is a common cause of discrete benign breast lumps in young women. It generally occurs in women between 15 and 25 years of age. It is the most frequent cause of breast masses in women under 25 years of age.
tend to develop more frequently and at a younger age in African American women.12
The possible cause of fibroadenoma
may be increased estrogen sensitivity in a localized area of the breast. Fibroadenomas are usually small (but can be large [2 to 3 cm]), painless, round, well delineated, and very mobile. They may be soft but are usually solid, firm, and rubbery in consistency. There is no accompanying retraction or nipple discharge. The lump is often painless. The fibroadenoma may appear as a single unilateral mass, although multiple bilateral fibroadenomas have been reported. Growth is slow and often ceases when size reaches 2 to 3 cm. Size is not affected by menstruation. However, pregnancy can stimulate dramatic growth.
Fibroadenomas are rarely associated with __________.
NURSING and COLLABORATIVE MANAGEMENT: FIBROADENOMA
Fibroadenomas are easily detected by physical examination and are often visible on mammography and ultrasound. Definitive diagnosis, however, requires biopsy and tissue examination by a pathologist.
Treatment of fibroadenomas
can include surgical excision, which is not urgent in women less than 25 years of age. In women over 35 years of age all new lesions should be evaluated by breast ultrasound and possible biopsy.
Fibroadenomas are not reduced by
radiation and are not affected by hormone therapy.
As an alternative to surgery, tumor removal can be accomplished using __________after an established diagnosis of a fibroadenoma. In this procedure a cryoprobe is inserted into the tumor using ultrasound guidance. Extremely cold gas is piped into the tumor. The frozen tumor dies and gradually shrinks.
The nurse frequently has the opportunity to counsel a young woman with fibroadenomas. During this contact the _______________of the lesion should be stressed and follow-up examinations should be encouraged.
GYNECOMASTIA IN MEN
a transient (comes and goes), noninflammatory enlargement of one or both breasts, is the most common breast problem in men. The condition is usually temporary and benign.
Gynecomastia in itself is not an established risk factor for___________.
The most common cause of gynecomastia
is a disturbance of the normal ratio of active androgen to estrogen in plasma or within the breast itself.
Gynecomastia may also be a manifestation of ________________. It is seen accompanying developmental abnormalities of the male reproductive organs. It may also accompany organic diseases, including testicular tumors, cancer of the adrenal cortex, pituitary adenomas, hyperthyroidism, and liver disease.
Gynecomastia may occur as a side effect of ________________, particularly with administration of estrogens and androgens, digitalis, isoniazid (INH) (treats TB), ranitidine (Zantac), and spironolactone (Aldactone). Use of heroin and marijuana can also cause gynecomastia.
caused by increased estrogen production is seen most often in boys between ages 13 and 17. It is usually limited, although occasionally the localized hyperplasia may measure 2 to 3 cm in size. Pubertal gynecomastia is almost always self-limiting, and disappears within 4 to 6 months of onset. Parents and the affected boy should be reassured that in almost all cases this is a normal physiologic phenomenon that will disappear spontaneously and will require no treatment. Rarely, unilateral gynecomastia in the young male may be marked and fail to regress. This is the only indication for surgical intervention (i.e., mastectomy).
Senescent (growing old/aging) Gynecomastia
occurs in 40% of older men. A probable cause is the elevation in plasma estrogen in older adult men as the result of increased conversion of androgens to estrogens in peripheral circulation. Although initially unilateral, the tender, firm, centrally located enlargement may become bilateral. When gynecomastia is characterized by a discrete, circumscribed mass, it must be diagnosed to differentiate it from the rarer breast cancer in males. Senescent hyperplasia requires no treatment and generally regresses within 6 to 12 months.
(dilation of any tubular tissue) is a benign breast disease of perimenopausal and postmenopausal women involving the ducts in the subareolar area. It usually involves several bilateral ducts. Nipple discharge is the primary symptom. This discharge is multicolored and sticky.
is initially painless but may progress to burning, itching, and pain around the nipple, as well as swelling in the areolar area. Inflammatory signs are often present, the nipple may retract, and the discharge may become bloody in more advanced disease.
