Breast cancer is most commonly diagnosed by a routine mammogram, also sometimes by self or physician breast exam.
When radiologists mention suspicion of malignancy on a mammogram, it is usually confirmed by an ultra sound examination. In some young women, especially with dense breasts, an MRI of the breast also done.
The next step is a pathological confirmation of the abnormality, either by needle or excisional biopsy.
DCIS (Ductal Carcinoma in situ)
This cancer originates in the lining of the milk duct, but has not invaded through the wall of the duct. Prognosis is excellent, but further treatment is needed, in terms of surgery (lumpectomy or very rarely mastectomy).
After a lumpectomy, radiation therapy is given, followed by hormonal therapy, either with Tamoxifen or an aromatos inhibitor as indicated. No CT Scan or bone scan indicated, but routine examination and yearly mammogram are needed as a follow up.
LCIS (Lobualar Carcinoma in situ)
This is basically considered a pre-cancerous condition. After confirming the diagnosis, further surgery such as a lumpectomy may or may not be considered, depending on the mammogram/ultra sound findings.
No radiation therapy is needed, and hormonal therapy as prevention can be considered. Only caveat is that LCIS has about 30% chance of presenting in the opposite breast. In old days, the option of bilateral mastectomy was discussed with the patient, but these days preventive hormonal therapy is considered sufficient.
INVASIVE DUCTAL CARCINOMA
Treatment option in this situation depends upon multiple factors.
a. Age of patient.
b. Size of tumor.
c. Whether or not tumor is positive for estrogen receptor and /or progesterone receptor, as well as Her2Neu receptor.
d. Whether or not axillary lymph nodes are involved and the number of lymph nodes involved with cancer.
e. Whether over all pathology reflects aggressive disease or not so aggressive disease.
Multiple factors are considered before a patient is advised about surgical option, i.e. lumpectomy vs. mastectomy.
a. Size and location of the tumor
b. Size of the patient’s breast
c. Patient preference
d. Any comorbid condition, which would contra indicate radiation therapy, etc.
Again multiple issues, including stage of disease, hormonal status, age, Her2Neu receptor status, the number of lymph nodes involved comorbid conditions, and overall health of the patient. In early stages, some postmenopausal patients may be better off with hormonal therapy alone, and in younger patients, whether or not anthracyclines will be included in the regimen, etc. Patient should ask their oncologist about any potential short and long term side effects of chemotherapy and hormonal therapy.
If the patient had a lumpectomy, radiation therapy is essentially part of treatment. In case of mastectomy, radiation therapy is considered if the tumor is 4-5 cm in size, and over 4 axillary lymph nodes are involved. Now it is recommended to be considered, even if less than 4 lymph nodes are involved.
Patient should ask her radiation oncologist both short, and long term side effects of radiation therapy.
INVASIVE LOBULAR CARCINOMA
This is usually treated stage to stage, as invasive ductal carcinoma.
METASTATIC BREAST CANCER
Prognosis varies widely in metastatic breast cancer. Some cancers are fatal within 6 months to 1 year, but others can live with their disease for maybe 15-20 years. There are multiple options in terms of chemotherapy and hormonal therapy that are available. The challenge for your medical oncologist is to understand the behavior of your disease, and make treatment recommendations accordingly to your particular situation. The goal should be to control the disease without causing undue side effects, plus to make sure the patient has a good quality of life.