Emory Breast Cancer offers information for those trying to grasp the medical implications of a diagnosis of breast cancer, including topics such as: clinical trials and treatment options. While the information within the website has been reviewed by physicians and nurses, it does not take the place of a visit to your doctor.

Understanding Breast Cancer

What Is Breast Cancer?
Breast cancer is a type of cancer that occurs when cells in the breast tissue divide and grow without control. About 80 percent of cases of breast cancer originate in the mammary ducts, while about 20 percent arise in the lobules. Cancerous tumors in the breast usually grow very slowly so that by the time one is large enough to be felt as a lump, it may have been growing for as much as ten years. One of the most important distinctions to understand is between invasive breast cancer and carcinoma in situ (kar-sin-O-ma in SY-too). Below is a brief overview of the key concepts.

Carcinoma In Situ
When abnormal cells grow inside the lobules or milk ducts but there is no sign that the cells have spread out to the surrounding tissue or beyond, the condition is called carcinoma in situ. The term "in situ," which means "in place," is used because with carcinoma in situ, the abnormal cells remain "in place" inside the lobules or ducts where they first developed. There are two main categories of carcinoma in situ: ductal carcinoma in situ and lobular carcinoma in situ.

Ductal Carcinoma In Situ (DCIS)
Normally the mammary ducts are hollow so that fluid can pass through them. With DCIS, excess cells that are very similar to invasive cancer cells grow inside the ducts. DCIS is not invasive cancer, but is considered a precancerous condition that has the potential to develop into invasive cancer eventually.

Lobular Carcinoma In Situ (LCIS)
Like the milk ducts, the lobules of the breast tissue have open space inside them. When large numbers of abnormal cells grow in the lobules, the condition is called LCIS. LCIS is not invasive cancer, and it is not a direct cancer precursor, that is, the abnormal cells found inside the lobules will not turn into cancer later on. LCIS is, however, a risk factor for invasive cancer. And, as with other risk factors for the disease, women who have LCIS are more likely to develop invasive cancer in either breast. Increasingly, providers refer to LCIS as "lobular neoplasia in situ," believing this title to be a more accurate depiction of the condition.

Invasive Cancer
When abnormal cells from inside the lobules or ducts break out into the surrounding tissue, the condition is called invasive breast cancer. This term, though, does not necessarily mean that disease may have been found anywhere beyond the breast. When invasive cancer is generally at its most treatable, such as when a tumor is relatively small and has not spread to the lymph nodes, it is considered "early stage." When the condition is more serious and successful treatment less likely, such as when a tumor is very large or has spread to other organs (like the liver, lungs, and bones), it is considered "advanced stage."

How Is Breast Cancer Diagnosed?
Breast cancer is often first suspected when a lump is felt (either by a woman or her physician) or when an abnormal area is found on a mammogram. Most of the time, these suspicious areas do not turn out to be cancer, but the only way to know for sure is through follow-up tests and/or biopsy. Follow-up tests, such as diagnostic mammogram and ultrasound imaging, can provide additional information about suspicious areas and help determine which are likely to be cancer and which are not. For those that are likely to be cancer, cells or tissue must be removed from the abnormal area of the breast and examined under the microscope. This procedure of removing the cells or tissue is called a biopsy and is the only way to make a definitive diagnosis of cancer.

Breast Cancer Stages
After a diagnosis of cancer has been confirmed, the cancer is classified into a particular stage. The stage of the cancer helps determine what treatment is necessary and how curative this treatment may be in getting rid of the disease and prolonging life (prognosis). Detecting breast cancer early is very important. The earlier the stage at diagnosis, the better the prognosis.
A number of methods for classifying stage exist. Most widely used, though, is the TNM classification (standing for tumor, nodes, metastases). TNM takes into account the size of the tumor (T), the number of cancerous lymph nodes (N), and whether or not the cancer has spread to other areas of the body (metastasis) (M). The stage of a cancer is usually determined at two separate times. The first time is based on results from a doctor's physical exam and tests like mammography (known as clinical staging), and the second time is based on a direct examination of the lymph nodes and tumor removed during surgery (known as pathologic staging).