-is not associated with malignancy. If an abscess develops, warm compresses and antibiotics are usually effective treatments. Therapy consists of close follow-up examinations or surgical excision of the involved ducts.
-Mass that feels hard, irregular borders, tender. Undistinguishable from cancer with testing.
may occur spontaneously or as a result of nipple manipulation.
A milky secretion is due to inappropriate lactation, ______________ as a result of such problems as drug therapy, endocrine problems, and neurologic disorders. Nipple discharge may also be idiopathic.
NIPPLE DISCHARGE: Secretions
can also be serous, grossly bloody, or brown to green. These may be caused by either benign or malignant disease. A slide can be made of the secretion to detect specific disease.
Diseases associated with nipple discharge
include malignancies, cystic disease, intraductal papilloma, and ductal ectasia.
NIPPLE DISCHARGE: Treatment
depends on identification of the cause. Warm Compresses & appropriate antibiotics. Surgical excision of ducts. In most cases, nipple discharge is not related to malignancy.
If galactorrhea is accompanied by various
____________ gynecologic endocrinopathies should be explored.
"Pedunculated"- outgrowth of tissue in stem-like fashion
An intraductal papilloma is a benign, wartlike growth found in the mammary ducts, usually near the nipple. Typically, there is an associated bloody nipple discharge, a mass, or both. Intraductal papillomas usually affect women 40 to 60 years of age. A single duct or several ducts may be involved. Treatment includes excision of the papilloma and the involved duct or duct system.
outgrowth of tissue in stem-like fashion
GERONTOLOGIC CONSIDERATIONS, AGE-RELATED BREAST CHANGES
Loss of subcutaneous fat and structural support and atrophy of mammary glands often result in pendulous breasts in the postmenopausal woman. The nurse should encourage older women to wear a well-fitting bra. Adequate support can improve physical appearance and reduce pain in the back, shoulders, and neck. It can also prevent intertrigo (dermatitis caused by friction between opposing surfaces of skin). Surgical lifting of sagging breasts is possible and may be desirable when reconstruction after a mastectomy is performed.
The decrease in glandular tissue in older women makes a breast mass easier to palpate. This decreased density is probably age related and occurs even with women on hormone replacement therapy, but to a lesser degree. Rib margins may be palpable in the older adult woman and can be confused with a mass. As a woman becomes more familiar with her own breasts and is reassured about her findings, the anxiety about this finding should decrease. The nurse should encourage the older woman to continue BSE and to have annual mammograms and clinical examinations because the incidence of breast cancer increases with age.
It can also prevent _____________(dermatitis caused by friction between opposing surfaces of skin)
early detection is key.
5 year survival rate is 97% if not spread. If spread to regional lymph nodes, than 79%, if spread further, than 23%
most common malignancy in American women
Breast cancer is the __________________________ except for skin cancer.
It is ____________ only to lung cancer as the leading cause of death from cancer in women. Over 211,000 new cases of breast cancer are diagnosed in women in the United States each year. About 1700 new cases are diagnosed in men.1 Each year in the United States, approximately 40,870 deaths (40,410 women and 460 men) occur related to breast cancer.
The incidence rate of breast cancer is _____________________, with a slight decline in the number of deaths related to breast cancer. The largest decreases have been noted in younger women, including both African American and white women.
-1, While in the shower or bath, when the skin is slippery with soap and water, examine your breasts. Use the pads of your second, third, and fourth fingers to firmly press every part of the breast. While examining your left breast, use your right hand, and use your left hand to examine your right breast. Using the pads of the fingers on your left hand, examine the entire breast using small circular motions in a spiral or in an up-and-down motion so that the entire breast area is examined. Repeat the procedure using your right hand to examine your left breast. Repeat pattern of palpation under the arm. Check for any lump, hard knot, or thickening of the tissue.
-2, Look at your breasts in a mirror. Stand with your arms at your sides.
-3, Raise your arms overhead and check for any changes in the shape of your breasts, dimpling of the skin, or any changes in the nipple.
