Back to Top | Back One Page

How Oncologists Were Selected


Consumers' Research Council of America has compiled a list of Top Oncologists throughout the United States by utilizing a point value system. This method uses a point value for criteria that we deemed valuable in determining Top Oncologists.

The criteria that was used and assessed a point value is as follows:

Experience:

Each year the Oncologist has been in practice

Training:

Education and Continuing Education

Professional Associations:

Member of Professional Medical Associations

Board Certification:

Completing an approved residency program and passing a rigid examination on that specialty

Simply put, Oncologists that have accumulated a certain amount of points qualified for the list. This does not mean that Oncologists that did not accumulate enough points are not good health care professionals; they merely did not qualify for this list because of the points needed for qualification.

Similar studies have been done with other professions using a survey system. This type of study would ask fellow professionals whom they would recommend. We found this method to be more of a popularity contest, for instance: professionals who work in a large office have much more of a chance of being mentioned as opposed to a professional who has a small private practice. In addition, many professionals have a financial arrangement for back-and-forth referrals. For these reasons, we developed the point value system.

Since this is a subjective call, there is no study that is 100% accurate. As with any profession, there will be some degree of variance in opinion. If you survey 100 patients from a particular physician on their satisfaction, you will undoubtedly hear that some are very satisfied, some moderately satisfied and some dissatisfied. This is really quite normal.

We feel that a point value system takes out the personal and emotional factor and deals with factual criteria. We have made certain assumptions. For example, we feel that the more years in practice is better than less years in practice; more education is better than less education, etc.

The Top Oncologists list that we have compiled is current as of a certain date and other Oncologists may have qualified since that date. Nonetheless, we feel that the list of Top Oncologists is a good reference of qualified specialists.

No fees, donations, sponsorships or advertising are accepted from any individuals, professionals, corporations or associations. This policy is strictly adhered to, ensuring an unbiased selection.


What is Oncology?


Oncology is the branch of medicine that studies tumors (cancer) and seeks to understand their development, diagnosis, treatment, and prevention. A Medical professional who practices oncology is an oncologist. The term originates from the Greek ogkos , meaning bulk, mass, or tumor and the suffix -ology, meaning "study of". The oncologist often coordinates the multi disciplinary care of cancer patients, which may involve physiotherapy, counseling, clinical genetics, to name but a few. On the other hand, the oncologist often has to liaise with pathologists on the exact biological nature of the tumor that is being treated.

Oncology is concerned with:

      

The diagnosis of cancer

Therapy (e.g. surgery, chemotherapy, radiotherapy and other modalities)

Follow-up of cancer patients after successful treatment

Palliative care of patients with terminal malignancies

Ethical questions surrounding cancer care

Screening efforts:

of populations, or

of the relatives of patients (in types of cancer that are thought to have a hereditary basis, such as breast cancer).

Diagnosis

The most important diagnostic tool remains the medical history: the character of the complaints and any specific symptoms (fatigue, weight loss, unexplained anemia, fever of unknown origin, paraneoplastic phenomena and other signs). Often a physical examination will reveal the location of a malignancy.

Diagnostic methods include:

      

Biopsy, either incisional or excisional;

Endoscopy, either upper or lower gastrointestinal, bronchoscopy, or nasendoscopy;

X-rays, CT scanning, MRI scanning, ultrasound and other radiological techniques;

Scintigraphy, Positron emission tomography and other methods of nuclear medicine;

Blood tests, including Tumor markers, which can increase the suspicion of certain types of tumors or even be pathognomonic of a particular disease.

Apart from in diagnosis, these modalities (especially imaging by CT scanning) are often used to determine operability, i.e. whether it is surgically possible to remove a tumor in its entirety.

Generally, a "tissue diagnosis" (from a biopsy) is considered essential for the proper identification of cancer. When this is not possible, empirical therapy (without an exact diagnosis) may be given, based on the available evidence (e.g. history, x-rays and scans.)

Occasionally, a metastatic lump or pathological lymph node is found (typically in the neck) for which a primary tumor cannot be found. This situation is referred to as " carcinoma of unknown primary", and again, treatment is empirical based on past experience of the most likely origin.

Therapy

It depends completely on the nature of the tumor identified what kind of therapeutical intervention will be necessary. Certain disorders will require immediate admission and chemotherapy (such as ALL or AML), while others will be followed up with regular physical examination and blood tests.

Often, surgery is attempted to remove a tumor entirely. This is only feasible when there is some degree of certainty that the tumor can in fact be removed. When it is certain that parts will remain, curative surgery is often impossible, e.g. when there are metastasis elsewhere, or when the tumor has invaded a structure that cannot be operated upon without risking the patient's life. Occasionally surgery can improve survival even if not all tumor tissue has been removed; the procedure is referred to as "debulking" (i.e. reducing the overall amount of tumor tissue). Surgery is also used for the palliative treatment of some of cancers, e.g. to relieve biliary obstruction, or to relieve the problems associated with some cerebral tumors. The risks of surgery must be weighed up against the benefits.

Chemotherapy and radiotherapy are used as a first-line radical therapy in a number of malignancies. They are also used for adjuvant therapy, i.e. when the macroscopic tumor has already been completely removed surgically but there is a reasonable statistical risk that it will recur. Chemotherapy and radiotherapy are commonly used for palliation, where disease is clearly incurable: in this situation the aim is to improve the quality of and prolong life.

Hormone manipulation is well established, particularly in the treatment of breast and prostate cancer. There is currently a rapid expansion in the use of monoclonal antibody treatments, notably for lymphoma (Rituximab), and breast cancer (Trastuzumab). Vaccine and other immunotherapies are the subject of intensive research. The application of ultrasound in the form of HIFU to solid tumors is under investigation.

Follow-up

A large segment of the oncologist's workload is the following-up of cancer patients who have been successfully treated. For some cancers, early identification of recurrence, with prompt treatment, can lead to better survival and quality of life. It depends on the nature of the cancer whether the follow-up lasts a number of years or remains "life long".

Palliative care

Approximately 50% of all cancer cases in the Western world can be cured with radical treatment. A large number of cancer patients will die from the disease, and a significant proportion of patients with incurable cancer will die of other causes. There may be ongoing issues with symptom control associated with progressive cancer, and also with the treatment of the disease. These problems may include pain, nausea, anorexia, fatigue, immobility, and depression. Not all issues are strictly physical: personal dignity may be affected. Moral and spiritual issues are also important.

While many of these problems fall within the remit of the oncologist, palliative care has matured into a separate, closely allied speciality to address the problems associated with advanced disease. Palliative care is an essential part of the multidisciplinary cancer care team. Palliative care services may be less hospital-based than oncology, with nurses and doctors who are able to visit the patient at home. Ethical issues. There are a number of recurring ethical questions and dilemmas in oncological practice. These include:

     

What information to give the patient regarding disease extent/progression/prognosis.

Entry into clinical trials, especially in the face of terminal illness.

Withdrawal of active treatment.

"Do Not Resuscitate" orders and other end of life issues.

These issues are closely related to the patients' personality, religion, culture, personal, and family life. The answers are rarely black and white. It requires a degree of sensitivity and very good communication on the part of the oncology team to address these problems properly.

Progress and research in oncology

There is a tremendous amount of research being conducted on all frontiers of oncology, ranging from cancer cell biology to chemotherapy treatment regimens and optimal palliative care and pain relief. This makes oncology an exciting and continuously changing field. Therapeutic trials often involve patients from many different hospitals in a particular region. In the UK, patients are often enrolled in large studies coordinated by Cancer Research UK (CRUK,), Medical Research Council (MRC,), the European Organization for Research and Treatment of Cancer (EORTC,) or the National Cancer Research Network (NCRN,).

Complementary and alternative therapies

Many cancer patients seek extra help from complementary and alternative therapies, which fall outside of conventional medicine. Most complementary therapies do not have a firm scientific or evidence base. Some patients undoubtedly find complementary therapies helpful while they are undergoing conventional treatment.

