Determining Your Breast Cancer Type
At Rocky Mountain Cancer Centers , we understand that the diagnosis of cancer can be overwhelming, not only for you, but also for your friends and relatives. Therefore, the sooner we determine your specific breast cancer type, the sooner we can get you on the path to treatment and recovery. To do this, we will perform an in-depth evaluation on the tissue sample collected from your breast biopsy, or on the tumor itself after your breast cancer surgery.
Screening For Breast Cancer
Regular mammography examinations to detect early breast cancer have become a key component of national breast cancer screening programmes. Mammography is also required for balanced diagnostic surveillance in epidemiological studies and clinical trials that evaluate the effect of hormones on breast cancer incidence. Menopausal estrogenprogestogen hormones increase the density of breast tissue and may affect the accuracy of mammography interpretation . It is therefore sensible to assess the overall results of breast cancer screening programmes to evaluate whether hormonal effects might cause a significant change in their effectiveness.
The case for breast cancer screening is based on the results of trials: the New York Health Insurance Plan trials and four Swedish trials were the principal randomized trials. Combined results of the Swedish trials in particular show a 27% reduction in mortality from breast cancer in women aged 6069 years invited for screening but failed to show a significant advantage for women aged 4059 years .
Trials of technique showed advantage to double reading and to the taking of two views at prevalent screening. Otherwise screening in the UK has been based on the single lateral oblique view. A trial of the screening of younger women still awaits final analysis.
How Estrogen Makes Some Cancers Grow
All cells have receptors so they can respond to hormonal changes. Breast cancer cells have receptors, too.
pathways. receptors on the surface of breast cancer cells work like satellite dishes. They detect and bring in hormone signals. These signals can direct cancer cells to grow, multiply and repair damage.
Breast cancer cells all have receptors, but not all of them have receptors for estrogen. When breast cells have estrogen receptors, the breast cancer is called positive, and estrogen helps the cancer to grow. When receptors are found, the cancer is called , or positive, and progesterone helps the cancer to grow. Your doctor may refer to the cancer as -positive or hormone-sensitive.
About two-thirds of breast cancers are hormone receptor-positive. They may be both – and PR-positive, ER-positive only, or PR-positive only. Even if the cancer has only one type of , or tests just slightly positive, studies show can protect you from having cancer return, or recur.
Depending on the type of hormonal therapy used to treat hormone receptor-positive breast cancer, it may
- block estrogen receptors
- reduce the amount of estrogen made in the body
- lessen the number of hormone receptors
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Selective Estrogen Receptor Modulators And Breast Cancer
Knowledge about hormonal effects on breast cancer has expanded in the last three decades with the development of selective estrogen receptor modulators . This chemically diverse group of compounds involves a tertiary structure allowing them to bind to the estrogen receptor and to exert a specific set of agonist or antagonist effects on estrogen target tissues. Factors which influence agonist or antagonist activity in a given target tissue or circumstance include differences in estrogen receptor expression, receptor conformation on ligand binding and the expression of co-regulating proteins . SERM are particularly useful in breast cancer management because they offer possible treatment and prevention through estrogen antagonism coupled with the potential for useful estrogen agonist effects on normal tissues including bone, the cardiovascular system, and perhaps the central nervous system.
Tamoxifen is the most widely used SERM in the treatment of breast cancer tamoxifen and raloxifene are both used in prevention strategies. Both drugs have anti-estrogenic activity against breast cancer because they interfere with binding of the estrogen receptor to DNA structures, specifically by recruiting co-repressors that interact with the estrogen receptor at the estrogen response elements within target genes.
The Relative Contributions Of Childbearing And Breastfeeding To Breast Cancer Risk
Although parity has long been known to protect against breast cancer risk, at least in the long term, the interdependence of key indices of childbearing, such as parity, timing of births and breastfeeding, make it difficult to disentangle which factors have an independent effect on breast cancer risk. For this reason, it is sensible to estimate first the effect of childbearing in the absence of breastfeeding, and then the additional effect of breastfeeding among parous women by adjusting for childbearing history.
Among women who have never breastfed, the risk of breast cancer increases in linear fashion with the age at first birth. Overall, the relative risk of breast cancer increases by 3% for each additional year by which the first birth is delayed. With childbearing the RR of breast cancer decreases with increasing parity after stratifying by age at first birth, each birth reduces the risk by 7% .
The effect of breastfeeding on breast cancer risk does not appear to be modified by any other reproductive factors such as age at first birth or parity. Nor is there any evidence to suggest that the decline in risk with total duration of breastfeeding differs according to a range of other characteristics including age, family history, menopausal status and ethnic origin.
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Possible Side Effects Of Hormone Therapy
Some side effects are common to all methods of hormone therapy and are due to the reduced levels of oestrogen.
- Mood changes.
Tamoxifen and aromatase inhibitors also produce some different side effects. You may experience some of the side effects listed, but are unlikely to experience them all.
For most people who are recommended to take hormone therapy for breast cancer, the risks of treatment are outweighed by the benefits.
