostic staging. The anatomic staging is defined by the areas of the body where the breast cancer is found and helps to define appropriate treatment. The prognostic staging helps medical professionals communicate how likely a patient is to be cured of the cancer assuming that all appropriate treatment is given.
The anatomic staging system is as follows:
Stage 0 breast disease is when the disease is localized to the milk ducts .
Stage I breast cancer is smaller than 2 cm across and hasn’t spread anywhere including no involvement in the lymph nodes.
Stage II breast cancer is one of the following:
- The tumor is less than 2 cm across but has spread to the underarm lymph nodes .
- The tumor is between 2 and 5 cm .
- The tumor is larger than 5 cm and has not spread to the lymph nodes under the arm .
Stage III breast cancer is also called “locally advanced breast cancer.” The tumor is any size with cancerous lymph nodes that adhere to one another or to surrounding tissue . Stage IIIB breast cancer is a tumor of any size that has spread to the skin, chest wall, or internal mammary lymph nodes .
Stage IV breast cancer is defined as a tumor, regardless of size, that has spread to areas away from the breast, such as bones, lungs, liver or brain.
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The Stages Of Breast Cancer And Your Treatment Options
Compared to most other cancers, staging breast cancer is more complex. And when it comes to treating breast cancer, there isnt a one-size-fits-all approach. Your treatment plan should be created especially for you and be coordinated across specialists and thats where your cancer care team comes in.
At HealthPartners, we believe cancer treatment and care is best managed by a group of doctors and specialists in whats known as multidisciplinary conferences. This is where breast surgeons, oncologists, radiologists, pathologists and other members of your care team gather to discuss the best treatment sequence for you.
Below we dive into the treatment options your care team might recommend at various breast cancer stages.
What Is Ductal Carcinoma In Situ
According to the American Cancer Society, DCIS is non-invasive orpre-invasive breast cancer, which means the cells that line the ductshave changed to cancer cells but havent spread through the walls ofthe ducts into the nearby breast tissue.
DCIS is considered a pre-cancer because sometimes it can become aninvasive cancer. This means that over time, DCIS may spread out of theducts into nearby tissue, and could metastasize. Currently, theres nogood way to predict which will become invasive cancer and which wont.Therefore, almost all women with DCIS will be treated.
In most cases, a woman with DCIS can choose betweenbreast-conserving surgery and simple mastectomy. In cases wherethe area of DCIS is very large, the breast has several areas of DCIS,or BCS cannot remove the DCIS completely, mastectomy might be a better option.
When Helen Spencer learned she had DCIS,she began a journey of decisions ranging from which hospital tochoose, to the type of surgery, to whether adjuvant hormone therapywould be worth the potential side effects. Readher story.
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To Treat Or Not To Treat
A recent retrospective study by Narod et al evaluated 10- and 20-year breast cancer-specific mortality among 108,196 women with DCIS identified from the SEER database. The 20-year breast cancer mortality was 3.3%, with no significant difference in mortality based on treatment received . Of note, all women underwent treatment appropriate for their clinical situation, according to clinical judgment and patient preference treatment was not assigned in a randomized fashion. Furthermore, all patients received treatment, and it is likely that women with higher-risk disease generally received more aggressive treatment. Nevertheless, this retrospective, non-randomized study has been misinterpreted by some as evidence that DCIS is an entity that does not require treatment, and that all treatments result in similar outcomes. While it is true that DCIS is a heterogeneous disease with a poorly understood natural history, the evidence supporting DCIS as a precursor to invasive carcinoma is strong and supported by prospective studies, and proof of safety of observation without surgical excision is lacking. In fact, although combining clinical factors does allow identification of a group of women with DCIS that is at a relatively low risk of recurrence after complete surgical excision , the ability to safely predict that a particular DCIS lesion will not invade when left in situ remains an unreached goal.
Stage Zero Breast Cancer: Whats The Optimal Treatment For Dcis
Before the advent of routine mammography, DCIS was rarely detected. But today, DCIS accounts for 20% of breast cancer diagnoses and would be the fifth most common cancer in women if classified independently.
Often called stage zero breast cancer, DCIS growths are confined to the inside of the breasts milk ducts, and many never develop into invasive cancers. Several treatment options are available, and opinions about the optimal treatment for DCIS vary widely among doctors.
A new study from researchers at Columbia University Vagelos College of Physicians and Surgeons may help women and their physicians narrow down the treatment choices.
