Posts Tagged ‘tumors’
Very few areas of medicine are changing faster than cancer care and Seattle physicians and researchers are leading the way.
A patient with pancreatic cancer at the Swedish Cancer Institute (SCI) recently became the first person in the United States to be treated with a new technology known as Volumetric intensity Modulated Arc Therapy (VMAT). VMAT cuts radiation treatment times by one-half to two-thirds through delivering a higher and more targeted dose to cancerous tumors, without compromising patient safety. To date, more than 10 patients have been treated with VMAT at the Swedish Cancer Institute. They have included patients with tumors of the brain, abdomen and pelvis.
“VMAT allows the delivery of higher radiation doses with greater precision. We will kill more cancer and patients will have fewer side effects,” said Vivek Mehta, M.D., director of SCI’s Center for Advanced Targeted Radiation Therapies.
Faster treatment times often mean improved comfort for patients, making it easier for them to remain still during the process. For the first VMAT patient, total treatment time was less than 10 minutes. More important, Dr. Mehta’s team was able to greatly reduce the radiation exposure to surrounding sensitive areas – including the spinal cord, left and right kidneys and the liver.
Dr. Mehta is the principal investigator on a VMAT clinical study that will last approximately six months and involve at least 20 separate patients. Part of the study’s purpose is to prove definitively that VMAT is both faster and safer than the existing treatment approach.
With VMAT, Swedish clinicians are able to treat more patients with complex cancers than they could in the past. That includes those who have had radiation therapy previously with limited success and patients with tumors adjacent to critical structures in the body. Also, the technology should benefit patients who find it difficult to lie completely still for the typical 30 or more minutes of treatment time.
Dr. Mehta estimates that 10 percent to 15 percent of people now treated at the Swedish Cancer Institute will be good candidates for VMAT.
Swedish clinicians are working closely with VMAT developer Elekta. “I believe we were chosen as the first North American site because Swedish has a proven track record of innovation in cancer care,” Dr. Mehta said. “Medical manufacturers often come to SCI’s Center for Advanced Targeted Radiotherapy with novel ideas and we select the technologies that have the greatest potential to improve treatment and save lives.”
What’s on the horizon?
Dr. Mehta believes the next innovation will be some form of adaptive radiotherapy. By borrowing software from other disciplines, clinicians may be able to see the results of the radiation therapy within 30 to 60 seconds and adapt their treatment plans instantly. Instead of viewing an image of the tumor in week one of treatment and not again for the typical six weeks, physicians could make near real-time corrections to both radiation targeting and dosage.
“We can cure about half of the patients we see, many of whom have very serious cancers. That is far better than a generation ago, but we need to keep improving outcomes for the other 50 percent,” said Dr. Mehta. “As the largest and most comprehensive cancer treatment program in the Pacific Northwest, that is our sole mission.”
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Note:
This website is not intended as a substitute for professional medical advice and does not address specific treatments or conditions specific to any patient. All health and treatment decisions must be made in consultation with your physician(s), utilizing your specific medical information. The information on this website is subject to change.
WHAT IS THE BRAIN?
Together, the brain and spinal cord form the central nervous system. This complex system is part of everything we do. It controls the things we choose to do,like walk and talk,and the things our body does automatically,like breathe and digest food. The central nervous system is also involved with our senses; seeing, hearing, touching, tasting, and smelling, as well as our emotions, thoughts, and memory.
The brain is a soft, spongy mass of nerve cells and supportive tissue. It has three major parts: the cerebrum, the cerebellum, and the brain stem. The parts work together, but each has special functions.
The cerebrum, the largest part of the brain, fills most of the upper skull. It has two halves called the left and right cerebral hemispheres. The cerebrum uses information from our senses to tell us what is going on around us and tells our body how to respond. The right hemisphere controls the muscles on the left side of the body, and the left hemisphere controls the muscles on the right side of the body. This part of the brain also controls speech and emotions as well as reading, thinking, and learning.
The cerebellum, under the cerebrum at the back of the brain, controls balance and complex actions like walking and talking.
The brain stem connects the brain with the spinal cord. It controls hunger and thirst and some of the most basic body function, such as body temperature, blood pressure, and breathing.
The brain is protected by the bones of the skull and by a covering of three thin membranes called meninges. The brain is also cushioned and protected by cerebrospinal fluid. This watery fluid is produced by special cells in the four hollow spaces in the brain, called ventricles. It flows through the ventricles and in spaces between the meninges. Cerebrospinal fluid also brings nutrients from the blood to the brain and removes waste products from the brain.
