Breast Cancer Health Article

Coping with cancer treatment

Surgery for breast cancer is physically well-tolerated by the patient, especially those undergoing minimal surgery in the axilla. Most patients can return to a normal lifestyle within a month or so after surgery. Exercises can help the patient regain strength and flexibility. Arm, shoulder, and chest exercises help, and complete recovery of activity is to be expected.

About 5-7% of patients undergoing complete axillary lymph node resection as part of their therapy may develop clinically significant lymphedema, or swelling in the arm on the side of involvement. If present, elevation and massage may be needed intermittently. Though usually not serious, on occasion this complication may interfere with complete physical recovery. The incidence of lymphedema is less with less axillary surgery. This is the reason for the enthusiasm for sentinel node biopsy as the surgical staging procedure in the axilla.

It is common after breast cancer treatment to be depressed or moody, to cry, lose appetite, or feel unworthy or less interested in sex. The breast is involved with a woman's identity and loss of it may be disturbing. For some, counseling or a support group can help. Many women have found a support group of breast cancer survivors to be an invaluable help during this stage. Involvement with volunteers from the local chapter of the Reach to Recovery program may be very helpful.

Nearly all patients undergo some form of adjuvant therapy for breast cancer. The magnitude of the toxicity of these adjuvant therapies is usually small and many patients receiving chemotherapy on this basis are capable of normal activity during this time. Certainly, those who progress to advanced disease are treated with more toxic chemotherapeutic regimens in an attempt to induce remission.

Clinical trials

The use of tamoxifen and other agents which alter the hormone status of the patient are under study. The National Surgical Adjuvant Breast and Bowel Project (NSABP) with support from the National Cancer Institute began a study in 1992 (called the Breast Cancer Prevention Trial, or BCPT) studying the use of tamoxifen as a breast cancer preventative for high-risk women. The results yielded from the study showed that tamoxifen significantly reduced breast cancer risk, and the U.S. Food and Drug Administration approved the use of tamoxifen to reduce breast cancer risk for high-risk patients in 1998. Another NSABP study, known as STAR, is seeking to understand if another drug, raloxifene, is as effective as tamoxifen in reducing breast cancer risk in high-risk patients. That study was begun in 1999, and participants are to be monitored for five years.

Neo-adjuvant therapies to allow the use of breast preservation in those with more advanced local disease are under investigation.

Immune therapies have not been helpful to date though there are vaccines being developed against proteins such as that produced by HER-2 that may be beneficial in the future.

High-dose chemotherapy with bone marrow rescue remains controversial. Factors can be identified that predict certain patients will develop metastatic disease. This treatment has been offered to this select group of patients but the toxicity is such that defining a clear indication for this treatment remains under study.

Prevention

As mentioned above, because of the results yielded from the BCPT clinical trial, tamoxifen can now be prescribed to high-risk women to help prevent breast cancer.

And, while most breast cancer can't be prevented, it can be diagnosed from a mammogram at an early stage when it is most treatable. The results of awareness and routine screening have allowed earlier diagnosis, which results in a better prognosis for those discovered.

Special Concerns

Though breast-preserving therapy is being done more frequently than in years past, modified radical mastectomy remains an option when selecting therapy for the primary tumor. This option may allow treatment without radiation in earlier stage patients, or may be necessary if the presentation of the tumor does not allow breast preservation. Loss of the breast is disfiguring and many patients so treated desire reconstruction of the breast. Breast reconstruction is performed either at the time of initial surgery (immediate) or it may be delayed. Alternatives include placement of implants or the rotation of muscle flaps from the abdomen or back. Most agree that breast preservation gives superior results to any form of reconstruction. When the breast is removed as part of primary therapy, these reconstructions are available and do produce very reasonable results.

See Also Breast ultrasound; Sentinel lymph node mapping; Tumor staging

Resources

BOOKS

Abelhoff, Armitage, Lichter, Niederhuber. Clinical Oncology Library. Philadelphia: Churchill Livingstone 1999.

American Joint Committee on Cancer. AJCC Clinical Staging Manual. Philadelphia: Lippincott-Raven, 1997.

Love, Susan and Karen Lindsey. Dr. Susan Love's Breast Book. Reading, MA: Addison-Wesley, 1995.

Mayers, Musa. Holding Tight, Letting Go: Living with Metastatic Breast Cancer. Sebastopol, CA: O'Reilly & Associates, 1997.

McKinnell, Robert G., Ralph E. Parchment, Alan O. Perantoni, and G. Barry Pierce. The Biological Basis of Cancer. New York: Cambridge University Press, 1998.

Schwartz, Spencer, Galloway, Shires, Daly, Fischer. Principles of Surgery. New York: McGraw Hill, 1999.

PERIODICALS

Esteva and Hortobagyi. "Adjuvant Systemic Therapy for Primary Breast Cancer." Surgical Clinics of North America Volume 79 No. 5 (October 1999) p 1075-1090.

Krag, et al, "The Sentinel Node in Breast Cancer." New England Journal of Medicine Volume 339 No. 14 (October 1, 1998), p 941-946.

Margolese, R. G., M.D. "Surgical Considerations For Invasive Breast Cancer." Surgical Clinics of North America Volume 79 No. 5 (October 1999), p 1031-1046.

Munster and Hudis. "Adjuvant Therapy for Resectable Breast Cancer." Hematology Oncology Clinics of North America Volume 13 No. 2 (April 1999) p 391-413.

Shuster, et al. "Multidisciplinary Care For Patients With Breast Cancer." Surgical Clinics of North America Volume 80 No. 2 (April, 2000) p 505-533.

ORGANIZATIONS

American Cancer Society. (800) ACS-2345. <http://www.cancer.org>.American Cancer Society's Reach to Recovery Program: <http://www2.cancer.org/bcn/reach.html>. Cancer Care, Inc. (800) 813-HOPE.<http://www.cancercareinc.org>.

Cancer Information Service of the NCI. (1-800-4-CANCER).<http://wwwicic.nci.nih.gov>.

National Alliance of Breast Cancer Organizations. 9 East 37th St., 10th floor, New York, NY 10016. (888) 80-NABCO.

National Coalition for Cancer Survivorship. 1010 Wayne Ave., 5th Floor, Silver Spring, MD 20910. (301) 650-8868.

National Women's Health Resource Center. 2425 L St. NW, 3rd floor, Washington, DC 20037. (202) 293-6045.

OTHER

Breast Cancer Online <http://www.bco.org/>

National Alliance of Breast Cancer Organizations <http://www.nabco.org/>

National Cancer Institute <http://rex.nci.nih.gov/PATIENTS/INFO_PEOPL_DOC.html>

Richard A. McCartney, M.D.

Carol A. Turkington