-4, Next, place your hands on your hips and press down firmly, tightening the pectoral muscles. Observe for asymmetry or changes, keeping in mind that your breasts probably do not exactly match.
-5, While lying down, feel your breasts as described in step 1. When examining your right breast, place a folded towel under your right shoulder and put your right hand behind your head. Repeat the procedure while examining your left breast.
are the most easily recognized mammogram abnormality. These deposits of calcium crystals form in the breast for many reasons, such as inflammation, trauma, and aging. Although most calcifications are benign, they also may be associated with preinvasive cancer.
current and prior mammograms
A comparison of ______________________may show early cancer tissue changes. Because some tumors metastasize late in the preclinical course, early detection by mammography allows for early treatment and the prevention of metastasis of these smaller lesions.
In younger women
mammography is less sensitive because of the greater density of breast tissue, resulting in more false-negative results.6 About 10% to 15% of all breast cancers cannot be seen on mammography and are detected only by palpation.
Suspicious masses should be ______________ even if mammogram findings are unremarkable.
Ultrasound is particularly useful in women with fibrocystic changes whose breasts are very dense. Unlike a mammogram, an ultrasound will not detect ___________________
is another diagnostic procedure that can be used to differentiate a benign tumor from a malignant tumor.
Magnetic resonance imaging
(MRI) may be used as a more sensitive nonspecific screening tool for women at high risk for breast cancer, or in women whose mammography or ultrasound is suspicious for malignancy. Limitations to MRI use include its high cost and greater rate of false positives when compared with mammography.
A definitive diagnosis of a suspicious area is often made by means of_________________________of biopsied tissue.
Biopsy techniques include_______________________(FNA) biopsy, stereotactic or ultrasound core biopsy, and open surgical biopsy.
is performed by inserting a needle into the lesion and aspirating cellular fluid into a syringe. Three or four passes are usually made.
FNA and cytologic
evaluation may be helpful in making a diagnosis and planning treatment. It should be done only if an experienced cytologist is available and all suspicious lesions read as negative are followed with a more definitive biopsy procedure.
If the aspirated specimen is positive for _________________, the patient can be given this information at the same visit.
Stereotactic and ultrasound core biopsy
are reliable diagnostic techniques for obtaining a biopsy of an abnormality seen on a mammogram. In this procedure mammography is used to locate the lesion. The skin is anesthetized, and a small skin incision is made to allow the entrance of a biopsy gun device. The gun is fired and removes a core sample of the lesion. This is repeated several times, and the core samples are sent for pathologic analysis. This technique has several advantages over an open surgical biopsy, including minimal scarring, the use of local anesthesia, outpatient procedure, reduced cost, and shorter recovery time.
Staging of Breast Cancer: stage I
tumor size: < 2cm
lymph node involvment: no
Staging of Breast Cancer: stage II A
tumor size: no evidence of tumor ranges to 5cm
lymph node involvment: no or 1-3 axilliary and/or internal mammary nodes
Staging of Breast Cancer: stage II B
tumor size: ranges to 2-<5cm
lymph node involvment: no or 1-3 axilliary and/or internal mammary nodes
Staging of Breast Cancer: stage IIIA
tumor size: ranges to >5cm
lymph node involvment: yes 4-9 axilliary and/or internal mammary nodes
Staging of Breast Cancer: stage IIIB
tumor size: any size with extension to chest wall or skin
lymph node involvment: yes 4-9 axilliary and/or internal mammary nodes
Staging of Breast Cancer: stage IIIC
tumor size: any size
lymph node involvment: yes 10 or more axilliary and/or internal mammary nodes
Staging of Breast Cancer: stage IV
tumor size: any size
lymph node any type of nodal involvement
The stages range from I to IV
with stage I being very small tumors (less than 2 cm) with no lymph node involvement and no metastasis. Further classification within these stages depends on the size of the tumor and the number of lymph nodes involved. Stage IV indicates the presence of metastatic spread, regardless of tumor size or lymph node involvement.
DO NOT ASSUME
that women who do self exam do it commonly or regularly
Breast: Women 40 and older
should have an annual mammogram and annual clinical breast examination (CBE) by a health care provider.