The spinal cord is made up of bundles of nerve fibers. It runs down from the brain through a canal in the center of the bones of the spine. These bones protect the spinal cord. Like the brain, the spinal cord is covered by the meninges and cushioned by brospinal fluid.
Spinal nerves connect the brain with the nerves in most parts of the body. Other nerves go directly from the brain to the eyes, ears, and other parts of the head. This network of nerves carries messages back and forth between the brain and the rest of the body.
WHAT ARE BRAIN TUMORS?
The body is made up of many types of cells. Each type of cell has special functions. Most cells in the body grow and then divide in an orderly way to form new cells as they are needed to keep the body healthy and working properly. When cells lose the ability to control their growth, they divide too often and without any order. The extra cells form a mass of tissue called a tumor. Each year, more than 16,000 people find out they have a brain tumor. Tumors are benign or malignant.
Benign brain tumors do not contain cancer cells. Usually these tumors can be removed, and they are not likely to recur. Benign brain tumors have clear borders. Although they do not invade nearby tissue, they can press on sensitive areas of the brain and cause symptoms.
Malignant brain tumors contain cancer cells. They interfere with vital functions and are life-threatening. Malignant brain tumors are likely to grow rapidly and crowd or invade the tissue around them. Like a plant, these tumors may put out “roots” that grow into healthy brain tissue. If a malignant tumor remains compact and does not have roots, it is said to be encapsulated. When an otherwise benign tumor is located in a vital area of the brain and interferes with vital functions, it may be considered malignant (even though it contains no cancer cells).
Doctors refer to some brain tumors by grade – from low grade (grade I) to high grade (grade IV). The grade of a tumor refers to the way the cells look under a microscope. Cells from higher grade tumors are more abnormal looking and generally grow faster than cells from lower grade tumors; higher grade tumors are more malignant than lower grade tumors.
WHAT CAUSES BRAIN TUMORS?
The causes of brain tumors are not known. Researchers are trying to solve this problem. The more they can find out about the causes of brain tumors, the better the chances of finding ways to prevent them.
Doctors cannot explain why one person gets a brain tumor and another doesn’t, but they do know that no one can “catch” a brain tumor from another person. Brain tumors are not contagious
Although brain tumors can occur at any age, studies show that they are most common in two age groups. The first group is children 3 to 12 years old; the second is adults 40 to 70 years old.
By studying large numbers of patients, researchers have found certain risk factors that increase a person’s chance of developing a brain tumor. People with these risk factors have a higher-than-average risk of getting a brain tumor. For example, studies show that some types of brain tumors are more frequent among workers in certain industries, such as oil refining, rubber manufacturing, and drug manufacturing.
Other studies have shown that chemists and embalmers have a higher incidence of brain tumors. Researchers also are looking at exposure to viruses as a possible cause. Because brain tumors sometimes occur in several members of the same family, researchers are studying families with a history of brain tumors to see whether heredity is a cause. At this time, scientists do not believe that head injuries cause brain tumors to develop.
In most cases, patients with a brain tumor have no clear risk factors. The disease is probably the result of several factors acting together.
WHAT ARE PRIMARY BRAIN TUMORS?
Tumors that begin in the brain tissue are known as primary brain tumors. Secondary tumors are those that develop when cancer spreads to the brain. Primary brain tumors are classified by the type of tissue in which they begin. The most common brain tumors are gliomas, which begin in the glial (supportive) tissue. There are several types of gliomas:
* Astrocytomas arise from small, star-shaped cells called astrocytes. They may grow anywhere in the brain or spinal cord. In adults, astrocytomas most often arise in the cerebrum. In children, they occur in the brain stem, the cerebrum, and the cerebellum. A grade III astrocytoma is sometimes called anaplastic astrocytoma. A grade IV astrocytoma is usually called glioblastoma multiforme.
* Brain stem gliomas occur in the lowest, stemlike part of the brain. The brain stem controls many vital functions. Tumors in this area generally cannot be removed. Most brain stem gliomas are high-grade astrocytomas.
* Ependymomas usually develop in the lining of the ventricles. They also may occur in the spinal cord. Although these tumors can develop at any age, they are most common in childhood and adolescence.