While most complementary therapies are probably harmless, they can be expensive. They may also be positively harmful if the patient forgoes conventional treatment altogether, in order to follow alternative regimens. Some alternative regimens are undoubtedly hazardous.

Specialities

There are several sub-specialties within oncology. Moreover, oncologists often develop an interest an expertise in the management of particular types of cancer.

Oncologists may be divided on the basis of the type of treatment provided.

      

Radiation oncology: treatment primarily with radiation, a process called radiotherapy.

Surgical oncology: surgeons who specialize in tumor removal.

In the United Kingdom and several other countries, oncologists may be either clinical or medical oncologists. The main difference is that clinical oncologists deliver radiotherapy, while medical oncologists do not.

Gynecologic oncology focuses on cancers of the female reproductive system.

In veterinary medicine, veterinary oncology is the subspecialty that deals with cancer diagnosis and treatment in animals.


Ocular Oncology


Ocular oncology is the branch of medicine dealing with tumors relating to the eye and its adnexa. Eye cancer can affect all parts of the eye.

Ocular oncology takes into consideration that the primary requirement for patients is preservation of life by removal of the tumor, along with best efforts directed at preservation of useful vision, followed by cosmetic appearance. The treatment of ocular tumors is generally a multi-specialty effort, requiring coordination between the ophthalmologist, medical oncologist, radiation specialist, head & neck surgeon / ENT surgeon, pediatrician/internal medicine/hospitalist and a multi-disciplinary team of support staff and nurses.

Eye cancers can be primary (starts within the eye) and metastatic cancer (spread to the eye from another organ). The two most common cancers that spread to the eye from another organ are breast cancer and lung cancer. Other less common sites of origin include the prostate, kidney, thyroid, skin, colon lymphoma and leukemia.

Types

Tumors in the eye and orbit can be benign like dermoid cysts, or malignant like rhabdomyosarcoma and retinoblastoma. The most common eyelid tumor is called basal cell carcinoma. This tumor can grow around the eye but rarely spreads to other parts of the body. Other types of common eyelid cancers include squamous carcinoma, sebaceous carcinoma and malignant melanoma.

The most common malignant primary intraocular tumor in adults is uveal melanoma. These tumors can occur in the choroid, iris and ciliary body. The latter are sometimes called iris or ciliary body melanoma.

The most common malignant intraocular tumor in children is called retinoblastoma. Affecting approximately 325 children per year in North America, early detection has allowed for cures exceeding 95%.

The most common orbital malignancy is orbital lymphoma. This tumor can be diagnosed by biopsy with histopathologic and immunohistochemical analysis. Most patients with orbital lymphoma can be offered chemotherapy or radiation therapy.

Orbital dermoid cysts are benign choristomas which are typically found at the junction of sutures, most commonly at the fronto-zygomatic suture. Large deep orbital dermoid cysts can have cause pressure effects on the muscles and optic nerve, leading to diplopia and loss of vision.


Experimental Cancer Treatments


Experimental cancer treatments are medical therapies intended or claimed to treat cancer (see also tumor) by improving on, supplementing or replacing conventional methods (surgery, chemotherapy, radiation, and immunotherapy). The entries listed below vary between theoretical therapies to unproven controversial therapies. Many of these treatments are alleged to only help against specific forms of cancer. It is not a list of treatments widely available at hospitals.

Angiostatic-based treatments

Every solid tumor (in contrast to liquid tumors like leukemia) needs to generate blood vessels to keep it alive once it reaches a certain size. Usually, blood vessels are not built elsewhere in an adult body unless tissue repair is actively in process. The anti-angiogenesis (angiostatic) agent endostatin and related chemicals can suppress the building of blood vessels, preventing the cancer from growing indefinitely. In tests with patients, the tumor became inactive and stayed that way even after the endostatin treatment was finished. The treatment has very few side effects but appears to have very limited selectivity. Other angiostatic agents like thalidomide and natural plant-based substances are being actively investigated.

Dichloroacetate (DCA) Treatment

Cancer cells generally use glycolysis rather than oxidation for energy (the Warburg effect), as a result of hypoxia in tumors and damaged mitochondria. The body often kills damaged cells by apoptosis, a mechanism of self-destruction that involves mitochondria, but this mechanism fails in cancer cells.

A study published in January 2007 by researchers at the University of Alberta, testing DCA on in vitro cancer cell lines and a rat model, found that DCA restored mitochondrial function, thus restoring apoptosis, killing cancer cells in vitro, and shrinking the tumors in the rats.

Bacterial treatments

Chemotherapeutic drugs have a hard time penetrating tumors to kill them at their core because these cells may lack a good blood supply. Researchers have been using anaerobic bacteria, such as Clostridium novyi, to consume the interior of oxygen-poor tumors. These should then die when they come in contact with the tumor's oxygenated sides, meaning they would be harmless to the rest of the body. A major problem has been that bacteria don't consume all parts of the malignant tissue. However combining the therapy with chemotherapeutic treatments can help to solve this problem. Another strategy is to use anaerobic bacteria that have been transformed with an enzyme that can convert a non-toxic prodrug into a toxic drug. With the proliferation of the bacteria in the necrotic and hypoxic areas of the tumor the enzyme is expressed solely in the tumor. Thus a systemically applied prodrug is metabolized to the toxic drug only in the tumor. This has been demonstrated to be effective with the non pathogenic anaerobe Clostridium sporogenes.

Gene therapy

Introduction of tumor suppressor genes into rapidly dividing cells has been thought to slow down or arrest tumor growth. Another use of gene therapy is the introduction of enzymes into these cells that make them susceptible to particular chemotherapy agents; studies with introducing thymidine kinase in gliomas, making them susceptible to aciclovir, are in their experimental stage.

Telomerase therapy

Because most malignant cells rely on the activity of the protein telomerase for their immortality, it has been proposed that a drug which inactivates telomerase might be effective against a broad spectrum of malignancies. At the same time, most healthy tissues in the body express little if any telomerase, and would function normally in its absence.

A number of research groups have experimented with the use of telomerase inhibitors in animal models, and as of 2005 and 2006 phase I and II human clinical trials are underway. Geron Corporation is currently conducting two clinical trials involving telomerase inhibitors. One uses a vaccine (GRNVAC1) and the other uses a lipidated drug (GRN163L).

Thermotherapy

Localized application of heat has been proposed as a technique for the treatment of malignant tumors. Intense heating will cause denaturation and coagulation of cellular proteins, rapidly killing cells within a tumor.

More prolonged moderate heating to temperatures just a few degrees above normal can cause more subtle changes. A mild heat treatment combined with other stresses can cause cell death by apoptosis. There are many biochemical consequences to the heat shock response within in cell, including slowed cell division and increased sensitivity to ionizing radiation therapy.

There are many techniques by which heat may be delivered. Some of the most common involve the use of focused ultrasound (FUS or HIFU), microwave heating, induction heating, or direct application of heat through the use of heated saline pumped through catheters. Experiments have been done with carbon nanotubes that selectively bind to cancer cells. Lasers are then used that pass harmlessly through the body, but heat the nanotubes, causing the death of the cancer cells. Similar results have also been achieved with other types of nanoparticles including gold-coated nanoshells and nanorods which exhibit certain degrees of 'tunability' of the absorption properties of the nanoparticles to the wavelength of light for irradiation. The success of this approach to cancer treatment rests on the existence of an 'optical window' in which biological tissue (i.e,. healthy cells) are completely transparent at the wavelength of the laser light while nanoparticles are highly absorbing at the same wavelength. Such a 'window' exists in the so-called near infrared region of the electromagnetic spectrum. In this way, the laser light can pass through the system without harming healthy tissue and only diseased cells, where the nanoparticles reside, get hot and are killed.