Breast: Women ages 20-39
should have a CBE by a health care provider every 3 years. A monthly breast self-examination (BSE) is an option for women starting in their 20s.
Breast: Women at increased risk
(e.g., family history, genetic tendency) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.
Surgical Therapy: Breast conservation surgery
with radiation therapy and modified radical mastectomy with or without reconstruction are currently the most common options for resectable breast cancer. Most women diagnosed with early-stage breast cancer (tumors smaller than 4 to 5 cm) are candidates for either treatment choice. The overall survival rate with lumpectomy and radiation is about the same as that with modified radical mastectomy.
Axillary Node Dissection.
Patients with palpable nodes can receive __________________(ALND) on the same side as the breast cancer is often performed, and until recently was the standard of care for invasive breast cancer. A typical ALND generally involves the removal of 12 to 20 nodes. Recently sentinel (from word meaning lookout) lymph node dissection (SLND) has replaced ALND for patients who do not have malignant cells identified in their sentinel nodes¬ who don not have palpable but may have microscopic disease in one or more nodes. If one or more sentinel lymph nodes contain malignant cells, generally an ALND is recommended.
Examination of the lymph nodes
provides prognostic information and helps determine further treatment (chemotherapy, hormone therapy, or both).
Lymphatic mapping and sentinel lymph node dissection
The one or two sentinel lymph nodes which receive all drainage are identified through a lumph node mapping procedure. ___________
__________________ (SLND) helps the surgeon identify the lymph node(s) that drain first from the tumor site (sentinel node).
A radioisotope and/or blue dye
is injected into the tumor site, and intraoperatively, it is determined in which sentinel lymph nodes (SLNs) the radioisotope and/or blue dye is located. A local incision is made in the axilla, and the surgeon dissects the blue-stained and/or the radioactive SLNs.
one to four
Generally with an SLND,___________axillary lymph nodes are removed. The nodes are then sent for a frozen section pathologic analysis.
If the SLNs are _____________, no further axillary surgery is required.
If the SLNs are ___________, a complete axillary dissection is usually done.
lower morbidity rates and greater accuracy
SLND has been associated with ______________
____________________ as compared with complete axillary node dissection.
is a valuable prognostic variable: the larger the tumor, the poorer the prognosis.
histologic types of breast cancer
The wide variety of __________________________ explains the heterogeneity of the disease. In general, the more well differentiated the tumor, the less aggressive it is.
Poorly differentiated tumors
appear morphologically disorganized and are more aggressive.
if sentinel is free from cancer,
the rest lymph nodes are clear. Can stain the breast blue for about a year.
(accumulation of lymph in soft tissue) can occur as a result of the excision or radiation of lymph nodes.When the axillary nodes cannot return lymph fluid to the central circulation, the fluid accumulates in the arm, causing obstructive pressure on the veins and venous return.The patient may experience heaviness, pain, impaired motor function in the arm, and numbness and paresthesia of the fingers as a result of lymphedema.
and progressive fibrosis can result from lymphedema. Although lymphedema is not always preventable, it can be controlled somewhat after surgery or radiation.
Breast conservation surgery
(also called lumpectomy) involves the removal of the entire tumor along with a margin of normal tissue. Following surgery, radiation therapy is delivered to the entire breast, ending with a boost to the tumor bed. If there is evidence of systemic disease, chemotherapy may be given before radiation therapy.
Contraindications to breast conservation surgery
include breast size too small in relation to the tumor size to yield an acceptable cosmetic result, masses and calcifications that are multifocal (within the same breast quadrant), masses that are multicentric (in more than one quadrant), diffuse calcifications in more than one quadrant, or central location of tumor near the nipple.
One of the main advantages of breast conservation surgery and radiation
is that it preserves the breast, including the nipple.
The goal of the combined surgery and radiation
is to maximize the benefits of both cancer treatment and cosmetic outcome while minimizing risks.
Disadvantages of breast conservation surgery and radiation
include the increased cost of the surgery plus radiation over surgery alone and the possible side effects of radiation.