Tumor Size
The size of a tumor is directly related to a patient's prognosis. In general, the larger the tumor, the lower the chances for effective treatment and long-term survival. The size of a tumor can be determined many different ways.

• The physician can estimate the size during a physical exam by touch (palpation).
• Pictures can be taken of the tumor using ultrasound or mammography.
• The tumor removed during excisional biopsy or surgery can be measured.

The most accurate of these methods involves measuring the entire tumor after it has been removed during excisional biopsy or surgery. Tumor size and location, however, can be estimated fairly well with less direct methods (such as ultrasound imaging, mammography, and a physical exam), and provide information that will help determine the best type of treatment for a woman's specific cancer. The size of a tumor is indicated by a "T" followed by a number. The number generally indicates the size of the tumor. In some cases, the size of the tumor cannot be determined (TX) or a tumor cannot be found (TO). If the cancer is in situ, this is indicated as Tis.

Nodal Status
Lymph nodes play an important role in the discussion of your treatment decisions. The lymphatic acts as a sewage system for cellular waste in the body. Lymph nodes, all along the lymphatic system, produce cellular components that help fight infection and they also act as filters to stop bacteria, cellular waste and cancer cells from entering the blood stream. Sentinel lymph nodes are the first nodes that receive lymphatic drainage from a cancerous tumor. These sentinel nodes are like gatekeepers for the rest of the nodes. A sentinel lymph node biopsy may be done before full breast surgery and /or neoadjuvant chemotherapy. If no sentinel nodes ("node negative") are found to have cancer cells then further node surgery may not be needed. Minimizing the number of lymph nodes removed decreases the chances of lymphedema (swelling of the arm). If any sentinel nodes are found to contain cancer cells, then an axillary node dissection will take place at the time of your full breast surgery. The number of nodes that contain cancer cells is a very important factor in determining treatment options.

Metastasis
Metastasis is defined as spread of the original cancer to other distant areas of the body. Evidence of metastatic disease will be very important in determining an appropriate plan of care.

First Visit

Thank you for choosing the Breast Cancer team at Emory Winship Cancer institute in partnership with Emory School of Medicine for your care. We understand that this is a challenging time for you and your family, and we, as a team, are committed to providing the highest quality of care in a supportive, comfortable environment.

Your First Visit: What to Expect
We welcome referrals from your physician (1-888-Winship) or you may contact the Breast Health Program directly by calling (404) 778-PINK, Option #3.

Before your first appointment, you will need:

• A copy of records pertaining to your breast concern
• Any breast imaging (mammogram, ultrasound, MRI) with reports
• Pathology slides (for known breast cancer) and reports

All of this information will be carefully reviewed with you so that an appropriate plan of care may be outlined for you at the time of your initial consult.

There are several ways by which you may enter the Breast Program at Winship Cancer Institute.

• For those with a breast health concern, (lump, discharge, pain,abnormal mammogram, high risk, family history), call (404) 778-PINK (option #3) to speak with a Breast Health Specialist who will offer directions as to the best way to enter the Breast Program.
• For those with a newly diagnosed breast cancer, call 1-888-WINSHIP to schedule an initial appointment with Surgical Oncology.
• For those with questions about chemotherapy or second opinions, call (404) 778-1900 to set up an initial consult with Medical Oncology.
• For specific breast related questions, you may contact us via email.

At whatever point you enter the Breast Program, you will be welcomed by a dedicated, professional staff, consisting of physicians, nurse practitioners, and nurse educators who will review your records, perform a comprehensive physical exam, discuss findings, recommend further tests and outline for you treatment plans, complete with written and verbal education.

Understanding that this is a very stressful time, we invite you and your significant others to ask any and all questions.

Breast Cancer Treatments
The past two decades have seen large improvements in the treatment of breast cancer. With increased early detection through mammography and surgery options that conserve much of the breast, some of the trauma associated with breast cancer treatment has been reduced while chances for long-term survival have increased. Winship's Breast team is committed to finding the best, most effective treatment for you.