* Oligodendrogliomas arise in the cells that produce myelin, the fatty covering that protects nerves. These tumors usually arise in the cerebrum. They grow slowly and usually do not spread into surrounding brain tissue. Oligodendrogliomas are rare. They occur most often in middle- aged adults but have been found in people of all ages.
There are other types of brain tumors that do not begin in glial tissue. Some of the most common are described below:
* Medulloblastomas were once thought to develop from glial cells. However, recent research suggests that these tumors develop from primitive (developing) nerve cells that normally do not remain in the body after birth. For this reason, medulloblastomas are sometimes called primitive neuroectodermal tumors (PNET). Most medulloblastomas arise in the cerebellum; however, they may occur in other areas as well. These tumors occur most often in children and are more common in boys than in girls.
* Meningiomas grow from the meninges. They are usually benign. Because these tumors grow very slowly, the brain may be able to adjust to their presence; meningiomas often grow quite large before they cause symptoms. They occur most often in women between 30 and 50 years of age.
* Schwannomas are benign tumors that begin in Schwann cells, which produce the myelin that protects the acoustic nerve, the nerve of hearing. Acoustic neuromas are a type of schwannoma. They occur mainly in adults. These tumors affect women twice as often as men.
* Craniopharyngiomas develop in the region of the pituitary gland near the hypothalamus. They are usually benign; however, they are sometimes considered malignant because they can press on or damage the hypothalamus and affect vital functions. These tumors occur most often in children and adolescents.
* Germ cell tumors arise from primitive (developing) sex cells, or germ cells. The most frequent type of germ cell tumor in the brain is the germinoma.
* Pineal region tumors occur in or around the pineal gland, a tiny organ near the center of the brain. The tumor can be slow growing (pineocytoma) or fast growing (pineoblastoma). The pineal region is very difficult to reach, and these tumors often cannot be removed
WHAT ARE SECONDARY BRAIN TUMORS?
Metastasis is the spread of cancer. Cancer that begins in other parts of the body may spread to the brain and cause secondary tumors. These tumors are not the same as primary brain tumors. Cancer that spreads to the brain is the same disease and has the same name as the original (primary) cancer. For example, if lung cancer spreads to the brain, the disease is called metastatic lung cancer because the cells in the secondary tumor resemble abnormal lung cells, not abnormal brain cells.
Treatment for secondary brain tumors depends on where the cancer started and the extent of the spread, as well as other factors, including the patient’s age, general health, and response to previous treatment.
WHAT ARE SYMPTOMS OF BRAIN TUMORS?
The symptoms of brain tumors depend mainly on their size and their location in the brain. Symptoms are caused by damage to vital tissue and by pressure on the brain as the tumor grows within the limited space in the skull. They also may be caused by swelling and a buildup of fluid around the tumor, a condition called edema . Symptoms also may be due to hydrocephalus , which occurs when the tumor blocks the flow of cerebrospinal fluid and causes it to build up in the ventricles. If a brain tumor grows very slowly, its symptoms may appear so gradually that they are overlooked for a long time.
The most frequent symptoms of brain tumors include:
* Headaches that tend to be worse in the morning and ease during the day
* Seizures (convulsions)
* Nausea or vomiting
* Weakness or loss of feeling in the arms or legs
* Stumbling or lack of coordination in walking (ataxic gait)
* Abnormal eye movements or changes in vision
* Drowsiness
* Changes in personality or memory
* Changes in speech
These symptoms may be caused by brain tumors or by other problems. If an individual is experiencing symptoms, they should consult a doctor right away.
HOW ARE BRAIN TUMORS DIAGNOSED?
To find the cause of a person’s symptoms, the doctor asks about the patient’s personal and family medical history and does a complete physical examination. In addition to checking general signs of health, the doctor does a neurologic exam. This includes checks for alertness, muscle strength, coordination, reflexes, and response to pain. The doctor also examines the eyes to check for swelling caused by a tumor pressing on the nerve that connects the eye and the brain.