One of the challenges in thermal therapy is delivering the appropriate amount of heat to the correct part of the patient's body. A great deal of current research focuses on precisely positioning heat delivery devices (catheters, microwave and ultrasound applicators, etc.) using ultrasound or magnetic resonance imaging, as well as of developing new types of nanoparticles that make them particularly efficient absorbers while offering little or no concerns about toxicity to the circulation system. Clinicians also hope to use advanced imaging techniques to monitor heat treatments in real time—heat-induced changes in tissue are sometimes perceptible using these imaging instruments.

Complementary and alternative cancer treatment

In the year 2000, the American Cancer Society published American Cancer Society's Guide to Complementary and Alternative Cancer Methods. There are over 200 substances and therapies in this book, and while there is a varying degree of success with each of the methods, it appears that some of the techniques will work at times, however no technique will work in all situations, which, practitioners claim, is similar to the success rate of conventional techniques. Many of these treatments are similar to ancient ways of dealing with disease. According to practitioners of such techniques, various options are available to anyone who wants this information, however, they caution that discretion is advised no matter what methods a person chooses to pursue.

Produced in collaboration with the American Cancer Society (ACS), NCCN Treatment Guidelines for Patients provide cost-free, specific, and understandable information that patients and their families can use to make timely and well-informed decisions about cancer treatment. Developed from the NCCN Clinical Practice Guidelines in Oncology™, the patient versions of the guidelines describe diagnosis and treatment of frequently occurring cancers and supportive care issues in an easy-to-read format. These guidelines provide patients access to the same decision pathways their oncologists use.

Controversial therapies

Diet therapy

In the late 1940s, German-born physician Dr. Max Gerson proposed a therapy claimed to be successful in the treatment of advanced cancer, normalizing metabolism and helping the body's immune system act on cancer cells. It is a high potassium, low sodium (saltless) diet, with no fats or oils, and high in fresh raw fruits and vegetables and their juices. (See for instance the lecture , and the book A Cancer Therapy: Results of Fifty Cases, by Max Gerson, M.D.) (ISBN 0-9611526-2-1). Other scientists give credence to published accounts of such treatments to suppress the growth rate of cancer, despite general disagreement on the underlying mechanisms: http://www.krysalis.net/cancer4.htm

As with Max Gerson, Johanna Budwig proposed another diet therapy claimed to treat cancer. Most oncologists have a belief that a diet alone cannot treat cancer. Reports of dramatic remissions as a result of the Budwig diet are anecdotal, and not supported by peer-reviewed research. (On the other hand, her diet is good from a nutritional point of view to counteract some side-effects of other treatments.) Some basic research on flax oil (preferred by Budwig) is available:

Insulin potentiation therapy

In insulin potentiation therapy (IPT), insulin is given in conjunction with low-dose chemotherapy. Its proponents claim insulin therapy increases the uptake of chemotherapeutic drugs by malignant cells, permitting the use of lower total drug doses and reducing side effects.

Some In vitro studies have demonstrated the principle of IPT.

The first clinical trial of IPT for treating breast cancer was done in Uruguay and published in 2003/2004. Insulin combined with low-dose methotrexate (a chemotherapy drug) resulted in greatly increased stable disease, and much reduced progressive disease, compared with insulin or low-dose methotrexate alone. Although the study was very small (30 women, 10 per group), the results appear to be very promising.


Breast Cancer


Breast cancer is a cancer of the glandular breast tissue. Worldwide, breast cancer is the fifth most common cause of cancer death (after lung cancer, stomach cancer, liver cancer, and colon cancer). In 2005, breast cancer caused 502,000 deaths (7% of cancer deaths; almost 1% of all deaths) worldwide. Among women worldwide, breast cancer is the most common cancer.

In the United States, breast cancer is the most prevalent cancer in women, and the second most common cause of cancer death in women (after lung cancer). In 2007, breast cancer is expected to cause 40,910 deaths (7% of cancer deaths; almost 2% of all deaths) in the U.S. Women in the U.S. have 1 in 8 lifetime chance of developing invasive breast cancer and a 1 in 33 chance of breast cancer causing their death.

The number of cases has significantly increased since the 1970s, a phenomenon partly blamed on modern lifestyles in the Western world.

Because the breast is composed of identical tissues in males and females, breast cancer also occurs in males, though it is less common. Time line of breast cancer suggesting probable heterogeneity. Primary breast cancers begin as single (or more) cells which have lost normal regulation of differentiation and proliferation but remain confined within the basement membrane of the duct or lobule. As these cells go through several doublings, at some point they invade through the basement membrane of the duct or lobule and ultimately metastasize to distant organs.

Time line of breast cancer suggesting probable heterogeneity. Primary breast cancers begin as single (or more) cells which have lost normal regulation of differentiation and proliferation but remain confined within the basement membrane of the duct or lobule. As these cells go through several doublings, at some point they invade through the basement membrane of the duct or lobule and ultimately metastasize to distant organs.

History

Breast cancer may be one of the oldest known forms of cancer tumors in humans. The oldest description of cancer (although the term cancer was not used) was discovered in Egypt and dates back to approximately 1600 BC. The Edwin Smith Papyrus describes 8 cases of tumors or ulcers of the breast that were treated by cauterization, with a tool called "the fire drill." The writing says about the disease, "There is no treatment. "For centuries, physicians described similar cases in their practices, with the same sad conclusion. It wasn't until doctors achieved greater understanding of the circulatory system in the 17th century that they could establish a link between breast cancer and the lymph nodes in the armpit. The French surgeon Jean Louis Petit (1674-1750) and later the Scottish surgeon Benjamin Bell (1749-1806) were the first to remove the lymph nodes, breast tissue, and underlying chest muscle. Their successful work was carried on by William Stewart Halsted who started performing mastectomies in 1882. He became known for his Halsted radical mastectomy, a surgical procedure that remained popular up to the 1970s.

Types of breast cancer

These are the pathological and clinical categories of breast cancer. There can be overlap between these categories; for example, a ductal carcinoma can also be an inflammatory breast cancer.

       Ductal carcinoma 65-90%
Lobular carcinoma 10%
Inflammatory breast cancer
Medullary carcinoma of the breast 5%
Colloid carcinoma 2%
Papillary carcinoma 1%
Metaplastic carcinoma
Triple Negative Breast Cancer

Symptoms

Early breast cancer can in some cases present as breast pain (mastodynia) or a painful lump. Since the advent of breast mammography, breast cancer is most frequently discovered as an asymptomatic nodule on a mammogram, before any symptoms are present. A lump under the arm or above the collarbone that does not go away may be present. When breast cancer associates with skin inflammation, this is known as inflammatory breast cancer. In inflammatory breast cancer, the breast tumor itself is causing an inflammatory reaction of the skin, and this can cause pain, swelling, warmth, and redness throughout the breast. Changes in the appearance or shape of the breast can raise suspicions of breast cancer.

Another reported symptom complex of breast cancer is Paget's disease of the breast. This syndrome presents as eczematoid skin changes at the nipple, and is a late manifestation of an underlying breast cancer.

Most breast symptoms do not turn out to represent underlying breast cancer. Benign breast diseases such as fibrocystic mastopathy, mastitis, functional mastodynia, and fibroadenoma of the breast are more common causes of breast symptoms. The appearance of a new breast symptom should be taken seriously by both patients and their doctors, because of the possibility of an underlying breast cancer at almost any age.

Occasionally, breast cancer presents as metastatic disease, that is, cancer that has spread beyond the original organ. Metastatic breast cancer will cause symptoms that depend on the location of metastasis. More common sites of metastasis include bone, liver, lung, and brain. Unexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills. Bone or joint pains can sometimes be manifestations of metastatic breast cancer, as can jaundice or neurological symptoms. Pleural effusions are not uncommon with metastatic breast cancer. Obviously, these symptoms are "non-specific," meaning they can also be manifestations of many other illnesses.