The goal of treating breast cancer is to eliminate the cancer from the body as completely as possible and prevent it from returning. This is usually done with a combination of surgery, radiation therapy and/or chemotherapy/ hormone therapy. Surgery and radiation therapy are called local treatments. They focus on getting rid of the cancer from a limited (local) area, such as the breast, chest wall and lymph nodes under the armpit (axillary nodes).

Chemotherapy and hormone therapy make up what is called systemic therapy. In systemic therapy, the entire body is treated to get rid of any cancer cells that may have spread from the breast tumor to other areas of the body. What exactly makes up a woman's treatment depends on many factors, such as her age, tumor stage and estrogen/progesterone receptor status, and the presence or absence of her 2 new protein. However, deciding on a particular treatment is as much a personal matter for a woman as it is a medical one. Each treatment option has risks and benefits. The type of treatment a woman decides upon should be based on an understanding of these risks and benefits and how they relate to her own personal values and lifestyle.

Decisions About Treatment Options
Most women with breast cancer have a number of decisions to make regarding the type of surgery and therapy to treat their disease. The choice of a particular treatment should be based on a good understanding of all the options and how each relates to a woman's personal values and lifestyle. Women with very similar types of cancer often choose different courses of treatment because they have different ideas of what they want from treatment and how the treatment will affect their lives both during and afterward. As you read on, an understanding of a few concepts defined below will assist with your treatment discussions and choices. More than 60 percent of women with breast cancer are diagnosed in stages 1 or 2. When appropriately treated, such women usually have a high rate of survival. Most women with stage 1 or 2 breast cancer are treated with a combination of surgery, radiation therapy, and/or adjuvant systemic therapy.

LOCAL TREATMENT: aimed at removing cancer from a specific area ie. Surgery, radiation

Surgery

Breast Conserving Surgery
Breast conserving surgery (also known as partial mastectomy, lumpectomy, wide excision, or excisional biopsy) is the standard of care in the treatment of breast cancer. The procedure is called "breast conserving" because only part of the breast - the part containing and closely surrounding the cancer - is removed. This leaves much of the breast looking as normal as possible. A total mastectomy is a complete removal of the breast.

In the past, total mastectomy was the favored treatment because it was thought to be the best means of getting rid of all the cancer in the breast and chest area. Today, however, many studies have consistently shown that breast conserving surgery, when used with radiation therapy, is just as effective as total mastectomy in treating early-stage breast cancer. Because of its effectiveness and ability to conserve the breast, many women today choose to have breast conserving surgery plus radiation rather than total mastectomy.

Your type of surgery is a decision made after careful discussion with your surgeon.

Lumpectomy: removes the tumor and a small wedge of surrounding tissue

Partial or Segmental Mastectomy: The tumor, and an area of tissue around the tumor are removed

Total Mastectomy: removes the breast tissue, nipple, areola

Modified Radical Mastectomy: removes the breast, nipple, areola, underarm lymph nodes.

Skin Sparing Mastectomy: a procedure that may be used when perfoming a simple or total mastectomy. This method removes the breast tissues from a circular incision around the areola. This procedure is often selected when reconstructive surgery is performed.

Sentinel Lymph Node Biopsy: (as discussed in staging) removal of first nodes that may receive drainage from a cancerous tumor, after these nodes are identified by injection of dye either around the tumor site or areola. If these nodes are identified as negative or not having any tumor cells inside, then there may be no need for further node dissection, thus reducing potential for lymphedema (swelling of the arm) .

Axillary Node Biopsy: The majority of the lymphatic fluid leaving the breast is drained through the nodes located in the area of the armpit, referred to as axillary nodes. Should any sentinel lymph nodes prove to contain cancer cells, an axillary node dissection may be completed at the time of your final breast surgery. This will give an accurate picture of the number of nodes involved with cancer, thus provide guidance for a proper treatment plan.

Radiation Therapy

Radiation therapy causes biologic effects in cells that cause a cancer cell's death. It is given after breast conservation surgery (lumpectomy or segmental mastectomy). 25 - 30 treatments are given over a period of 51/2 weeks to 61/2 weeks in daily doses. The dose is calculated to prevent a tumor cell from being repaired while allowing normal cells to recover before the next dose.

Visit the Radiation Oncology website for more information.