Modified Radical Mastectomy
includes removal of the breast and axillary lymph nodes, but it preserves the pectoralis major muscle. This surgery would be selected over breast conservation therapy if the tumor is too large to excise with good margins and attain a reasonable cosmetic result. Some patients may select this surgical procedure over lumpectomy when presented with the choice of either procedure.
When a modified radical mastectomy is performed, the patient has the option of __________________. If the patient chooses to have reconstructive surgery, it can be performed immediately following the mastectomy or it can be delayed until postoperative recovery is complete (as long as 6 months).
Follow-up Care: breast reconstruction
After surgery, the woman must be followed up for the rest of her life at regular intervals. Most women have professional examinations every 6 months for 2 years and then annually thereafter. In addition, the woman should practice monthly BSE on both breasts or the remaining breast and the mastectomy site. The most common site of local recurrence of breast cancer is at the surgical site. The woman should also have yearly mammography of the remaining breast or breast tissue.
Breast reconstructive surgery
may be done simultaneously with a mastectomy or some time afterward to achieve symmetry and to restore or preserve body image. The timing of reconstructive surgery should be individualized based on the psychologic needs of the patient. Immediate breast reconstruction after mastectomy is commonly performed.
The advantages to immediate reconstruction
are only one surgical procedure, one anesthesia induction, and one recovery period. Also, surgery takes place before the development of scar tissue or adhesions. Early reconstruction does not delay or influence further treatment or adversely affect predicted survival.
Breast reconstructive surgery: Indications
The main indication for breast reconstruction is to improve the woman's self-image and regain a sense of normality.
Breast reconstructive surgery: Present techniques cannot
restore lactation, nipple sensation, or erectility. Therefore the erotic functions of the breast are not present.
Although the breast will not fully resemble its __________________ appearance, the reconstructed appearance usually represents an improvement over the mastectomy scar. The contour of the breast is restored without the use of an external prosthesis.
Types of Reconstruction: Breast Implants
are placed in a pocket under the pectoralis muscle, which protects the implant and provides soft tissue coverage over the implant. Implants can be placed either at the time of mastectomy or later. Because many mastectomy patients have insufficient tissue, simple placement of an implant may lead to small breast reconstruction that is tight or firm.
Types of Reconstruction:Tissue Expansion.
can be used to stretch the skin and muscle at the mastectomy site before inserting implants The use of tissue expanders and breast implants is the most common breast reconstruction technique currently used. Placement of the expander can be performed at the time of mastectomy or at a later date. The tissue expander, which is minimally inflated at the time of surgery, is gradually filled by weekly injections of sterile water or saline solution, which stretch the skin and muscle. Once the tissue is adequately stretched and the anticipated breast size is reached, the expander is surgically removed and a permanent implant is inserted. Some expanders are designed to remain in place and become the implant, eliminating the need for a second surgical procedure. Tissue expansion does not work well in individuals with extensive scar tissue from surgery or radiation therapy.
The body's natural response to the presence of a foreign substance is the formation of a ________________ around the implant. If excessive capsular formation occurs as a result of infection, hematoma, trauma, or reaction to a foreign body, a contracture can develop, resulting in a deformed breast.
Surgeons differ in their approaches to the prevention of __________________, although gentle manual massage around the implant is routine. Prevention of the problems that cause excessive capsule formation is critical.
Breast reconstructive surgery: postoperative complications
include skin ulceration, hypertrophic scar formation, intercostal neuralgia, and wound infection.
Musculocutaneous Flap Procedure
If insufficient muscle is left after mastectomy or if the chest wall has been radiated, the person's own tissue may be used to repair the soft tissue defects. Musculocutaneous flaps are most often taken from the back (latissimus dorsi muscle) or the abdomen (transverse rectus abdominis muscle). In the latissimus dorsi musculocutaneous flap, a block of skin and muscle from the patient's back is used to replace tissue removed during mastectomy. A small implant may be needed beneath the flap to gain reasonable breast shape and size. A disadvantage of this technique is an additional scar on the back.