DCIS is considered a pre-invasive cancer, but the current standard of care is to treat it like an early-stage invasive breast cancer, says Apar Gupta, MD, assistant professor of radiation oncology at Columbia University Vagelos College of Physicians and Surgeons and lead author of the study.
However, not all treatments for invasive breast cancer may be optimal for DCIS, Gupta says. His study suggests that in most cases of DCIS, the side effects of hormone therapy may outweigh its benefits.
The CUIMC Newsroom spoke with Gupta to learn how the studys findings can help providers and their patients navigate treatment for DCIS. Below are excerpts from the conversation:
Why is DCIS treatment controversial?
How does your study help women make a decision about treatment after lumpectomy?
Is there a role for hormone therapy?
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Dcis Accounts For 1 In 5 Breast Cancer Diagnoses
Studies have shown that 20% of breast cancer diagnoses are classified as DCIS. With lifespans getting longer and more women getting regular mammograms and access to better technology, DCIS detection rates have increased.
Earlier detection also means more people are getting diagnosed and treated sooner, and theres less chance of the condition turning into invasive breast cancer.
What Is Stage 0 Lcis
Lobular carcinoma in situ at Stage 0 generally is not considered cancer. Although it has carcinoma in the name, it really describes a growth of abnormal but non-invasive cells forming in the lobules. Some experts prefer the name lobular neoplasia for this reason because it accurately refers to the abnormal cells without naming them as cancer. LCIS, however, may indicate a woman has an increased risk of developing breast cancer.
If you have been diagnosed with LCIS, your doctor may recommend regular clinical breast exams and mammograms. He or she may also prescribe Tamoxifen, a hormone therapy medication that helps prevent cancer cells from growing.
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Treatment Of Stage Iii Breast Cancers
Sometimes large breast cancers invade into muscles or attach to major arteries, veins or nerve trunks, which makes them impossible to surgically remove completely.
So, for these patients, the treatment usually starts with radiation or chemo to try to shrink it first, before surgery. But even a large tumor that has not attached itself onto muscle can, sometimes, be completely removed. There is no direct relationship between tumor size and whether or not it may be treated surgically or not.
Obviously, Stage 3 breast cancers that surgeons can completely remove do tend to have a significantly better prognosis than inoperable stage 3 breast cancers. However, some breast tumors, particularly those that are ER-positive, respond very well to chemotherapy. So well, in fact, that they actually downstage.
So, it is difficult to predict the overall prognosis for stage 3 breast cancer, as it will vary from individual to individual. If the response to chemotherapy is favorable, the overall survival rate is around 72%.
Stages Of Breast Cancer: Stage Iiib
A stage IIIb breast cancer is one in which the tumor may be of any size but it has grown into the chest wall or the skin of the breast. A stage IIIb designation also applies if there is evidence of either
- axillary lymph node metastasis
- internal mammary node metastasis
presenting in such a way as to suggest that total surgical removal is not possible.
There is a unique type of breast cancer, inflammatory breast cancer, that causes the breast to appear red and swollen. This is because the cancer cells block some of the lymphatic vessels. Inflammatory breast cancers tend to have a poorer prognosis and are generally stage IIIb at least.
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What Should The Initial Definitive Therapy For The Cancer Be
Ductal carcinoma in situ
DCIS may be treated with breast conserving surgery or mastectomy with or without immediate reconstruction. The decision for type of surgery is based on the extent of the lesion relative to breast size, whether adequate clear margins can be achieved with partial mastectomy, ability to receive radiation therapy, and patient preference.
With mastectomy, skin sparing techniques can be utilized to facilitate reconstruction with excellent cosmesis. However, it is important that anterior margins of the mastectomy are clear of calcifications and tumor. for thin patients with large areas of microcalcifications, skin sparing may result in a positive margin on the mastectomy specimen if skin over these calcifications is not taken in the resection.
For DCIS treated with breast conserving surgery, radiation is indicated in most circumstances to reduce risk of local recurrence. Clinical trials have demonstrated a 50-60% reduction in local recurrence. However, for certain tumors, that absolute benefit is low.
The following factors should be considered in determining the role of radiation therapy:
size of the DCIS
tumor grade and extent of comedonecrosis
width of margins
Van Nuys Prognostic Index
Lymph node evaluation
Circumstances in which sentinel node biopsy should be considered even with breast conserving surgery include:
Stage 1 Breast Cancer
What is Stage 1 breast cancer?