SYSTEMIC TREATMENT: aimed at removing /eliminating cancer which may have escaped from the breast tumor ie. chemotherapy and /or hormonal/endocrine therapy

Neoadjuvant Preoperative Therapy: systemic chemotherapy or hormonal/endocrine therapy prior to surgical intervention

Adjuvant Therapy: systemic or (hormonal/endocrine and/or chemo) therapy after surgical intervention used with intent to cure

Endocrine/Hormonal Therapy: A systemic treatment, in pill form, usually given after surgery, radiation, and/or chemotherapy, to block andy remaining estrogen productione (which may feed tumors) within the body. Familiar names include: tamoxifen, arimidex, aromasin, femara.

Biologic Treatment - Herceptin, Avastin

Chemotherapy

Chemotherapy is used to kill cancer cells. It may begin prior to surgery or four to six weeks after the final surgery. In newly diagnosed breast cancers, most often chemotherapy agents are used in combination. The schedule of administration depends on the chemotherapy to be used; most often, in a newly diagnosed case, treatments may be given every 2 to 3 weeks (each treatment being a cycle) for 4 to 8 cycles. Cycling chemotherapy allows the body a chance to rest and recover between treatments. An entire course of chemotherapy may last from 3 to 12 months, again, depending on the medications being used.

The decision to use chemotherapy is personalized to each woman and takes into account a combination of many factors, such as age, nodal status, tumor type, and size, and presence or absence of hormone receptors (er/pr) or her2neu. Overall however, there are some general guidelines used in making decisions whether or not to utilize chemotherapy:

In Premenopausal women, chemotherapy is most often recommended for women with:

• Tumors larger than 1 cm, whether or not lymph nodes have been found to contain cancer cells.
• Any size tumor, if lymph nodes are found to be positive for cancer cells.

Although controversial, some premenopausal women with negative nodes, or no cancer cells found in lymph nodes, and whose tumors are smaller than 1 cm, may still choose/be advised to undergo chemotherapy treatment if certain tests show their cancer to be more aggressive.

In Post menopausal Women the decision to choose chemotherapy is a bit more complicated. Because the benefits of chemotherapy are not as great in older women, the bar is generally set higher for its use. One important consideration for postmenopausal women in making decisions for or against chemotherapy, is the estrogen/progesterone receptor status. Because hormone/endocrine therapy (tamoxifen, aromatase inhibitors) is generally of greater benefit than chemotherapy in postmenopausal women with tumors that are estrogen/progesterone receptor positive, and therefore more responsive to endocrine/hormonal therapy, are less likely to opt for chemotherapy. This said, chemotherapy is most often recommended in postmenopausal women with:

• Tumors larger than 1 cm that are estrogen and/or progesterone receptor negative, regardless of nodal status.
• Tumors that are estrogen and/or progesterone receptor positive, but nodes prove to be positive or tumor is a larger size.

Women who are frail or have other medical illnesses may not be candidates for chemotherapy as risks may outweigh benefits.

Going through Chemotherapy
Chemotherapy drugs may be taken in pill form or infused into a vein (intravenous). Sometimes a combination of the two is used. Intravenous medications are given in the clinic's ambulatory infusion center, or in a doctor's office. Each chemotherapy session typically last from 2 to 6 hours, not all of which involves administration of the medications. Labs are drawn prior to chemotherapy to ensure adequate blood counts (white blood cells, hemoglobin, hematocrit, are some of several). Typically then a visit with your oncology provider follows, and only then, with approval from the team, will your particular chemotherapy combination be mixed for you.

At each visit an IV catheter is inserted into a vein in the arm, allowing medications to drip slowly into the blood stream. In some case a woman may have a Port-a-cath inserted that remains under the skin of the chest for the duration of treatment. This allows the medications to be administered without the need for a new IV start each visit. However, one must keep in mind that the insertion of a Port-a-cath is a surgical procedure.

Patients may bring along a family member or friend during their chemotherapy session. Television and various activities are usually available. It is advised that one dress warmly, in layers, as it is always cool in the treatment areas. Plan to bring along a favorite water based beverage and a snack or two, keeping in mind that strong odors may be bothersome to others in the treatment area.