Epidemiologic risk factors and etiology

Epidemiological risk factors for a disease can provide important clues as to the etiology of a disease. The first work on breast cancer epidemiology was done by Janet Lane-Claypon, who published a comparative study in 1926 of 500 breast cancer cases and 500 control patients of the same background and lifestyle for the British Ministry of Health.

Today, breast cancer, like other forms of cancer, is considered to be the final outcome of multiple environmental and hereditary factors.

       1. Lesions to DNA such as genetic mutations. Exposure to estrogen has been experimentally linked to the mutations that cause breast cancer. Beyond the contribution of estrogen, research has implicated viral oncogenesis and the contribution of ionizing radiation.
2. Failure of immune surveillance, which usually removes malignancies at early phases of their natural history.
3. Abnormal growth factor signaling in the interaction between stromal cells and epithelial cells, for example in the angiogenesis necessary to promote new blood vessel growth near new cancers.
4. Inherited defects in DNA repair genes, such as BRCA1, BRCA2 and p53.

Although many epidemiological risk factors have been identified, the cause of any individual breast cancer is often unknowable. In other words, epidemiological research informs the patterns of breast cancer incidence across certain populations, but not in a given individual. Approximately 5% of new breast cancers are attributable to hereditary syndromes, while no etiology is known for the other 95% of cases.

Age

The risk of getting breast cancer increases with age. A woman who lives to age 90 has a lifetime risk of about 14.3%, or one in seven. The probability of breast cancer rises with age, but breast cancer tends to be more aggressive when it occurs in younger people. One type of breast cancer that is especially aggressive and that occurs disproportionately in younger people is inflammatory breast cancer. It is initially staged as Stage IIIb or Stage IV. It also is unique because it often does not present with a lump, so it is often undetected by mammography or ultrasound. It presents with the signs and symptoms of a breast infection like mastitis, and the treatment is usually a combination of surgery, radiation, and chemotherapy.

Sex

Men have a lower risk of developing breast cancer (approximately 1.08 per 100,000 men per year), but this risk appears to be rising.

Heredity

 In 5% of breast cancer cases, there is a strong inherited familial risk. Two autosomal dominant genes, BRCA1 and BRCA2, account for most of the cases of familial breast cancer. Family members who harbor mutations in these genes have a 60% to 80% risk of developing breast cancer in their lifetimes. Other associated malignancies include ovarian cancer and pancreatic cancer. If a mother or a sister was diagnosed breast cancer, the risk of a hereditary ‘’’BRCA1’’’ or ‘’’BRCA2’’’ gene mutation is about 2-fold higher than those women without a familial history. In addition to the BRCA genes associated with breast cancer, the presence of NBR2, near breast cancer gene 1, has been discovered, and research into its contribution to breast cancer pathogenesis is ongoing. Commercial testing for ‘’’BRCA1’’’ and ‘’’BRCA2’’’ gene mutations has been available since at least 2004. Genetic testing for BRCA gene mutations is conducted exclusively by Myriad Genetics, located in Salt Lake City.

Diet

Dietary influences have been proposed and examined, and recent research suggests that low-fat diets may significantly decrease the risk of breast cancer as well as the recurrence of breast cancer. Another study showed no contribution of dietary fat intake on the incidence of breast cancer in over 300,000 women. A randomized controlled study of the consequences of a low-fat diet, the Women's Health Initiative, failed to show a statistically significant reduction in breast cancer incidence in the group assigned to a low-fat diet, although the authors did find evidence of a benefit in the subgoup of women who followed the low-fat diet in a strict manner. Another randomized trial, the Nurses' Health Study II, found increased breast cancer incidence in premenopausal women only, with higher intake of animal fat, but not vegetable fat. Taken as a whole, these results point to a possible association between dietary fat intake and breast cancer incidence, though these interactions are hard to measure in large groups of women.

In a study published in the Journal of the American Medical Association, biomedical investigators found that Brassica vegetable intake (broccoli, cauliflower, cabbage, kale and Brussels sprouts) were inversely related to breast cancer development. The relative risk among women in the highest decile of Brassica vegetable consumption (median, 1.5 servings per day) compared to the lowest decile (virtually no consumption) was 58%. That is, women who consumed the most Brassica vegetables were 58% less likely to develop breast cancer.

A significant environmental effect is likely responsible for the different rates of breast cancer incidence between countries with different dietary customs. Researchers have long measured that breast cancer rates in an immigrant population soon come to resemble the rates of the host country after a few generations. The reason for this is speculated to be immigrant uptake of the host country diet. The prototypical example of this phenomenon is the changing rate of breast cancer after the arrival of Japanese immigrants to America.

Alcohol

Alcohol appears to increase the risk of breast cancer, though meaningful increases are limited to higher alcohol intake levels. Breast cancer constitutes about 7.3% of all cancers. Among women, breast cancer comprises 60% of alcohol-attributable cancers. The UK's Review of Alcohol: Association with Breast Cancer concludes that "studies confirm previous observations that there appears to be an association between alcohol intake and increased risk of breast cancer in women. On balance, there was a weak association between the amount of alcohol consumed and the relative risk."

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) concludes that "Chronic alcohol consumption has been associated with a small (averaging 10 percent) increase in a woman's risk of breast cancer." According to these studies, the risk appears to increase as the quantity and duration of alcohol consumption increases. Other studies, however, have found no evidence of such a link.

The Committee on Carcinogenicity of Chemicals in Food, Consumer Products Non-Technical Summary concludes, "the new research estimates that a woman drinking an average of two units of alcohol per day has a lifetime risk of developing breast cancer 8% higher than a woman who drinks an average of one unit of alcohol per day. The risk of breast cancer further increases with each additional drink consumed per day. The research also concludes that approximately 6% (between 3.2% and 8.8%) of breast cancers reported in the UK each year could be prevented if drinking was reduced to a very low level (i.e. less than 1 unit/week)."

A review article from JAMA also found that breast cancer incidence seems to increase with increasing alcohol consumption. It has been reported that "two drinks daily increase the risk of getting breast cancer by about 25 percent" (NCI), but the evidence is inconsistent. The Framingham study has carefully tracked individuals since the 1940s. Data from that research found that drinking alcohol moderately did not increase breast cancer risk (Wellness Facts). Similarly, research by the Danish National Institute for Public Health found that moderate drinking had virtually no effect on breast cancer risk.

One study suggests that women who frequently drink red wine may have an increased risk of developing breast cancer.

"Folate intake counteracts breast cancer risk associated with alcohol consumption" and "women who drink alcohol and have a high folate intake are not at increased risk of cancer." Those who have a high (200 micrograms or more per day) level of folate (folic acid or Vitamin B9) in their diet are not at increased risk of breast cancer compared to those who abstain from alcohol. Foods rich in folate include citrus fruits, citrus juices, dark green leafy vegetables (such as spinach), dried beans, and peas. Vitamin B9 can also be taken in a multivitamin pill.

Obesity

Gaining weight after menopause can increase a woman's risk. A recent study found that putting on 9.9kg (22lbs) after menopause increased the risk of developing breast cancer by 18%.

Hormones

Persistently increased blood levels of estrogen are associated with an increased risk of breast cancer, as are increased levels of the androgens androstenedione and testosterone (which can be directly converted by aromatase to the estrogens estrone and estradiol, respectively). Increased blood levels of progesterone are associated with a decreased risk of breast cancer in premenopausal women. A number of circumstances which increase exposure to endogenous estrogens including not having children, delaying first childbirth, not breastfeeding, early menarche (the first menstrual period) and late menopause are suspected of increasing lifetime risk for developing breast cancer.

Hormonal contraceptives may produce a slight increase in the risk of breast cancer diagnosis among current and recent users, but this appears to be a short-term effect. In 1996 the largest collaborative reanalysis of individual data on over 150,000 women in 54 studies of breast cancer found a relative risk (RR) of 1.24 of breast cancer diagnosis among current combined oral contraceptive pill users; 10 or more years after stopping, no difference was seen. Further, the cancers diagnosed in women who had ever used hormonal contraceptives were less advanced than those in nonusers, raising the possibility that the small excess among users was due to increased detection. The relative risk of breast cancer diagnosis associated with current and recent use of hormonal contraceptives did not appear to vary with family history of breast cancer.