The transverse rectus abdominis musculocutaneous
(TRAM) flap is the most frequently used flap operation. The rectus abdominis muscles are paired flat muscles running from the rib cage down to the pubic bone. Arteries running inside the muscle provide branches at many levels, and these branches supply the fat and skin across a large expanse of the abdomen. With this technique the surgeon elevates a large block of tissue from the lower abdominal area, but leaves it attached to the rectus muscle This tissue is then tunneled or placed as "free flaps" under the skin up to the area where the breast will be reconstructed. Then it is molded and fashioned to form a breast. The abdominal incision is closed, giving the patient a result that is similar to having an abdominoplasty. This surgical procedure can last 2 to 8 hours, with recovery taking 4 to 6 weeks.
The transverse rectus abdominis musculocutaneous: Complications
include bleeding, hernia, and infection. An implant may be used in addition to the flap if the flap does not provide the desired cosmetic result alone.
The majority of patients who have breast reconstruction also have nipple-areolar reconstruction. Nipple reconstruction gives the reconstructed breast a much more natural appearance. Nipple-areolar reconstruction is usually done a few months after breast reconstruction. Tissue to construct a nipple may be taken from the opposite breast or from a small flap of tissue on the reconstructed breast mound. The areola may be grafted from the labia, skin in the area of the groin, or lower abdominal skin, or it may be tattooed with a permanent pigmented dye. In some patients a small implant may be placed under the completed nipple-areolar reconstruction to add additional projection.
may be used for breast cancer as:
(1) primary treatment to prevent local breast recurrences after breast conservation surgery
(2) adjuvant treatment following mastectomy to prevent local and nodal recurrences, and (3) palliative treatment for pain caused by local recurrence and metastases.
Primary Radiation Therapy.
is usually performed after local excision of the breast mass. The breast (and the regional lymph nodes in some cases) is radiated daily over the course of approximately 5 to 6 weeks. An external beam of radiation is used to deliver an approximate total dose of 4500 to 5000 cGy (4500 to 5000 rads; 1 rad=1 cGy). A "boost" treatment to the full breast may also be given, either before or after therapy has been completed. The boost is a dose of radiation delivered to the area in which the original tumor was located. It can be given by external beam and usually adds 10 treatments to the total number given. Fatigue, skin changes, and breast edema may be temporary side effects of external beam radiation therapy. Radiation of the axilla is also effective in decreasing the incidence of axillary recurrence. Chemotherapy may be used systemically to enhance the local effects of radiation.
the probability of the presence of local residual cancer cells
The decision to use radiation therapy after mastectomy is based on ___________________________________(related to size of cancer and number of involved lymph nodes). Radiating the area will not prevent the appearance of distant metastasis at a later date.
depends on the degree of possible spread of the cancer
The site of radiation therapy (lymph nodes, chest wall, or both) _________________________.
(internal radiation) is a procedure that is an alternative to traditional radiation treatment for early-stage breast cancer. For many years, internal radiation therapy has primarily been delivered using a multicatheter implant method that requires many catheters to be placed in the breast. After placement, a radioactive seed is delivered into each catheter to treat the target area.
One of the latest advances in the treatment of breast cancer and currently the most widely practiced method of brachytherapy is _______________________. Traditional radiation treatments can take 5 to 6 weeks. In contrast, high-dose brachytherapy using the balloon catheter may require only 5 days.
The MammoSite technique
uses a balloon catheter to insert radioactive seeds into the breast after the tumor is removed Radiation is emitted by a tiny radioactive seed attached by a wire on the way to an afterloader, a computer-controlled machine. The seed travels through the MammoSite applicator into the inflated balloon. Where the seed goes and how much radiation it releases is carefully determined. The radiation dose is focused on the area of the breast at highest risk for tumor recurrence.
The MammoSite system
is a minimally invasive method of delivering internal radiation therapy. Radiation therapy with the MammoSite is performed over a 1- to 5-day period on an outpatient basis. Patients typically receive treatments twice a day for 5 days.
The MammoSite may also be used as a boost therapy
in conjunction with external radiation. A boost is a procedure that delivers additional therapy directly to the area of the breast at highest risk for tumor recurrence.
No source of radiation remains
in the body between treatments or after the final treatment is over. The tiny radioactive seed is inserted only during treatment and then removed. Neither the MammoSite nor the liquid inside is radioactive in any way. Once the final session is completed, the balloon is deflated and the MammoSite system is easily removed.