Types of Chemotherapy
More that 30 different types of chemotherapy medications are used. The most effective of these, known as "first line" are Doxorubicin, Epirubicin, Methotrexate, Cyclophosphamide, 5-Fluorouracil, and Paclitaxel. Although each of these individual drugs is effective on its own, research has consistently shown that combining different drugs further increases their ability to kill cancer cells. Some of the most frequently used chemotherapy combinations include:

• Adriamycin/Cytoxan (AC)= a combination of cyclophosphamide (C) and doxorubicin (A). This combination is given through an IV either every 14 or 21 days
• Adriamycin/Cytoxan followed by Taxol = as above, followed by Taxol every 14 days for 4 cycle
• Cytoxan/Methotrexate/5 Fluorouracil (CMF) = a combination that is given through an IV every 21 days
• Herceptin, a monoclonal antibody, is used to treat tumors that overexpress the Her2Neu protein

Side Effects of Chemotherapy
As most people are aware, chemotherapy has several side effects. Some are short term that may develop during treatment and start to go away soon after treatment ends. Even though many side effects are common during therapy, there is no need to suffer in silence. There are many ways to address adverse effects so it is important to let your oncology team know of any bothersome symptoms.

Fatigue: anemia ( a decrease in the oxygen carrying red blood cell count) and chemotherapy may cause fatigue.

Infection: Chemotherapy will cause your white blood count to fall, leaving you potentially open to serious infections. It is most essential to let your oncology team know if you develop a fever over 100.5, especially after your first week of treatment. Treatment may include antibiotic therapy by mouth, or may require hospitalization to administer IV antibiotics.

Gastrointestinal Irritation: Nausea, vomiting, diarrhea or constipation are common side effects of chemotherapy and may be prevented/treated. Let your oncology team know of any symptoms. Our registered dietitian is available for personal consultations at 404-778-5646.

Sore Mouth: often called "stomatitis," is another possible side effect of chemotherapy. Your nurse educator will provide you with mouth care information and education re: appropriate oral care.

Hair Loss: Depending on the therapy chosen, hair loss may be minimal, or may completely fall out. In most cases, hair grows back usually within 3 to 6 month after the completion of chemotherapy.

What Else You Need to Know
Exercise: The importance of exercise, especially if you are accustomed to routine exercise, cannot be stressed enough. Not only does it maintain muscle tone, circulation, and respiration, but it also encourages a more positive outlook. If you are not accustomed to a regular exercise routine, a physical therapist is part of your Oncology Team and will be available to discuss exercise options.

Intimacy: Physical intimacy with your significant other may be affected by numerous factors, both physical and psychological, during treatment. It will depend on how you feel, both mentally and physically, your energy level and the comfort level of your relationship. Don't be surprised if your energy level is low and your desire is just not there. Sometimes it takes time. Talk through anxieties you and your partner may be feeling -- communication is so important. Here are some things you and your partner may want to consider as you feel up to resuming sexual activity:

• Pick occasions when both of you have time and energy; after naps may be right.
• Set the scene for romance -- this may keep you relaxed
• For women, the treatment you are undergoing/went through, may cause vaginal dryness. There are several product, ie. Astroglide, that may ease this discomfort. Discuss this with your oncology team -- they will have several suggestions!
• Most importantly, it is important for both of you to know that, from a medical standpoint, sexual activity is not contraindicated. It is important to keep the closeness viable, especially during times as challenging as undergoing treatment for breast cancer.
  

Contraception: While undergoing chemotherapy, it is important to realize that even though your menstrual cycle may be absent or irregular, you may still ovulate. Conceiving during chemotherapy could be harmful to a fetus. It is most important to discuss contraception with your medical oncologist.

Fertility Issues: If future pregnancies are a possibilty, you should discuss fertility issues with your medical oncologist. Emory Healthcare offers a full-service Reproductive Center.

Depression: From diagnosis , through treatment, to recovery and assuming life as a "cancer survivor", this will be one of the most challenging times for you and your significant others. It is helpful to realize that feelings of sadness, depression, anxiety , and being overwhelmed, are all expected throughout your breast cancer journey. It is important to share your emotional challenges with your oncology team. There are members of your team trained to help you deal with the emotions brought on by your cancer diagnosis. Our social workers/therapists are available at any time during your visits to Winship Cancer Institute.