Stage 1 breast cancers are still relatively small, and theyve either not yet spread to the lymph nodes or theres only been a tiny bit of spread in the sentinel lymph node which is where the cancer is most likely to spread first. There are two types of Stage 1 breast cancer:
- Stage 1A Stage 1A breast cancer means the tumor is no larger than 2 centimeters, and the cancer has not spread outside the breast or to lymph nodes.
- Stage 1B Stage 1B breast cancer means there are small groups of cancer cells in the lymph nodes. There may or may not be a tumor smaller than 2 centimeters in the breast.
What are the treatment options for Stage 1 breast cancer?
- Surgery Like with Stage 0, a lumpectomy and mastectomy are both options at this stage:
- Lumpectomy This kind of breast conservation surgery is a viable option when the cancerous cells are confined to one area of the breast.
- Mastectomy A mastectomy may be recommended if cancer is found throughout the breast.
Stage 1 breast cancer treatment timeline
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How Is Stage 0 Breast Cancer Diagnosed
Contact your physician if you have a lump or other changes to your breasts. Discuss your family history of cancer and ask how often you should be screened.
Stage 0 breast cancer is often found during mammogram screening. Following a suspicious mammogram, your doctor may order a diagnostic mammogram or another imaging test, such as an ultrasound.
If theres still some question about the suspicious area, youll need a biopsy. Biopsy is the only way to diagnose cancer. For this, the doctor will use a needle to remove a tissue sample. A pathologist will examine the tissue under a microscope and provide a report to your doctor.
The pathology report will say whether there are atypical cells present and, if so, how aggressive they may be.
A Mammogram Can Reveal Dcis
A routine mammogram is usually the way DCIS is discovered and diagnosed. When DCIS is present, it will typically show up as a cluster of calcifications of varying shapes and sizes within a breast duct .
These calcifications are the result of tiny specks of calcium that form in the cells of old cancer cells that have died off and piled up. If calcifications are seen on a mammogram, a biopsy will then be performed to confirm the diagnosis of DCIS.
While the incidence of DCIS has risen sharply since the 1970s, this increase has been attributed primarily to the increased use of screening mammograms.
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It’s Confusing Even For Doctors
A recent study in the Annals of Internal Medicine found that pathologists disagree with one another about 8% of the time when diagnosing breast biopsy samples, and that cases of DCIS were the most difficult to reach a conclusion about. About 19% of DCIS cases were overinterpreted in the study, meaning they were mistakenly categorized at a higher grade or as invasive cancer, and about 12% were underinterpreted, or mistakenly categorized at lower grades.
The authors write that non-invasive breast lesions represent a “gray zone” in medicine, where there’s not always a right or wrong diagnosis. They say that revised guidelines are needed to make sure DCIS patients get a consistent diagnosis they can trust.
How Is Stage 0 Detected
Although it rarely presents as a mass, DCIS is most often detected with mammograms, and in certain cases, with MRIs. Keeping up with regular breast self-exams, recommended screenings and mammography, and if appropriate in limited cases MRI, is the best self-defense, says Dr. Cappuccino.
Once detected, surgical removal of the abnormal cells is often recommended, in most cases with a lumpectomy, even though DCIS doesnt usually form a lump. Following surgery, radiation therapy is often recommended to reduce both the risk of a future invasive cancer and the risk of DCIS recurring. Hormone-blocking pills may also be recommended to help decrease the risk of recurrence.
The doctors at Roswell Park are meticulous about providing thorough and expert evaluations using state-of-the-art imaging technology, such as digital breast tomosynthesis, also known as 3D mammography, and ultrasound and MRI as needed. Our pathologists, who specialize in breast diseases, provide expert reviews and work with a multidisciplinary team to offer expert analysis of each patient to determine their treatment with the goal of helping them achieve the best possible outcome, says Dr. Cappuccino.
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What Is Stage 4 Breast Cancer
Also known as metastatic breast cancer, the cancer in this stage has spread beyond the breast, underarm and internal mammary lymph nodes to other parts of the body near to or distant from the breast. The cancer has spread elsewhere in the body. The affected areas may include the bones, brain, lungs or liver and more than one part of the body may be involved.
At stage 4, TNM designations help describe the extent of the disease. Higher numbers indicate more extensive disease. Most commonly, stage 4 breast cancer is described as:,
- T: T1, T2, T3 or T4 depends on the size and/or extent of the primary tumor.
- N1: Cancer has spread to the lymph nodes.
- M1: The disease has spread to other sites in the body.