Here is a list of possible side effects that might be experienced on tamoxifen and aromatase inhibitors:
If You Cant Have Surgery
Surgery is the main treatment for breast cancer, but some women have health problems that mean they cant have surgery. Some women choose not to have surgery.
In this case, if your breast cancer is oestrogen receptor positive, your doctor might recommend hormone therapy. This treatment won’t get rid of the cancer but can stop it growing or shrink it.
The treatment can often control the cancer for some time. Your doctor might change you to a different type of hormone treatment if your cancer starts growing again.
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Previous Breast Cancer Or Lump
If you have previously had breast cancer or early non-invasive cancer cell changes in breast ducts, you have a higher risk of developing it again, either in your other breast or in the same breast.
A benign breast lump does not mean you have breast cancer, but certain types of breast lumps may slightly increase your risk of developing cancer.
Some benign changes in your breast tissue, such as cells growing abnormally in ducts , or abnormal cells inside your breast lobes , can make getting breast cancer more likely.
Breast Cancer Rates Fell When Regular Hormone Therapy Decreased
Breast cancer rates dropped by half in tandem with the discontinuation of hormone replacement therapy, according to a study published online in the Journal of the National Cancer Institute. The study was reported in the Telegraph in the United Kingdom.
The Telegraph said:
Dr Prithwish De, of the Canadian Cancer Society, and colleagues, found that use of HRT dropped from 12.7 per cent in 2002 to 4.9 per cent in 2004.
During the same period breast cancer rates dropped by 9.6 per cent even though the same number of women were having mammography tests.
Between 2004 and 2006 use of HRT remained stable at around five per cent of women aged 50 to 59 but breast cancer rates began to increase again.
Dr De wrote: The results support the hypothesised link between the use of hormone replacement therapy and invasive breast cancer incidence and indicate that the sharp decline in breast cancer incidence in 2002 is likely explained by the concurrent decline in the use of hormone replacement therapy among Canadian women.’
The studys authors said these numbers support existing evidence of the link between HRT and breast cancer.
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What Are Hormone Inhibitors And How Do They Work
Hormone inhibitors also target breast cancer cells with hormone receptors, but unlike hormone blockers, they work by reducing the bodys hormone production. When breast cancer cells are cut off from the food supply the tumor begins to starve and die.Generally, the benefits of using hormone therapy and chemotherapy together have a much greater combined effect than using either alone. If your breast cancer is positive for hormone receptors, your doctor may recommend both therapies.
How Hormone Therapy Works
Oestrogen and progesterone are hormones which are naturally produced in the human body. Before menopause, oestrogen is mostly produced by the ovaries. After menopause, when the ovaries are no longer active, a small amount continues to be produced in other tissues such as fat, muscle and adrenal glands.
Normal breast cells contain receptors that are able to recognise these hormones and allow them to access the cells, where they release signals encouraging growth and development. All breast cancers are tested for the presence of these oestrogen and progesterone receptors, using tissue taken at the time of biopsy or surgery. Approximately 70% of breast cancers retain these receptors, and rely on these hormones to grow. These hormone-sensitive cancers are described as oestrogen receptor positive and/or progesterone receptor positive .
Hormone therapy is also used to shrink or slow the growth of a breast cancer when surgery is not appropriate, for example in an older person with other major health issues. It is also used to help shrink advanced stage breast cancers or slow their growth.
Hormone therapy for breast cancer is not the same as HRT . HRT raises the level of oestrogen +/- progesterone in the body and is not used in the treatment of breast cancer.
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Family History Breast Cancer And Hormone Use
To study the relationship between breast cancer, family history and external hormones, a lifetime history of drug use, medical conditions, socio-economic status and lifestyle factors is required, because of multiple associations. It is not adequate to study only small sections of past history, such as in database studies.
Epidemiological studies have established a set of relatively convincing risk factors for breast cancer such as: family history of breast cancer, possibly due to inherited genetic abnormalities rapid growth early in life, greater height, higher socio-economic status, and older age. In addition, some probable risk factors are: diet low in fruit and vegetable intake, or high in meat/fat intake, higher alcohol consumption, high post-menopausal body mass index , lack of exercise and history of benign breast tumours . The strength of the association with all known risk factors is in the same range, from 1.2- to 6-fold increased RR . In observational research, it is rather unlikely that one could distinguish causality from bias and residual confounding with risk estimates ranging from 0.5 to 2.0 with the use of epidemiological methods, and many breast cancer risk estimates are within this range. In addition, there is variability in the results of the observational studies: the risk estimates are not consistent, ranging from lowered risk of breast cancer to increased risk.
The Endocrine System And Hormones
The endocrine system is a group of glands and cells in the body that make hormones and release them into the blood. Hormones are natural substances that act like chemical messengers between different parts of the body. They control many functions including growth, reproduction, sexual function, sleep, hunger, mood and metabolism . Certain cells in the body have proteins called receptors that react to a hormone. How the cell responds depends on which hormone it is reacting to.
There are many organs and glands that make up the endocrine system.