Services

Emory Winship strives to offer Breast Cancer patients more than just excellent care by providing additionally services for the patient and family.

Breast Cancer Education Class for the Newly Diagnosed Patient -- This class, held every other Friday from 10:00 am -- 1:00 pm is led by a Breast Health Specialist. Tailored to the newly diagnosed patient, the education class offers answers to questions related to breast cancer including: side effects of treatments, sexual issues and nutrition during therapy. The class is free and an informal lunch with support staff is provided. Registration is requested. To register, call 404-778-PINK, Option #3 or you may email our Breast Health Specialist.

Patient and Family Resource Center -- At Winship, we know that cancer patients and their families need more than just top notch medical care. That's why we created the Patient and Family Resource Center: to give patients and their families a single source to turn to for help. The Center combines a comfortable atmosphere with a library of educational literature about cancer--from diagnosis to treatment and recovery. There are informational brochures, magazines, books and videos, in English and Spanish, available for check-out. We have materials targeted toward children as well as adults. Computer terminals with Internet access for research or checking e-mail are located in private rooms within the Center. Our staff is available to answer questions and to help you find the cancer resources you need. Radiance Boutique has created a private personal atmosphere where patients may schedule an appointment or stop in to receive a wide range of services and supplies for their special needs from diagnosis through their recovery.

Nutritional Services -- Nutrition plays an important role in your care during and after treatment at Winship. Recommendations about food and eating for cancer patients can be very different from the usual suggestions for healthful eating. This can be confusing for many patients because these new suggestions may seem to be the opposite of what they've always heard. Our licensed dietitian is available to answer questions and address concerns about managing your diet, weight, treatment side effects, and supplement information. To schedule a personal appointment with the nutritionist, please call (404) 778-5646.

Pastoral Care -- The personal and spiritual concerns of patients and families are important to the quality of care Winship provides. At Winship, the Pastoral Services department provides chaplains that offer spiritual care, support and presence to patients, families and staff. The support of the chaplain continues from the outpatient to inpatient care facilities. Located on the first floor, the Winship interfaith Purdom Chapel, is open to everyone for individual time of silence, prayer and meditation. Chaplains are available 24 hours a day, seven days a week. To speak to a chaplain during business hours, contact the Pastoral Services office at (404) 778-4691. To reach a chaplain after business hours and on weekends, call (404) 712-2000 and ask the operator to page the on-call chaplain.

Lymphedema Specialist/Physical Therapist -- is available by appointment to discuss concerns regarding lymphedema (arm swelling post breast cancer surgery). You will need a prescription from your physician. Once you have that, call 404-778-4529 to schedule an appointment.

Genetic Counseling/ High Risk Clinic -- Emory University's Cancer Genetics Program provides risk assessment and counseling for patients and families concerned aout the possiblity of a hereditary cancer risk. A genetic counseling visit includes a review of the family history of cancer, personalized risk assessment and discussion of surveillance and genetic testing options. A summary letter is provided to the patient and their referring physician. Visit the Emory Genetics Department to find additional information about the program or to find out who may benefit from genetic counseling.

Patient Counseling -- Coping with cancer can be a daunting experience. Illness and treatment may affect family life, functioning at work or school, financial stability, or ability to plan for the future. Persons with cancer and their loved ones may experience periods of sadness or anxiety as they adjust to the ramifications of illness. Communication with family, friends or coworkers can become straine and daily responsibilities such as caring for children, or managing the household may become difficult to handle while undergoing treatment. Feeling "in control" may be a challenge.

Oncology social workers are available to help those who are affected by cancer to cope with these concerns. Each provides practical assistance, individual, family and group counseling. In addition, they moderate support and educationcal programs and can provide referrals to community resources. To contact the appropriate social worker, please call 1-888-WINSHIP (1-888-946-7447) or 404-778-1900.

Support Groups

Young Woman's Breast Cancer Support Group meets monthly with quarterly dinner meetings. For times and locations, call (404) 778-PINK, Option #3.