Depending on the results of the physical and neurologic examinations, the doctor may request one or both of the following:
* A CT (or CAT) scan is a series of detailed pictures of the brain. The pictures are created by a computer linked to an x-ray machine. In some cases, a special dye is injected into a vein before the scan. The dye helps to show differences in the tissues of the brain
* MRI ( magnetic resonance imaging ) gives pictures of the brain, using a powerful magnet linked to a computer. MRI is especially useful in diagnosing brain tumors because it can “see” through the bones of the skull to the tissue underneath. A special dye may be used to enhance the likelihood of detecting a brain tumor
The doctor also may request other tests:
* A skull x-ray can show changes in the bones of the skull caused by a tumor. It can also show calcium deposits, which are present in some types of brain tumors
* In a brain scan, areas of abnormal growth in the brain are revealed and recorded on special film. A small amount of a radioactive material is injected into a vein. This dye is absorbed by the tumor, and the growth shows up on the film (the radiation leaves the body within 6 hours and is not dangerous)
* An angiogram, or arteriogram, is a series of x-rays taken after a special dye is injected into an artery (usually in the area where the abdomen joins the top of the leg). The dye, which flows through the blood vessels of the brain, can be seen on the x-rays. These x-rays can show the tumor and the blood vessels that lead to it
* A myelogram is an x-ray of the spine. A special dye is injected into the cerebrospinal fluid in the spine, and the patient is tilted to allow the dye to mix with the fluid. This test may be done when the doctor suspects a tumor in the spinal cord
WHAT IS THE TREATMENT FOR BRAIN TUMORS?
Treatment for a brain tumor depends on a number of factors. Among these are the type, location, and size of the tumor, as well as the patient’s age and general health. Treatment methods and schedules often vary for children and adults. A treatment plan is developed to fit each patient’s needs.
The patient’s doctor may want to discuss the case with other doctors who treat brain tumors. Also, the patient may want to talk with the doctor about taking part in a research study of new treatment methods. Such studies are called clinical trials.
Many patients want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. A person with a brain tumor will have many questions, and the doctor is the best person to answer them. Most patients want to know what kind of tumor they have, how it can be treated, how effective the treatment is likely to be, and how much it is likely to cost.
Many people find it helpful to make a list of their questions before they see the doctor. Taking notes can make it easier to remember what the doctor says. Some patients also find that it helps to have a family member or friend with them when they talk with the doctor,either to take part in the discussion or just to listen.
Patients and their families have a lot to learn about brain tumors and their treatment. They should not feel that they need to understand everything the first time they hear it. They will have other chances to ask the doctor to explain things that are not clear.
Treatment Methods
Brain tumors are treated with surgery, radiation therapy, and chemotherapy. Depending on the patient’s needs, several methods may be used. The patient may be referred to doctors who specialize in different kinds of treatment and work together as a team. This medical team often includes a neurosurgeon, a medical oncologist, a radiation oncologist, a nurse, a dietitian, and a social worker. The patient also might work with a physical therapist, an occupational therapist, and a speech therapist.
Before treatment begins, most patients are given steroids, which are drugs that relieve swelling (edema). They also may be given anticonvulsant medicine to prevent or control seizures. If hydrocephalus (a condition which results in fluid accumulation around the brain) is present, the patient may need a shunt to drain the cerebrospinal fluid. A shunt is a long, thin tube placed in a ventricle of the brain and then threaded under the skin to another part of the body, usually the abdomen. It works like a drainpipe: excess fluid is carried away from the brain and is absorbed in the abdomen. (In some cases, the fluid is drained into the heart).
Surgery is the usual treatment for most brain tumors. To remove a brain tumor, a neurosurgeon makes an opening in the skull. This operation is called a craniotomy.
Whenever possible, the surgeon attempts to remove the entire tumor. However, if the tumor cannot be completely removed without damaging vital brain tissue, the doctor removes as much of the tumor as possible. Partial removal helps to relieve symptoms by reducing pressure on the brain and reduces the amount of tumor to be treated by radiation therapy or chemotherapy.
Some tumors cannot be removed. In such cases, the doctor may do only a biopsy. A small piece of the tumor is removed so that a pathologist can examine it under a microscope to determine the type of cells it contains. This helps the doctor decide which treatment to use.
Sometimes, a biopsy is done with a needle. Doctors use a special head frame (like a halo) and CT scans or MRI to pinpoint the exact location of the tumor. The surgeon makes a small hole in the skull and then guides a needle to the tumor. (Using this technique to do a biopsy or for treatment is called stereotaxis).
Radiation therapy (also called radiotherapy) is the use of high-powered rays to damage cancer cells and stop them from growing. It is often used to destroy tumor tissue that cannot be removed with surgery or to kill cancer cells that may remain after surgery. Radiation therapy is also used when surgery is not possible.
Radiation therapy may be given in two ways. External radiation comes from a large machine. Generally, external radiation treatments are given 5 days a week for several weeks. The treatment schedule depends on the type and size of the tumor and the age of the patient. Giving the total dose of radiation over an extended period helps to protect healthy tissue in the area of the tumor.
