When it comes to treatment options and decisions, a woman does not just have "breast cancer." She has a disease that is much more specific and involves: the stage of the cancer (is it in the breast only or has it spread to regional lymph nodes or elsewhere in the body?); the type (what are the estrogen-receptor and progesterone-receptor levels in the tumor tissue?); her age, overall health, and menopausal; and, finally, whether the cancer has just been diagnosed or is a recurrence.

Because doctors can now pinpoint so many of these details about breast cancer, there have been three general treatment advances. First, doctors have been able to reduce the use of radical mastectomy. Second, doctors and patients accept that there is no longer a need to rush into treatment. And, third, there have been major improvements in "adjuvant" or post-operative therapies.

"Today we know that from a survival perspective, a lumpectomy with radiation equals a radical mastectomy for most patients," explains Lillie Shockney, RN, BS, MAS, Administrative Director of Breast Center and Instructor in the Department of Surgery, Johns Hopkins University School of Medicine in Baltimore, Maryland and a 14-year breast cancer survivor. "One exception, for example, is someone with inflammatory breast cancer, which comprises 2% of patients."

Because of the knowledge that most breast cancers are slow-growing, "women should not have their hair on fire," when they receive a diagnosis, Shockney continues. "They have time to fact-find and make good, informed decisions. In fact, generally, if someone tells them to have surgery next week, they should leave the office."

Knowing and understanding the good news about breast cancer treatment means that once a woman begins to manage her feelings after diagnosis, she has some time
to research and make a decision based on medical information and her own good judgment.

Another big change is that patients are no longer treated by one doctor but by a group of physicians called "the treatment team." This team often includes a breast surgeon (often the same person who performed the biopsy), a radiation oncologist, and a medical oncologist. The radiation oncologist is a specialist who treats cancer with radiation. The medical oncologist focuses on treating cancer with chemotherapy, hormonal therapies, and drugs such as Herceptin. Everyone on the team–and the patient, as well as her loved ones–should have all the information that the diagnostic team knows before taking any treatment steps. In other words, the team does not make decisions about chemotherapy and radiation after surgery. Instead, all decisions–the course of treatment–are designed before anything happens. And patients have a full understanding of the treatment plan before moving forward.

Here are other advances in the treatment of breast cancer, including surgeries, chemotherapy, radiation, and hormone therapy or biologics that breast cancer patients should know about:

Surgical Procedures

About 70% of patients with breast cancer now get routine axillary lymph node dissection with a lumpectomy rather than having a radical mastectomy. The axillary lymph nodes are located in the under arm and are directly related to breast health. In the past, some (if not all) axillary lymph nodes were removed even before shown to be cancerous. This approach made for a rough recovery and left about 30% of patients with pain and reduced mobility.

"These days, however, an alternative to axillary lymph node dissection is sentinel lymph node dissection, which is less invasive," says Harry D. Bear, M.D., Ph.D., a surgical oncologist and head of the Breast Health Center at Massey Cancer Center.

Virginia Commonwealth University in Richmond. "There is good and bad news with sentinel node mapping," continues Bear. The good news is that it can improve a woman's recovery. "But doctors may find something that leads them to the lymph node removal, which may change the type of radiation and chemotherapy a woman receives in the long run."

"When we do sentinel node mapping, it's hard to argue that women get out of the hospital faster and they move their arm faster," says Joan Mortimer, M.D., Deputy Director for Clinical Oncology at Moores UCSD Cancer Center and professor of medicine in the UCSD School of Medicine. "The downside is that we take the sentinel lymph node and we're not sure this is valuable." The sentinel node is the first node that drains the breast into the axilla, which can affect the type of surgery than can be done at a later date if a more problematic cancer is found or if the cancer recurs.
In sentinel node mapping, "we find more microscopic cancer and put stains on it," Mortimer explains. "We find cells that could be breast cancer we never would have seen these cells in the past."