Data exist from both observational and randomized clinical trials regarding the association between postmenopausal hormone replacement therapy (HRT) and breast cancer. The largest meta-analysis (1997) of data from 51 observational studies, indicated a relative risk of breast cancer of 1.35 for women who had used HRT for 5 or more years after menopause. The estrogen-plus-progestin arm of the Women's Health Initiative (WHI), a randomized controlled trial, which randomized more than 16,000 postmenopausal women to receive combined hormone therapy or placebo, was halted early (2002) because health risks exceeded benefits. One of the adverse outcomes prompting closure was a significant increase in both total and invasive breast cancers (RR = 1.24) in women randomized to receive estrogen and progestin for an average of 5 years. HRT-related breast cancers had adverse prognostic characteristics (more advanced stages and larger tumors) compared with cancers occurring in the placebo group, and HRT was also associated with a substantial increase in abnormal mammograms. Short-term use of hormones for treatment of menopausal symptoms appears to confer little or no breast cancer risk.

Environmental causes

Tobacco

Most studies have not found an increased risk of breast cancer from active tobacco smoking, although a number of studies suggest an increased risk of breast cancer in both active smokers and those exposed to secondhand smoke compared to women who reported no exposure to secondhand smoke.

Radiation

Women who have received high-dose ionizing radiation to the chest (for example, as treatments for other cancers) have a relative risk of breast cancer between 2.1 to 4.0.

Impact of environmental estrogenic mimics

Although environmental exposures are not generally cited as risk factors for the disease (except for diet, pharmaceuticals and radiation), a substantial and growing body of evidence indicates that exposures to certain toxic chemicals and hormone-mimicking compounds including chemicals used in pesticides, cosmetics and cleaning products contribute to the development of breast cancer. A recent Canadian study concluded that female farm workers are three times more likely to have breast cancer. The increasing prevalence of these substances in the environment may explain the increasing incidence of breast cancer, though direct evidence is sparse.

Dioxins

Although not well-quantified, there has long been a concern about risk associated with environmental estrogenic compounds, such as dioxins.

Light levels

Researchers at the National Cancer Institute and National Institute of Environmental Health Sciences have concluded a study that suggests that artificial light during the night can be a factor for breast cancer.

Viral breast cancer pathogenesis research

Humans are not the only mammals prone to breast cancer. Some strains of mice, namely the house mouse (Mus domesticus) are prone to breast cancer which is caused by infection with the mouse mammary tumor virus (MMTV or "Bittner virus" for its discoverer Hans Bittner), by random insertional mutagenesis. This finding is taken to mean that a viral etiology of human breast cancer is at least possible, though there is no definitive evidence to support the claim that MMTV causes human breast cancer. For example, there may be critical differences between cancer pathogenesis in mice and people. The understanding of the role of MMTV or other viruses in human breast cancer is preliminary as of May 2007.

Factors with minimal or no impact on breast cancer risk

Abortion

Studies in rats led to speculation that abortion may increase the risk of breast cancer because of hormones initiating breast tissue growth in early pregnancy. Some early interview and record based case-control studies indicated a possible correlation, but more recent record based studies and a large meta-analysis study do not support this association. The subject was examined by a National Cancer Institute (NCI) workshop in 2003, in response to the Bush Administration's alteration of the NCI's website to emphasize studies indicating a potential link. The NCI expert panel concluded, with the strongest level of evidence, that induced abortion is not associated with an increased breast cancer risk.

Deodorants

Much has been made of the possible contribution of aluminum-containing underarm antiperspirants to the incidence of breast cancer, since the most common location of a breast cancer is the upper outer quadrant of the breast. Aluminum salts, such as those used in anti-perspirants, have recently been classified as metalloestrogens. In research published in the Journal of Applied Toxicology, Dr. Philippa D. Darbre of the University of Reading has shown that aluminum salts increase estrogen-related gene expression in human breast cancer cells grown in the laboratory. Fortunately, this in-vitro association between aluminum salts and estrogen activity does not translate into an increased risk of breast cancer in humans. The lack of association between underarm deodorants and breast cancer has been the subject of a number of research articles.

Fertility treatments

There is no persuasive connection between fertility medications and breast cancer.

Phytoestrogens and soy

Phytoestrogens such as found in soybeans have been extensively studied in animal and human in-vitro and epidemiological studies. The literature support the following conclusions:

       1. Plant estrogen intake, such as from soy products, in early adolescence may protect against breast cancer later in life.
2. Plant estrogen intake later in life is not likely to influence breast cancer incidence either positively or negatively.

It seems reasonable to conclude that soybean-based phytoestrogens are not a major contributor to the incidence of breast cancer.

Prevention in high-risk individuals

Prophylactic oophorectomy

Prophylactic oophorectomy (removal of ovaries), in high-risk individuals, when child-bearing is complete, reduces the risk of developing breast cancer by 60%, as well as reducing the risk of developing ovarian cancer by 96%.

Managing side effects of prophylactic oophorectomy

Non-hormonal treatments

The side effects of Oophorectomy may be alleviated by medicines other than hormonal replacement. Non-hormonal biphosphonates (such as Fosamax and Actonel) increase bone strength and are available as once-a-week pills. Low-dose Selective Serotonin Reuptake Inhibitors (e.g. Paxil, Prozac) alleviate vasomotor menopausal symptoms, i.e. "hot flashes".

Hormonal treatments

Short-term hormone replacement with estrogen, in high-risk BRCA mutation carriers, was not shown to increase the risk of breast cancer in women who are post-oophorectomy. The results were published in JCO in 2004, and the conclusions based on a computerized simulation using models of risk and benefit, a lower level of data than a randomized trial per se. PMID 14981106. This result can probably be generalized to other women at high risk, in whom short term (i.e., one or two year) treatment with estrogen for hot flashes, may be acceptable.

Prophylactic mastectomy

Bilateral prophylactic mastectomies have been shown to prevent breast cancer in high-risk individuals, such as patients with BRCA1 or BRCA2 gene mutations.

Medications

Hormonal therapy has been used for chemoprevention in individuals at high risk for breast cancer. In 2002, a clinical practice guideline by the U.S. Preventive Services Task Force (USPSTF) recommended "clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention" with a grade B recommendation.

Selective estrogen receptor modulators (SERMs)

The guidelines were based on studies of SERMs from the MORE, BCPT P-1, and Italian trials. In the MORE trial, the relative risk reduction for raloxifene was 76%. The P-1 preventative study demonstrated that tamoxifen can prevent breast cancer in high-risk individuals. The relative risk reduction was up to 50% of new breast cancers, though the cancers prevented were more likely estrogen-receptor positive (this is analogous to the effect of finasteride on the prevention of prostate cancer, in which only low-grade prostate cancers were prevented). The Italian trial showed benefit from tamoxifen.

Additional randomized controlled trials have been published since the guidelines. The IBIS trial found benefit from tamoxifen. In 2006, the NSABP STAR trial demonstrated that raloxifene had equal efficacy in preventing breast cancer compared with tamoxifen, but that there were fewer side effects with raloxifene. The RUTH Trial concluded that "benefits of raloxifene in reducing the risks of invasive breast cancer and vertebral fracture should be weighed against the increased risks of venous thromboembolism and fatal stroke". Raloxifene is only FDA-approved for osteoporosis as of May 2007.

Aromatase inhibitors

Aromatase inhibitors may prove to prevent breast cancer.

Screening

X-ray mammography

Due to the high incidence of breast cancer among older women, screening is now recommended in many countries. Recommended screening methods include breast self-examination and mammography. Mammography has been estimated to reduce breast cancer-related mortality by 20-30%. Routine (annual) mammography of women older than age 40 or 50 is recommended by numerous organizations as a screening method to diagnose early breast cancer and has demonstrated a protective effect in multiple clinical trials. The evidence in favor of mammographic screening comes from eight randomized clinical trials from the 1960s through 1980s. Many of these trials have been criticized for methodological errors, and the results were summarized in a review article published in 1993.