Radiation can also come from radioactive materials placed directly in the tumor (implant radiation therapy). Depending on the material used, the implant may be left in the brain for a short time or permanently. Implants lose a little radioactivity each day. The patient stays in the hospital for several days while the radiation is most active.
External radiation may be directed just to the tumor and the tissue close to it or, less often, to the entire brain (sometimes the radiation is also directed to the spinal cord). When the whole brain is treated, the patient often receives an extra dose of radiation to the area of the tumor. This boost can come from external radiation or from an implant.
Stereotactic radiosurgery is another way to treat brain tumors. Treatment is given in just one session; high- energy rays are aimed at the tumor from many angles. In this way, a high dose of radiation reaches the tumor without damaging other brain tissue. (This use of radiation therapy is sometimes called Gamma Knife® Surgery).
Chemotherapy is the use of drugs to kill cancer cells. The doctor may use just one drug or a combination, usually giving the drugs by mouth or by injection into a blood vessel or muscle. Intrathecal chemotherapy involves injecting the drugs into the cerebrospinal fluid.
Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Patients often do not need to stay in the hospital for treatment. Most drugs can be given in the doctor’s office or the outpatient clinic of a hospital. However, depending on the drugs used, the way they are given, and the patient’s general health, a short hospital stay may be necessary.
Clinical Trials
Researchers are looking for treatment methods that are more effective against brain tumors and have fewer side effects. When laboratory research shows that a new method has promise, doctors use it to treat cancer patients in clinical trials. These trials are designed to answer scientific questions and to find out whether the new approach is both safe and effective. Patients who take part in clinical trials make an important contribution to medical science and may have the first chance to benefit from improved treatment methods.
Many clinical trials of new treatments for brain tumors are under way. Doctors are studying new types and schedules of radiation therapy, new anticancer drugs, new drug combinations, and combinations of chemotherapy and radiation.
Scientists are trying to increase the effectiveness of radiation therapy by giving treatments twice a day instead of once. Also, they are studying drugs called radiosensitizers. These drugs make the cancer cells more sensitive to radiation. Another method under study is hyperthermia , in which the tumor is heated to increase the effect of radiation therapy.
Many drugs cannot reach the brain cells because of the blood- brain barrier, a network of blood vessels and cells that filters blood going to the brain. Researchers continue to look for new drugs that will pass through the blood-brain barrier. Studies are under way using different techniques to temporarily disrupt the barrier so that drugs can reach the tumor.
In other studies, scientists are exploring new ways to give the drugs. Drugs may be injected into an artery leading to the brain or may be put directly into the ventricles. Doctors also are studying the effectiveness of placing tiny wafers containing anticancer drugs directly into the tumor (the wafers dissolve over time).
Researchers are also testing the use of very high doses of anticancer drugs. Because these higher doses may damage healthy bone marrow, doctors combine this treatment with bone marrow transplantation to replace the marrow that has been destroyed.
Biological therapy is a new way of treating brain tumors that is currently under study. This type of treatment is an attempt to improve the way the body’s immune system fights disease.
Patients interested in taking part in a clinical trials should discuss this option with their doctor. They may want to read “What Are Clinical Trials All About?”, a National Cancer Institute (NCI) booklet that explains some of the possible benefits and risks of treatment studies.
One way to learn about clinical trials is through PDQ, a computerized resource of cancer treatment information. Developed by NCI, PDQ contains an up-to-date list of trials in progress all over the country. Doctors can use a personal computer or the services of a medical library to get PDQ information. The Cancer Information Service, at 1-800-4-CANCER, is another source of PDQ information for doctors, patients, and the public.
WHAT ARE THE SIDE EFFECTS OF TREATMENT FOR BRAIN CANCER?
Cancer treatment often causes side effects. These side effects occur because treatment to destroy cancer cells damages some healthy cells as well.
The side effects of cancer treatment vary. They depend on the type of treatment used and on the area being treated. Also, each person reacts differently. Attempts are made to plan the patient’s therapy to keep side effects to a minimum. Patients are very carefully watched so that any problems which occur can be addressed.
A craniotomy is a major operation. The surgery may damage normal brain tissue, and edema may occur. Weakness, coordination problems, personality changes, and difficulty in speaking and thinking can result. Patients can also have seizures. In fact, for a short time after surgery, symptoms may be worse than before. Most of the side effects of surgery lessen or disappear with time.