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Surgery To Stop The Ovaries From Working
This is also a type of ovarian ablation. You might choose to have an operation to remove your ovaries instead of having drug treatment to stop them working. You have this operation as keyhole surgery. It is called laparoscopic oophorectomy and you have it under general anaesthetic . You usually stay in hospital overnight.
The surgeon makes a number of small cuts into your tummy . They put a long bendy tube called a laparoscope into one of the cuts. The laparoscope connects to a video screen.
The surgeon puts small instruments through the other cuts to carry out the operation and remove the ovaries. They close the cuts with stitches and cover them with small dressings.
Removing your ovaries causes you to have a sudden menopause. The symptoms include hot flushes, sweating and mood swings.
How Do I Know If My Cancer Is Hormone
Your doctor can find out by testing your cancers cells. Theyll take a small piece of your tumor, called a biopsy. It goes to a lab for testing. The lab technician will use a microscope to look at the cells in the sample. If they see a lot of receptors on them, that means your tumor is hormone-sensitive.
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What Is Hormone Receptor
Breast cancer tumors that are hormone receptor-positive need the hormones estrogen or progesterone to grow. Approximately 75% of breast cancers are hormone-positive in post-menopausal patients. Your healthcare provider will perform a biopsy and laboratory testing to determine the cancer type and most effective treatment.
Factors During Adult Life
Four lines of evidence point to hormones, and particularly sex hormones, as playing a role in the development of breast cancer in the adult woman . The first springs from the powerful role that female reproductive factors and, indeed, gender itself, play on breast cancer occurrence. Breast cancer risk is increased, for example, in women with earlier menarche and later menopause. The second line of evidence relies on experimental animal data indicating that estrogen and progesterone promote some types of mammary tumours. The third line of evidence derives from studies indicating that exogenous estrogens and progesterone in hormonal contraceptives and menopause hormone treatment regimens increase breast cancer risk, whereas tamoxifen reduces this risk. The fourth line of evidence involves analytic epidemiological studies, particularly cohort investigations, that implicate various hormones and expression of hormone receptors in the risk of breast cancer . Studies of endogenous hormones may be more directly relevant to the pathogenesis of breast cancer than studies of exogenous hormones.
What Are Hormone Receptors
Breast cancers that are hormone receptor positive have receptors for the female hormones oestrogen and/or progesterone on the inside of the cancer cells.
In breast cancer cells that are hormone receptor positive, oestrogen and/or progesterone, which are naturally produced in the body, make the cancer grow. You can think of it as the receptor being the lock and oestrogen being the key. The oestrogen fits into the receptor and switches the cancer cell on, causing it to grow. Hormone therapy for breast cancer can starve cancer cells by upsetting this process.
Testing for hormone receptors is part of the routine pathology testing following surgery. Testing is done on a core biopsy sample if surgery is not planned.
Your doctor will be able to tell you if your breast cancer is hormone receptor positive or not. Most, but not all breast cancer is hormone receptor positive.
The hormonal therapies described in this brochure only work against breast cancers that are hormone receptor positive. Other treatments need to be used for cancers that are hormone receptor negative.
Questions To Ask Your Doctor
To learn more about estrogen and progesterone receptor testing for breast cancer, consider asking your doctor the following questions:
What are the results of the ER and PR tests on my tumor sample? What do they mean?
Does this laboratory meet the standard guidelines like those from ASCO and the CAP?
Has a board-certified pathologist diagnosed my cancer?
Do you know if this is an experienced lab and if my tissue was quickly given to the pathologist after my biopsy or surgery, as recommended by guidelines?
Can I obtain a copy of my pathology report ?
Is my ER and PR status indicated on the pathology report? Was the ASCO-CAP guideline recommendation used to define the status?
Based on these test results, what treatments do you recommend and why?
- What are the possible side effects of these treatments?
Stopping The Ovaries Working
In premenopausal women, doctors might use a type of hormone treatment to stop the ovaries from producing oestrogen. This type of drug is called a luteinising hormone releasing hormone . For example, goserelin and leuprorelin . You might have this on its own or with other hormone therapy drugs.
LHRH drugs work by blocking a hormone made in the pituitary gland that stimulates your ovaries to make and release oestrogen. This stops your ovaries from working. So you won’t have periods or release eggs while you are having the injections.
When you stop taking the drug, your ovaries should start working again. But, if you’re close to the age at which your menopause would naturally start, your periods might not start again.
When Are Hormone Blockers Used
Hormone inhibitors and blocker options may depend on a persons stage of life.
- Hormone inhibitors are only used in postmenopausal women. They can be given to premenopausal women if steps are taken by the treatment team to put the ovaries to sleep by blocking the ovaries from producing estrogen or progesterone.
- Hormonal therapy may also be called anti-hormone treatment. Think of it as the opposite of hormone replacement therapy . If pathology tests show that the tumor in your breast has hormone receptors , then hormonal therapy may be recommended for you after the completion of your acute treatment .
- Hormonal therapy keeps breast cancer cells from receiving or using the natural female hormones in your body which they need to grow. Hormonal therapy also blocks the ability of health breast cells to receive hormones that could stimulate breast cancer cells to regrow again in the form of recurrence of the breast cancer within the breast or elsewhere in the body.