We’re back with the second part of the episode! In this episode we’re going to talk about how we diagnose breast cancer, how physicians stage (basically letting you know how severe it is) and all the treatment options. We also wanted to get back to talking about prevention strategies and how important screening is in today’s world. So let’s get into it...
In general in order to diagnose and evaluate the first step is to do a breast exam. Part of this requires looking and feeling both breasts and lymph nodes in your underarm area. So clinical breast exams your physician does but you should also do them once a month at home. There are different techniques and we use the recommendations provided by the National Breast C Cancer Foundation.
They recommend as follows: First, if you’re in the shower you use the pads of your fingers and go in a circular motion from the outside to the center and don’t ignore the armpit area. We can't stress it enough that you have breast tissue that goes all the way to the armpit area (this is also true for men, so be aware).
Second, if you’re in front of the mirror you can look at your breasts and you start with your arms on the sides then do the same with your arms raised over your head. What you want to look for is any irregularities with regards to the contours of the breast, swelling, dimpling in the skin, or changes in the nipples. You can also put your palms on your hips and press firmly till you flex your chest basically, looking at your boobs to see any changes that particularly stick out on one or both sides of the breasts.
Finally, you can also do a breast exam while lying down. So in this care, you want to put a pillow under your shoulder and raise your arm behind your head. Then you take your opposite hand and again make small circular motions over the entire breast as well as, thee armpit. Also, you want to squeeze the nipple looking for any discharge or lumps.
Moving along from at home breast exams, if you do find something you will be opted to do either a mammogram or ultrasound. For people that are over 35 we would do a mammogram which is basically an x-ray of the breast and this is what we use to also screen the general population every two years starting at age fifty or earlier if you have certain risk factors (if you remember, we talked about this on the first part of the breast cancer episode).
A diagnostic mammogram is different from a screening because we are evaluating a lump or something that you have already noticed is off. In some cases, particularly in people who are younger than 35 you do an ultrasound (it’s a probe you put gel on it and then look around to look for a mass or a cyst).
After all of this if there is something that is concerning for a cancer or if you can’t tell if it’s just a simple cyst or not you will need to do a biopsy. This is basically when they take a little piece of your breast tissue so that it can be tested for cancer. They can also use it to look at genetics and aggressiveness of the cancer. The genetics is important because there are certain hormone receptors you can target when planning treatment. In other cases, you can do a breast MRI but that’s for another time.
I hope we're not going over anyone's here so stick with us! After you do all of this if you’re found to have cancer or if the findings are highly suspicious for a malignancy and we are waiting for the biopsy results to come back your doctor will start the “staging” process. For staging people do various blood tests, they also do a mammogram of the other breast (the unaffected one) to look for evidence of other sites of cancer, a bone scan, CT and PET scan go along with that to look at other sites in the body that may have been involved. Note these further tests don’t apply to everyone but help in staging once people have been diagnosed with breast cancer.
The whole concept of staging is to know where your breast cancer is in terms of severity and prognosis. It ranges from stage 0 and goes up to stage IV. Stage 0 means it's not invasive and is contained where as stage IV is metastatic which means it has spread beyond the breast and is typically linked with a worse outcome. Staging also includes the grade which has to do with the various tumor markers and plays a role in treatment some that you may have heard of include estrogen, progesterone and HER2.
Treatment options depend on this entire workup which is why it is SOOOOO IMPORTANT! We live in a world where so many new things are coming out on the daily with various immune and hormone therapies that go beyond the scope of what we will talk about today but there are many many options in today's world! In most cases people have surgery and receive additional treatment like chemotherapy, hormone or radiation therapy. Sometimes you will have chemotherapy done before the surgery and these treatment options kind of depend on your stage of disease.
We wanted to briefly explain the surgical options without going into much of the science behind it. Many of you may have heard of some of these surgical options. The first one is a lumpectomy where you try to remove the tumor and save as much of the breast as possible. A mastectomy on the other hand, is when you are basically removing the entire breast (no breast tissue left behind) this typically included the nipple and areola but new things have become popular known as skin-sparing or nipple sparing mastectomies.
Sentinel node biopsy involves the removal of certain amount of lymph nodes to see if they have been involved which helps with knowing where the cancer is spreading. If lymph nodes are involved you go on to do axillary lymph node dissection.
In some individuals you may choose to do a mastectomy of the uninvolved breast (this is usually done specifically for those at increased risk). Note that most people who have it in one breast won’t develop cancer in the other breast.
There are side effects however, like in everything. With surgeries these include infection, arm swelling, pain, bleeding, rarely nerve damage but you discuss all these things before undergoing these procedures.
After these surgeries some people choose to do breast reconstruction or augmentation depending on how much of the tissue they have left. Can’t wait to talk about implants on another episode but we will spare you for the wealth of information you are getting today!
Then there are other treatment options which generally apply to most cancers. You can do radiation therapy which can be targeted through a machine externally or by giving you brachytherapy where you place radioactive material inside your body. These therapies can take anywhere from three days to six weeks depending on the treatment you and your physician choose. Side effects of radiation can be redness, or a sunburn like rash more commonly and rarely can have damage to the heart or lung or even cause secondary cancers which is really really rare (but something worth mentioning).
Chemotherapy on the other hand, is used to destroy fast growing cells. This will involve destroying both the cancer and normal cells but some can be targeted to kill specific cell types like the cancer cells if there is a chemotherapy that targets the specific marker that is associated with your cancer. Side effects of chemotherapy include hair loss, nausea, vomiting, fatigue and infection. More serious side effects that are rare include early menopause, infertility, nerve damage, heart and kidney damage to name some of the big ones.
Recently and very promising in the future is hormone therapy! It helps target those who have estrogen positive and progesterone positive cancers. Targeted therapy is most commonly used for those that have HER2 positive breast cancers and this will damage the cells that express this receptor versus the healthy cells. Immunotherapy for those with triple negative breast cancer meaning they don’t have the estrogen, progesterone or HER2 expressed on their cells. These are all additional treatment options we have today and in this field there is a lot more to come! Immunology in general is very interesting to a lot of physicians today. This is a very interesting part of medicine for us because one day you will hopefully be able to target one specific cell type and potentially cure people without causing damage to your “good” cells.
Finally, there are things called palliative treatment options. These focus on quality of life and pain relief but are not to be used as a curative measure. This is a very important part of therapy which can be discussed at a later point because it is different from hospice and there is a lot of confusion about this.
So overall with breast cancer it is important to know these things so you can understand your options and various things that go on. Granted this is targeted to each person and will be different on a case by case basis. But to end this two part podcast we want to talk about the importance of coping strategies because it is very important to manage your stress during this time.
1. Number one we talked about HRT and avoiding alcohol. These come with side effects but also may not help your overall state of being. Avoid excess alcohol!
2. Go to meetings. There are individual ones and group ones where you can talk about what you're going through with other people who are going through it or with specialists who have dealt with what you're dealing with in the past.
3. Talk to your family and friends. During this time, no matter how strong you are you need to be open in talking with your loved ones. And if you are not the one suffering support those who are. You'd be surprised how much better this can make us and those around us feel.
4. Have an outlet! Read a book, find a new exercise routine, go on a quick getaways. Find what you need to do to destress and recuperate. It is very important to treat your body and your mind right during this time, but really always!
If you or anyone you know has breast cancer and needs resources you can utilize some of th ones we've provided!
A. National Breast Cancer Foundation
B. CDC
C. Beyond The Shock
D. The American Cancer Society
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