Most of the side effects of radiation therapy go away soon after treatment is over. However, some side effects may occur or persist long after treatment is completed.
Some patients have nausea for several hours after treatment. Patients receiving radiation therapy may become very tired as treatment continues. Resting is important, but doctors usually advise their patients to try to stay reasonably active. Radiation therapy to the scalp causes most patients to lose their hair. When it grows back, the new hair is sometimes softer and may be a slightly different color. In some cases, hair loss is permanent.
Skin reactions in the treated area are common. The scalp and ears may be red, itchy, or dark. These areas may look and feel sunburned. The treated area should be exposed to the air as much as possible but should be protected from the sun. Patients should not wear anything on the head that might cause irritation. Good skin care is important at this time. The doctor may suggest certain kinds of soap or ointment, and patients should not use any other lotions or creams on the scalp without the doctor’s advice.
Sometimes, brain cells killed by radiation form a mass in the brain. The mass may look like a tumor and may cause similar symptoms, such as headaches, memory loss, or seizures. Doctors may suggest surgery or steroids to relieve these problems. About 4 to 8 weeks after radiation therapy, patients may become quite sleepy or lose their appetite. These symptoms may last several weeks, but they usually go away on their own. Still, patients should notify the doctor if they occur.
Children who have had radiation therapy for a brain tumor may have learning problems or partial loss of eyesight. If the pituitary gland is damaged, children may not grow or develop normally.
The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect rapidly growing cells, such as blood cells that fight infection, cells that line the digestive tract, and cells in the hair follicles. As a result, patients may have a lowered resistance to infection, loss of appetite, nausea, vomiting, or mouth sores. Patients also may have less energy and lose their hair. These side effects usually go away gradually after treatment stops.
Some anticancer drugs can cause infertility. Women taking certain anticancer drugs may have symptoms of menopause (hot flashes and vaginal dryness; periods may be irregular or stop). Some drugs used to treat children and teenagers may affect their ability to have children later in life.
Certain drugs used in the treatment of brain tumors can cause kidney damage. Patients are given large amounts of fluid while taking these drugs. Patients also may have tingling in the fingers, ringing in the ears, or difficulty hearing. These problems may not clear up after treatment stops.
Treatment with steroids to reduce swelling in the brain can cause increased appetite and weight gain. Swelling of the face and feet is common. Steroids can also cause restlessness, mood swings, burning indigestion, and acne . Patients should not stop using steroids or change their dose without consulting the doctor, however. The use of steroids must be stopped gradually to allow the body time to adjust.
Loss of appetite can be a problem for patients during therapy. People may not feel hungry when they are uncomfortable or tired. Some of the common side effects of cancer treatment, such as nausea and vomiting, can also make it hard to eat. Yet, good nutrition is important because patients who eat well generally feel better and have more energy. In addition, they may be better able to withstand the side effects of treatment. Eating well means getting enough calories and protein to help prevent weight loss, regain strength, and rebuild normal tissues. Many patients find that eating several small meals and snacks during the day works better than trying to have three large meals.
Patients being treated for a brain tumor may develop a blood clot and inflammation in a vein, most often in the leg. This is called thrombophlebitis. A patient who notices swelling in the leg, leg pain, or redness in the leg should notify the doctor right away.
Doctors, nurses, and dietitians can explain the side effects of cancer treatment and can suggest ways to deal with them.
WHAT IS REHABILITATION AFTER BRAIN CANCER TREATMENT?
Rehabilitation is a very important part of the treatment plan. The goals of rehabilitation depend on the patient’s needs and how the tumor has affected his or her daily activities. The medical team makes every effort to help patients return to their normal activities as soon as possible.
Patients and their families may need to work with an occupational therapist to overcome any difficulty in activities of daily living, such as eating, dressing, bathing, and using the toilet. If an arm or leg is weak or paralyzed, or if a patient has problems with balance, physical therapy may be necessary. Speech therapy may be helpful for individuals having trouble speaking or expressing their thoughts. Speech therapists also work with patients who are having difficulty swallowing.
If special arrangements are necessary for school-age children, they should be made as soon as possible. Sometimes, children have tutors in the hospital or after they go home from the hospital. Children who have problems learning or remembering what they learn may need tutors or special classes when they return to school.
WHAT HAPPENS AFTER TREATMENT FOR BRAIN CANCER?