Improvements in mortality due to screening are hard to measure; similar difficulty exists in measuring the impact of Pap smear testing on cervical cancer, though worldwide, the impact of that test is likely enormous. Nationwide mortality due to cancer before and after the institution of a screening test is a surrogate indicator about the effectiveness of screening, and results of mammography are favorable.

The U.S. National Cancer Institute recommends screening mammography with a baseline mammogram at age 35, mammograms every two years beginning at age 40, and then annual mammograms beginning at age 50. In the UK, women are invited for screening once every three years beginning at age 50. Women with one or more first-degree relatives (mother, sister, daughter) with premenopausal breast cancer should begin screening at an earlier age. It is usually suggested to start screening at an age that is 10 years less than the age at which the relative was diagnosed with breast cancer.

Part of the difficulty in interpreting mammograms in younger women stems from the problem of breast density. Radiographically, a dense breast has a preponderance of glandular tissue, and younger age or estrogen hormone replacement therapy contribute to mammographic breast density. After menopause, the breast glandular tissue gradually is replaced by fatty tissue, making mammographic interpretation much more accurate. Some authors speculate that part of the contribution of estrogen hormone replacement therapy to breast cancer mortality arises from the issue of increased mammographic breast density. Breast density is an independent adverse prognostic factor on breast cancer prognosis.

Several scientific groups however have expressed concern about the public's perceptions of the benefits of breast screening. In 2001, a controversial review published in The Lancet claimed that there is no reliable evidence that screening for breast cancer reduces mortality. The results of this study were widely reported in the popular press.

False positives are a major problem of mammographic breast cancer screening. Data reported in the UK Million Woman Study indicates that if 134 mammograms are performed, 20 women will be called back for suspicious findings, and four biopsies will be necessary, to diagnose one cancer. Recall rates are higher in the U.S. than in the UK. The contribution of mammography to the early diagnosis of cancer cannot be overstated, but it comes at a huge financial and psychological cost to the women found to have a nodule.

In general, digital mammography and computer-aided mammography have increased the sensitivity of mammograms, but at the cost of more numerous false positive results.

Mammography is still the modality of choice for screening of early breast cancer, since it is relatively fast, reasonably accurate, and widely available in developed countries. Breast cancers detected by mammography are usually much smaller (earlier stage) than those detected by patients or doctors as a breast lump.

Breast MRI

Magnetic resonance imaging (MRI) has been shown to detect cancers not visible on mammograms, but has long been regarded to have disadvantages. For example, although it is 27-36% more sensitive, it is less specific than mammography. As a result, MRI studies will have more false positives (up to 5%), which may have undesirable financial and psychological costs. It is also a relatively expensive procedure, and one which requires the intravenous injection of a chemical agent to be effective. Proposed indications for using MRI for screening include:

       Strong family history of breast cancer
Patients with BRCA-1 or BRCA-2 oncogene mutations
Evaluation of women with breast implants
History of previous lumpectomy or breast biopsy surgeries
Axillary metastasis with an unknown primary tumor
Very dense or scarred breast tissue

However, two studies published in 2007 demonstrated the strengths of MRI-based screening:

       In March 2007, an article published in the New England Journal of Medicine demonstrated that in 3.1% of patients with breast cancer, whose contralateral breast was clinically and mammographically tumor-free, MRI could detect breast cancer. Sensitivity for detection of breast cancer in this study was 91%, specificity 88%.
In August 2007, an article published in The Lancet compared MRI breast cancer screening to conventional mammographic screening in 7,319 women. MRI screening was highly more sensitive (97% in the MRI group vs. 56% in the mammography group) in recognizing early high-grade Ductal Carcinoma in situ (DCIS), the most important precursor of invasive carcinoma. Despite the high sensitivity, MRI screening had a positive predictive value of 52%, which is totally accepted for cancer screening tests. The author of a comment published in the same issue of The Lancet concludes that "MRI outperforms mammography in tumor detection and diagnosis."

Breast ultrasound

Ultrasound alone is not usually employed as a screening tool but it is a useful additional tool for the characterization of palpable tumors and directing image-guided biopsies. U-Systems is a US-based company that is selling a breast-cancer detection system using ultrasound that is fully-automated. Using an ultrasound allows a look at dense breast tissue which is not possible with digital mammography. It is closely correlated with the digital mammography. The other significant advantage over digital mammography is that it is a pain-free procedure.

Breast self-exam

Breast self-exam was widely discussed in the 1990s as a useful modality for detecting breast cancer at an earlier stage of presentation. A large clinical trial in China reduced enthusiasm for breast self-exam. In the trial, reported in the Journal of the National Cancer Institute first in 1997 and updated in 2002, 132,979 female Chinese factory workers were taught by nurses at their factories to perform monthly breast self-exam, while 133,085 other workers were not taught self-exam. The women taught self-exam tended to detect more breast nodules, but their breast cancer mortality rate was no different from that of women in the control group. In other words, women taught breast self-exam were mostly likely to detect benign breast disease, but were just as likely to die of breast cancer. An editorial in the Journal of the National Cancer Institute reported in 2002, "Routinely Teaching Breast Self-Examination is Dead. What Does This Mean?"

Diagnosis

The diagnosis of breast cancer is established by the pathological (microscopic) examination of surgically removed breast tissue. A number of procedures can obtain tissue or cells prior to definitive treatment for histological or cytological examination. Such procedures include fine-needle aspiration, nipple aspirates, ductal lavage, core needle biopsy, and local surgical excisional biopsy. These diagnostic steps, when coupled with radiographic imaging, are usually accurate in diagnosing a breast lesion as cancer. 

Occasionally, pre-surgical procedures such as fine needle aspirate may not yield enough tissue to make a diagnosis, or may miss the cancer entirely. Imaging tests are sometimes used to detect metastasis and include chest x-ray, bone scan, CT, MRI, and PET scanning. While imaging studies are useful in determining the presence of metastatic disease, they are not in and of themselves diagnostic of cancer. Only microscopic evaluation of a biopsy specimen can yield a cancer diagnosis. Ca 15.3 (carbohydrate antigen 15.3, epithelial mucin) is a tumor marker determined in blood which can be used to follow disease activity over time after definitive treatment. Blood tumor marker testing is not routinely performed for the screening of breast cancer, and has poor performance characteristics for this purpose.

Breast cancer is staged according to the TNM system, updated in the AJCC Staging Manual, now on its sixth edition. Prognosis is closely linked to results of staging, and staging is also used to allocate patients to treatments both in clinical trials and clinical practice.

Summary of stages:

        Stage 0 Carcinoma in situ
 Stage I Tumor (T) does not exceed 2 cm, no axillary lymph nodes (N) involved.
 Stage IIA T 2-5 cm, N negative, or T <2 cm and N positive.
 Stage IIB T > 5 cm, N negative, or T 2-5 cm and N positive (< 4 axillary nodes).
 Stage IIIA T > 5 cm, N positive, or T 2-5 cm with 4 or more axillary nodes
 Stage IIIB T has penetrated chest wall or skin, and may have spread to < 10 axillary N
 Stage IIIC T has > 10 axillary N, 1 or more supraclavicular or infraclavicular N, or internal mammary N.
 Stage IV Distant metastasis (M)

Breast lesions are examined for certain markers, notably sex steroid hormone receptors. About two thirds of postmenopausal breast cancers are estrogen receptor positive (ER+) and progesterone receptor positive (PR+). Receptor status modifies the treatment as, for instance, only ER-positive tumors, not ER-negative tumors, are sensitive to hormonal therapy.