Palliative Radiation Therapy
In addition to reducing the primary tumor mass with a resultant decrease in pain, radiation therapy is also used to stabilize symptomatic metastatic lesions in such sites as bone, soft tissue organs, brain, and chest. Radiation therapy relieves pain and is often successful in controlling recurrent or metastatic disease for long periods.
Breast cancer: Chemotherapy
Chemotherapy refers to the use of cytotoxic drugs to destroy cancer cells. Breast cancer is one of the solid tumors that is the most responsive to chemotherapy.
can decrease the size of the primary tumor, possibly permitting less extensive surgery. Breast cancer survival rates are not altered when comparing preoperative chemotherapy to postoperative chemotherapy.30
The use of combinations of drugs
is clearly superior to the use of a single drug. The benefit of combination treatment results from the use of drugs that have different actions on cell growth and division.
The more common combination-therapy protocols are
(1) cyclophosphamide (Cytoxan), methotrexate, and 5-fluorouracil (5-FU), referred to as CMF;
(2) doxorubicin (Adriamycin) and cyclophosphamide, referred to as AC, with or without the addition of a taxane such as paclitaxel (Taxol) or docetaxel (Taxotere); or (3) cyclophosphamide, epirubicin (Ellence) or doxorubicin (Adriamycin), and 5-FU, referred to as CEF or CAF, respectively. Docetaxel, capecitabine (Xeloda), and an albumin-bound form of paclitaxel (Abraxane) are used in women whose metastatic breast cancer has not responded to standard chemotherapy.
(Navelbine), a relatively new chemotherapeutic drug for treating metastatic breast cancer, is well tolerated with fewer and milder side effects than other chemotherapy drugs.
Hormonal Therapy: Estrogen
can promote the growth of breast cancer cells if the cells are estrogen receptor positive. Hormonal therapy removes or blocks the source of estrogen, thus promoting tumor regression.
Two advances have increased the use of hormone therapy in breast cancer
First, hormone receptor assays, which are reliable diagnostic tests, have been developed to identify women who are likely to respond to hormone therapy. Both estrogen and progesterone receptor status of the tumor can be determined. The importance of these assays is their ability to predict whether hormonal therapy is a treatment option for women with breast cancer, either at the time of initial therapy or if the cancer recurs.
Second, drugs have been developed that can inactivate the hormone-secreting glands as effectively as surgery or radiation.
Premenopausal and perimenopausal
women are more likely to have tumors that are not hormone dependent, whereas women who are postmenopausal are more likely to have hormone-dependent tumors.
Chances of tumor regression
are significantly greater in women whose tumors contain estrogen and progesterone receptors.
can occur by destroying the ovaries by surgery or radiation therapy or drug therapy
Hormonal therapy can
(1) block or destroy the estrogen receptors or (2) suppress estrogen synthesis through inhibiting aromatase, an enzyme needed for endogenous estrogen synthesis.
Hormonal therapy may be used as
an adjuvant to primary treatment or in patients with recurrent or metastatic cancer.
(Nolvadex) has been the hormonal agent of choice in estrogen receptor-positive women with all stages of breast cancer for the past 30 years.
Tamoxifen, an antiestrogen drug, blocks the estrogen receptor sites of malignant cells and thus inhibits the growth-stimulating effects of estrogen. It is commonly used in advanced and early-stage breast cancer and to treat recurrent disease.
Tamoxifen may also be used to prevent breast cancer in high-risk individuals. Side effects of tamoxifen are minimal but include hot flashes, mood swings, vaginal discharge, and other effects commonly associated with decreased estrogen.
Tamoxifen increases the risk of
blood clots, cataracts, stroke, and endometrial cancer in postmenopausal women.
Aromatase inhibitor drugs
interfere with the enzyme that synthesizes endogeneous estrogen, are used in the treatment of breast cancer in postmenopausal women.
-do not block the production of estrogen by the ovaries. Thus they are of little benefit in premenopausal women.
Aromatase inhibitor drugs include