Regular follow-up is very important after treatment for a brain tumor. The doctor will want to check closely to be sure that the tumor has not returned. Check-ups usually include general physical and neurologic exams. From time to time, the patient will have CT scans or MRI.
Patients who receive radiation therapy to large areas of the brain or certain anticancer drugs may have an increased risk of developing leukemia or a second tumor at a later time. Also, radiation that affects the eyes may lead to the development of cataracts . Patients should carefully follow their doctor’s advice on health care and checkups. If any unusual health problem occurs, they should report it to the doctor as soon as it appears.
The diagnosis of a brain tumor can change the lives of patients and the people who care about them. These changes can be hard to handle. Patients and their families may have many different and sometimes confusing emotions.
At times, patients and those close to them may feel frightened, angry, or depressed. These are normal reactions when people face a serious health problem. Most patients, including children and teenagers, find it helps to share their thoughts and feelings with loved ones. Sharing can help everyone feel more at ease and can open the way for others to show their concern and offer their support.
Worries about tests, treatments, hospital stays, rehabilitation, and medical bills are common. Parents may worry about whether their children will be able to take part in normal school or social activities. Doctors, nurses, social workers, and other members of the health care team may be able to calm fears and ease confusion. They also can provide information and suggest helpful resources.
Patients and their families are naturally concerned about what the future holds. Sometimes, they use statistics to try to figure out whether the patient will be cured or how long he or she will live. It is important to remember, however, that statistics are averages based on large numbers of patients. They can’t be used to predict what will happen to a certain patient because no two cancer patients are alike. The doctor who takes care of the patient and knows that person’s medical history is in the best position to discuss the patient’s outlook (prognosis).
People should feel free to ask the doctor about their prognosis, but it is important to keep in mind that not even the doctor can tell exactly what will happen. When doctors talk about recovering from a brain tumor, they may use the term remission rather than cure. Even though many people recover completely, doctors use this term because a brain tumor can recur.
WHAT SUPPORT IS AVAILABLE TO CANCER PATIENTS?
Living with a serious disease is not easy. Everyone involved faces may problems and challenges. Finding the strength to cope with these difficulties is easier when people have helpful information and support services.
The doctor can explain the disease and give advice about treatment, going back to work or school, or other activities. If patients want to discuss concerns about the future, family relationships, and finances, it also may help to talk with a nurse, social worker, counselor, or a member of the clergy.
Friends and relatives who have had personal experience with cancer can be very supportive. Also, it helps many patients to meet and talk with other people who are facing problems like theirs. Cancer patients often get together in self-help and support groups, where they can share what they have learned about cancer and its treatment and about coping with the disease. In addition to groups for adults with cancer, special support groups for children or teens with cancer or for parents whose children have cancer are available in many cities. It is important to keep in mind, however, that each patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another, even if they both have the same kind of cancer. It is a good idea to discuss the advice of friends and family members with the doctor.
Often, a social worker at the hospital or clinic can suggest local and national groups that will help with rehabilitation, emotional support, financial aid, transportation, or home care. The American Cancer Society is one such group. This nonprofit organization has many services for patients and their families.
The American Brain Tumor Association is another organization that can help patients find support groups in local areas.
Candlelighters Childhood Cancer Foundation sponsors support groups for parents of children with cancer. In some cities, the Foundation has special groups for children or teens with cancer, as well.
Information about other programs and services for cancer patients and their families is available through the Cancer Information Service. The toll-free number is 1-800-4-CANCER.
BRAIN TUMORS AT A GLANCE
* Brain tumors can be either malignant or benign
* The causes of brain tumors are not known
* Brain tumors can occur at any age
* Primary brain tumors initially form in the brain tissue
* Secondary brain tumors are cancers that have spread to the brain tissue from tissue elsewhere in the body
* The symptoms of brain tumors depend on their size and their location in the brain
* Brain tumors are diagnosed by the doctor based on the results of a medical history and physical examination and results of a variety of specialized tests of the brain and nervous system
* Treatment of a brain tumor depends on the type, location, and size of the tumor, as well as the age and health of the patient
Further Reading: http://www.elekta.com/gammaknife
Radiotherapy, the treatment of cancer with radiation, is a very important element of curative treatment for cancer, and is also important for maintaining and/or improving patients’ quality of life. It is anticipated that it will retain a key role in cancer treatment for the next 10-20 years and will continue to make a significant contribution to improved treatment and palliative outcomes.