The breast cancer is also usually tested for the presence of human epidermal growth factor receptor 2, a protein also known as HER2, neu or erbB2. HER2 is a cell-surface protein involved in cell development. In normal cells, HER2 controls aspects of cell growth and division. When activated in cancer cells, HER2 accelerates tumor formation. About 20-30% of breast cancers overexpress HER2. Those patients may be candidates for the drug Herceptin, both in the postsurgical setting (so-called "adjuvant" therapy), and in the metastatic setting.

Treatment personalization with gene expression profiling

Recently, the acceleration of gene expression profiling research has made available additional markers to predict disease recurrence. Beyond conventional TNM staging, doctors can now order a gene expression profile on tumors to predict whether a breast cancer patient will have a high chance of developing breast cancer again. There are currently 2 commercial tests on the market, MammaPrint and Oncotype DX. Oncotype DX is not used in every clinical setting; for example, in a patient with positive lymph nodes who is a candidate for chemotherapy, the test would not change therapy decisions. The most useful setting for Oncotype DX testing is where there are negative lymph nodes, and the benefit of chemotherapy is felt to be small. In up to 10% of patients, there will be disease recurrences, but treating every patient with chemotherapy is overkill. In this setting, a high-risk score on the Oncotype DX can help doctors decide whether to recommend chemotherapy.

Treatment

The mainstay of breast cancer treatment is surgery when the tumor is localized, with possible adjuvant hormonal therapy (with tamoxifen or an aromatase inhibitor), chemotherapy, and/or radiotherapy. At present, the treatment recommendations after surgery (adjuvant therapy) follow a pattern. This pattern is subject to change as every two years a worldwide conference takes place in St. Gallen, Switzerland to discuss the actual results of worldwide multi-center studies. Depending on clinical criteria (age, type of cancer, size, metastasis) patients are roughly divided to high risk and low risk cases which follow different rules for therapy. Treatment possibilities include Radiation Therapy, Chemotherapy, Hormone Therapy, and Immune Therapy.

An online resource for helping to quantify the relative risks and benefits of chemotherapy and hormonal therapy is Adjuvant!.

In planning treatment, doctors can also use PCR tests like Oncotype DX or micro array tests like MammaPrint that predict breast cancer recurrence risk based on gene expression. In February 2007, the MammaPrint test became the first breast cancer predictor to win formal approval from the Food and Drug Administration. This is a new gene test to help predict whether women with early stage breast cancer will relapse in five or 10 years, this could help influence how aggressively they fight the initial tumor.

Surgery

Depending on the staging and type of the tumor, just a lumpectomy (removal of the lump only) may be all that is necessary or removal of larger amounts of breast tissue may be necessary. Surgical removal of the entire breast is called mastectomy.

While there has been an increasing utilization of lumpectomy techniques for breast-conservation cancer surgery, mastectomy may be the preferred treatment in certain instances:

       Two or more tumors exist in different areas of the breast (a "multifocal" cancer).
The breast has previously received radiation (XRT) treatment.
The tumor is large relative to the size of the breast.
The patient has had scleroderma or another disease of the connective tissue, which can complicate XRT treatment.
The patient lives in an area where XRT is inaccessible.
The patient is apprehensive about their risk of local recurrence after lumpectomy.

Standard practice requires the surgeon to establish that the tissue removed in the operation has margins clear of cancer, indicating that the cancer has been completely excised. If the tissue removed does not have clear margins, then further operations to remove more tissue may be necessary. This may sometimes require removal of part of the pectoralis major muscle which is the main muscle of the anterior chest wall.

During the operation, the lymph nodes in the axilla are also considered for removal. In the past, large axillary operations took out ten to forty nodes to establish whether cancer had spread. This had the unfortunate side effect of frequently causing lymphedema of the arm on the same side, as the removal of this many lymph nodes affected lymphatic drainage. More recently, the technique of sentinel lymph node (SLN) dissection has become popular, as it requires the removal of far fewer lymph nodes, resulting in fewer side effects. The sentinel lymph node is the first node that drains the tumor, and subsequent SLN mapping can save 65-70% of patients with breast cancer from having a complete lymph node dissection for what could turn out to be a negative nodal basin. Advances in Sentinel Lymph Node mapping over the past decade have increased the accuracy of detecting Sentinel Lymph Node from 80% using blue dye alone to between 92% and 98% using combined modalities. SLN biopsy is indicated for patients with T1 and T2 lesions (<5cm) and carries a number of recommendations for use on patient subgroups.

Radiation therapy

Radiation therapy consists of the use of high powered X-rays or gamma rays (XRT) that precisely target the area that is being treated. These X-rays or gamma rays are very effective in destroying the cancer cells that might recur where the tumor was removed. These X-rays are delivered by a machine called a linear Accelerator or LINAC. Alternatively, the use of implanted radioactive catheters (brachytherapy), similar to those used in prostate cancer treatment, is being evaluated. The use of radiation therapy for breast cancer is usually given after surgery has been performed and is an essential component of breast conserving therapy. The purpose of radiation is to reduce the chance that the cancer will recur. Radiation therapy works for breast cancer by eliminating the microscopic cancer cells that may remain near the area where the tumor was removed during surgery. Since by the nature of radiation and its effects on normal cells and cancer cells alike the dose that is given is to ensure that the cancer cells are eliminated. However, the dose cannot be given in one sitting. Radiation causes some damage to the normal tissue around where the tumor was but normal healthy tissue can repair itself. The treatments are given typically over a period of five to seven weeks, performed five days a week. Each treatment session takes about fifteen minutes per day. Breaking the treatments up over this extended period of time gives the healthy normal tissue a chance to repair itself. Cancer cells do not repair themselves as well as normal cells, which explains the efficacy of radiation therapy.

Although radiation therapy can reduce the chance that breast cancer will recur in the breast, it is much less effective in prolonging patient survival. The National Cancer Institute reviews this information in a paragraph that begins: “Breast-conserving surgery alone without radiation therapy . . .” The NCI includes six studies; none of them found a survival benefit for radiation therapy. Abstracts from all six studies are available for review. Patients who are unable to have radiation therapy after lumpectomy should consult with a surgeon who understands this research and who believes that lumpectomy (or partial mastectomy) alone is a reasonable treatment option.

Indications for radiation

Indications for radiation treatment are constantly evolving. Patients treated in Europe have been more likely in the past to be recommended adjuvant radiation after breast cancer surgery. Radiation therapy is usually recommended for all patients who had (lumpectomy, quadrant-resection). Radiation therapy is usually not indicated in patients with advanced (stage IV disease) except for palliation of symptoms like bone pain. In general recommendations would include:

       As part of breast conserving therapy of breast cancer when the whole breast is not removed (lumpectomy or wide local excision)
After mastectomy: Patients with higher chances of cancer recurring such as : large primary tumor and involvement of 4 or more lymph nodes.

Other factors which may influence adding adjuvant radiation therapy:

       Tumor close to or involving the margins on pathology specimen
Multiple areas of tumor (multicentric disease)
Microscopic invasion of lymphatic or vascular tissues
Microscopic invasion of the skin, nipple/areola, or underlying pectoralis major muscle
Patients with <4 LN involved, but extension out of the substance of a LN
Inadequate numbers of axillary LN sampled

Types of radiotherapy

Radiotherapy can be delivered in many ways. Most commonly this is done using radiation from linear accelerators. Since this is delivered from outside, one needs to restrict the amount of dose that can be given at one time so that normal tissues are not harmed. So the course usually lasts for several days, typically every day for 5 to 6 weeks.

New technology has allowed more precise delivery of radiotherapy in a portable fashion - for example in the operating theatre. Targeted intraoperative radiotherapy (TARGIT) is a method of delivering therapeutic radiation from within the breast using a portable x-ray generator called Intrabeam. It is undergoing clinical trials in several countries at present to test whether it can replace the whole course of radiotherapy in selected patients. It may also be able provide a much better boost dose to the tumor bed and appears to provide superior control. This will be tested in a TARGIT-B trial.