Chemotherapy

While little has changed in terms of chemo delivery systems, the scheduling of chemotherapy has evolved in recent years, says Harold Burstein, M.D., Ph.D., a clinician and clinical investigator in the Breast Oncology Center at the Dana Farber Cancer Institute in Boston.

Delivery scheduling is important in chemotherapy because of what chemo drugs do. They fight cancer cells by interfering with the process of rapidly dividing cells. But because cancer cells aren't the only rapidly dividing cells in the body, there are harsh side effects as the body responds to this intrusion to its natural rhythm. To combat the side effects, doctors give chemotherapy in cycles, with each treatment period followed by a brief recovery period. Those cycles were usually spaced three weeks apart to allow the body to recuperate, but this down time also allowed cancer cells to begin to re-multiply.

A recent study found that giving chemotherapy every two weeks works better than giving it every three weeks, even though this dose is more intense. This plan attacks the cancer cells before they begin to multiply again, which has been shown to be an effective approach.

Researchers have also learned that women who have estrogen receptive negative cancer do better with chemo than other breast cancer patients. And although it hasn't happened yet, some physicians expect that the national guidelines for chemotherapy will change shortly. One day, chemotherapy might be used primarily for the 30% of the breast cancer survivors whose breast cancer is not fueled by estrogen.

Radiation

The biggest thing that's come along in radiation is the "accelerated partial breast radiation for early stage disease," says Douglas W. Arthur, M.D., radiation oncologist also at the Breast Health Center at the Massey Cancer Center, Virginia Commonwealth University. Previously, the standard of care was to have whole-breast radiation over six weeks, which created several logistical challenges. Women had trouble taking six weeks off from work (and their lives) to receive radiation. Also, not all women lived close enough to a treatment center to actually get the radiation for such an extended period. As a result, some women who were supposed to get radiation would simply skip it.

Doctors have found that, for some women, a lumpectomy with radiation two times a day for five days is more realistic - and equally effective - than a six-week program.

Hormone and Biological Therapy

Along with chemotherapy, hormone and biological therapy medications fall under a category called "adjuvant treatment." Unlike surgery and radiation, these treatments target microscopic cancer cells that have spread from the primary cancer in the breast, explains Peter A. Kaufman, M.D., of Norris Cotton Cancer Center; Dartmouth-Hitchcock Medical Center in New Hampshire.

"Herceptin is the most recent major advance women have at their disposal these days," Kaufman says. "A number of years ago, a gene that helped control how cancer cells grown, divide, and repair themselves was found. It is known as HER2 (also called HER2/neu or human epidermal growth factor receptor 2). It's an oncogene that induces cancer genes to behave more aggressively and allows a cancer to metastasize more readily."

Now physicians know that if a woman has a breast cancer with increased levels of this gene, she is likely to have a more negative overall prognosis. Fortunately, Herceptin is an antibody that recognizes and attacks this specific gene and, when combined with conventional treatments such as chemotherapy, is extremely effective. In a recent study evaluating Herceptin in women with early stage breast cancer, "we have seen a 50% reduction in the risk of recurrence at an early time point, which is quite dramatic," Kaufman continues.

Another promising treatment is a new class of medicines called aromatase inhibitors, which lower the amount of estrogen in post-menopausal women who have hormone-receptor-positive breast cancer. These medications stop aromatase (an enzyme) from turning androgen into estrogen, which lowers the amount of estrogen in the bloodstream. Some of these medicines are Arimidex (anastrozole), Aromasin (exemestane), and Femara (letrozole) and are not being prescribed in place of tamoxifen, which can have distressing side effects.

No matter what the stage, the goal of all breast cancer treatment is two-fold: to prevent the cancer from spreading and to prevent its recurrence. That means the early stages of cancer are truly curable and when it comes to Stage IV cancer, "we've changed its history," Kaufman says. "It's not curable, but it can be effectively treated and we can put it in remission. We have changed it into a chronic illness, so it's treatable but not curable." And those are truly stunning achievements for the treatment revolutions in breast cancer. Imagine where we'll be in just a few more years.