Side effects of radiation therapy

The side effects of radiation have decreased considerably over the past decades. Aside from general fatigue caused by the healthy tissue repairing itself, there will probably be no side effects at all. Some patients develop a suntan-like change in skin color in the exact area being treated. As with a suntan, this darkening of the skin will fade with time. Other side effects experienced with radiation include the fact that radiation therapy can and often does cause permanent changes in the color and texture of skin, in addition to:

       reddening of the skin
muscle stiffness
mild swelling
tenderness in the area
long-term shrinking of the irradiated breast

Along with improved cosmetic outcome of treatment with radiation, there have been improvements in the techniques that deliver radiation to the breast. One such new technology is using IMRT (intensity modulated radiation therapy), in which the radiation oncologist can change the shape and intensity of the radiation beam at different points across and inside the breast. This allows for a more focused beam of radiation directed at the tumor cells and leaves most of the healthy tissue unaffected by the radiation.

Another new procedure involves a type of brachytherapy, where a radioactive source is temporarily placed inside the breast in direct contact with the tumor bed (area where tumor was removed). This technique is called a Mammosite and is currently undergoing clinic trials.

The use of adjuvant radiation has significant potential effects if the patient has to later undergo breast reconstruction surgery. Fibrosis of chest wall skin from radiation negatively affects skin elasticity and makes tissue expansion techniques difficult. Traditionally most patients are advised to defer immediate breast reconstruction when adjuvant radiation is planned and are most often recommended surgery involving autologous tissue reconstruction rather then breast implants.

Systemic therapy

Systemic therapy uses medications to treat cancer cells throughout the body. Any combination of systemic treatments may be used to treat breast cancer. Systemic treatments include chemotherapy, immune therapy, and hormonal therapy.

Chemotherapy

Chemotherapy (drug treatment for cancer) may used before surgery, after surgery, or instead of surgery in those patients who are unsuitable for surgery.

Hormonal treatment

Patients with estrogen receptor positive tumors will typically receive hormonal therapy after chemotherapy is completed. Typical hormonal treatments include:

       Tamoxifen is typically given to premenopausal women to inhibit the estrogen receptors
Aromatase inhibitors are typically given to postmenopausal women to lower the amount of estrogen in their systems
GnRH-analogues
ovarian ablation or suppression is used in premenopausal women

Targeted therapy

In patients whose cancer expresses an over-abundance of the HER2 protein, a monoclonal antibody known as trastuzumab (Herceptin ®) is used to block the activity of the HER2 protein in breast cancer cells, slowing their growth. This drug was originally used only in the treatment of patients with metastatic disease, however in the summer of 2005 two large clinical trials published results suggesting that patients with early-stage disease also benefit significantly from Herceptin. The drug was approved by the FDA in 1998 for the treatment of metastatic breast cancer, though oncologists have also been using it since 2005 for postoperative patients with localized, Her-2/neu positive disease. 

Antiangiogenic therapy

A commercially-available monoclonal antibody that blocks the activation of the VEGF receptor, bevacizumab, underwent testing in a randomized clinical trial in . There has been no formal publication of the data in the peer-reviewed literature as of May, 2007. The data indicate that bevacizumab delays disease progression for up to five months over conventional chemotherapy, but survival was no better. Genentech, manufacturer of bevacizumab, has filed a supplemental biological application with the FDA for approval of bevacizumab in the setting of metastatic breast cancer, on the strength of the improvement in progression-free survival.

Preclinical

Protein tyrosine phosphatase 1B (PTP1B)

In the March 2007, edition of the scientific journal, Nature Genetics, researchers from Canada's McGill University reported that they have developed a potential drug target for treating up to 40 percent of breast cancers by blocking an enzyme called protein tyrosine phosphatase 1B (PTP1B), which has been implicated in the onset of breast cancer in mouse models of the disease. Elevated levels of PTP1B have also been found in diabetes and obesity.

A drug to block the activity of PTP1B is under development by Merck, and was found to delay the development of breast tumors and prevent lung cancer up to two months from the administration of the drug. The researchers hope to continue further research in mouse models which are also HER-2 positive (responsive to Herceptin) so that the drug could benefit a significant population of women.

Flax seeds

Preliminary research into flax seeds indicate that flax can significantly change breast cancer growth and metastasis, and enhance the inhibitory effect of tamoxifen on estrogen-dependent tumors.

Traditional Chinese medicine

The use of traditional Chinese medicine to treat breast cancer has been claimed, but no successful clinical trials have yet been reported.

Psychological aspects of breast cancer diagnosis and treatment

The emotional impact of cancer diagnosis, symptoms, treatment, and related issues can be severe. Most larger hospitals are associated with cancer support groups which can help patients cope with the many issues that come up in a supportive environment with other people with experience with similar issues. Online cancer support groups are also very beneficial to cancer patients, especially in dealing with uncertainty and body-image problems inherent in cancer treatment.

Prognosis

There are several prognostic factors associated with breast cancer. Stage is the single most important prognostic factor in breast cancer, as it will take into consideration local involvement, lymph node status and whether metastatic disease is present or not. The higher the stage at the time of diagnosis, the worse the prognosis of breast cancer is. Node negative breast cancer patients have a much better prognosis compared to node positive patients.

Presence of estrogen and progesterone receptors in the cancer cell is another important prognostic factor, and may guide treatment. Hormone receptor positive breast cancer is usually associated with much better prognosis compared to hormone negative breast cancer.

HER2/neu status has also been described as a prognostic factor. Patients whose cancer cells are positive for HER2/neu have more aggressive disease and may be treated with trastuzumab, a monoclonal antibody that targets this protein.

Breast cancer in males

Less than 1% of breast cancers occur in men, and incidence is about 1 in 100,000. Men with gynecomastia do not have a higher risk of developing breast cancer. There may be an increased incidence of breast cancer in men with prostate cancer. The prognosis, even in stage I cases, is worse in men than in women. The treatment of men with breast cancer is similar to that in older women. Since the male breast tissue is confined to the area directly behind the nipple, treatment for males has usually been a mastectomy with axillary surgery. This may be followed by adjuvant radiotherapy, hormone therapy (such as tamoxifen), or chemotherapy.

Breast cancer metastasis

Most people understand breast cancer as something that happens in the breast. However it can metastasize (spread) via lymphatics to nearby lymph nodes, usually those under the arm. That is why surgery for breast cancer always involves some type of surgery for the glands under the arm — either axillary clearance, sampling, or sentinel node biopsy. Breast cancer can also spread to other parts of the body via blood vessels. So it can spread to the lungs, pleura (the lining of the lungs), liver, brain, and most commonly to the bones.

Seventy percent of the time that breast cancer spreads to other locations, it spreads to bone, especially the vertebrae and the long bones of the arms, legs, and ribs. Breast cancer cells "set up house" in the bones and form tumors. Usually when breast cancer spreads to bone, it eats away healthy bone, causing weak spots, where the bones can break easily. That is why breast cancer patients are often seen wearing braces or using a wheelchair, and why they complain about aching bones.

When breast cancer is found in bones, it has usually spread to more than one site. At this stage, it is treatable, often for many years, but it is not curable. Like normal breast cells, these tumors in the bone often thrive on female hormones, especially estrogen. Therefore, the doctor often treats the patient with medicines that lower her estrogen levels.

Breast cancer awareness

In the month of October, breast cancer is recognized by survivors, family and friends of survivors and/or victims of the disease. A pink ribbon is worn to recognize the struggle that sufferers face when battling the cancer.

Pink for October is an initiative started by Matthew Oliphant, which asks that any sites willing to help make people aware of breast cancer, change their template or layout to include the color pink, so that when visitors view the site, they see that the majority of the site is pink. Then after reading a short amount of information about breast cancer, or being redirected to another site, they are aware of the disease itself.

continue to page 2


Contact Us || CRC Home Page || Top Oncologists Search Engine

Copyright © Consumers' Research Council of America. All rights reserved.