Radiotherapy owes its pre-eminent position in the treatment of cancer to its ability to deliver, with precision, a lethal radiation dose to each cancer cell situated within a chosen area of the body. The main aim of treatment is to give a sufficient radiation dose to the tumor to cause destruction without producing unacceptable damage to surrounding normal tissue. The higher the differential between the dose to the tumor and that received by the normal tissue, the better the chance of a cure. This high differential hinges on the precision with which the size and position of the tumor can be ascertained and, equally importantly, on the accuracy with which the required dose of radiation can be delivered to the chosen site. Radiation can be delivered in a variety of ways, depending on the nature of the cancer. The most commonly used method is called external beam therapy, which directs high energy X-ray radiation at the tumor. Although the radiation affects both cancer and normal cells, because of the nature of the cancer cells it has a greater effect on them. Treatment aimed at cure will give the highest possible dose of radiation, within safe limits, to attempt to kill all the cancer cells. Sometimes smaller doses are used, where the aim is to reduce the size of a tumor and/or relieve symptoms. Radiotherapy treatment is given using either a machine called a linear accelerator or, for some skin tumors, a superficial X-ray unit. To receive the radiotherapy, the patient lies on a couch under the machine, and is asked to remain still during the actual treatment. Every course of radiotherapy treatment is designed to suit the particular needs of the person receiving it, so prior to treatment the patient will make a preliminary visit to the hospital for the course of treatment planned. A typical treatment will last six weeks, with the patient visiting the hospital every day.
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Cancer is a group of many related diseases. All forms of cancer involve out-of-control growth and spread of abnormal cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person’s life, normal cells divide more rapidly until the person becomes an adult. After that, normal cells of most tissues divide only to replace worn-out or dying cells and to repair injuries. Cancer cells, however, continue to grow and divide, and can spread to other parts of the body. These cells accumulate and form tumors (lumps) that may compress, invade, and destroy normal tissue. If cells break away from such a tumor, they can travel through the blood stream or the lymph system to other areas of the body. There, they may settle and form ‘colony’ tumors. In their new location, the cancer cells continue growing. The spread of a tumor to a new site is called metastasis. When cancer spreads, though,it is still named after the part of the body where it started. For example, if prostate cancer spreads to the bones, it is still prostate cancer, and if breast cancer spreads to the lungs it is still called breast cancer. Leukemia, a form of cancer, does not usually form a tumor. Instead, these cancer cells involve the blood and blood-forming organs (bone marrow, lymphatic system, and spleen), and circulate through other tissues where they can accumulate.
It is important to realize that not all tumors are cancerous. Benign (non-cancerous) tumors do not metastasise and, with few exceptions, are not life-threatening. Cancer is classified by the part of the body in which it began,and by its appearance under a microscope. Different types of cancer vary in their rates of growth, patterns of spread, and responses to different types of treatment. That’s why people with cancer need treatment that is aimed at their specific form of the disease.
Cancer is a group of more than 100 different diseases. They affect the body’s basic unit, the cell. Cancer occurs when cells become abnormal and divide without control or order. Like all other organs of the body, the colon and rectum are made up of many types of cells. Normally, cells divide to produce more cells only when the body needs them. This orderly process helps keep us healthy.
If cells keep dividing when new cells are not needed, a mass of tissue forms. This mass of extra tissue, called a growth or tumor, can be benign or malignant.
Benign tumors are not cancer. They can usually be removed and, in most cases, they do not come back. Most important, cells from benign tumors do not spread to other parts of the body. Benign tumors are rarely a threat to life.
Malignant tumors are cancer. Cancer cells can invade and damage tissues and organs near the tumor. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. This is how cancer spreads from the original (primary) tumor to form new tumors in other parts of the body. The spread of cancer is called metastasis.
When cancer spreads to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if colon cancer spreads to the liver, the cancer cells in the liver are colon cancer cells. The disease is metastatic colon cancer (it is not liver cancer).
Note:
This website is not intended as a substitute for professional medical advice and does not address specific treatments or conditions specific to any patient. All health and treatment decisions must be made in consultation with your physician(s), utilizing your specific medical information. The information on this website is subject to change.
“Your mammogram is suspicious for breast cancer.” “Your biopsy was positive for breast cancer.” These are among the most terrifying words a woman can hear from her doctor. Breast cancer elicits so many fears, including those relating to surgery, death, loss of body image and loss of sexuality. Managing these fears can be facilitated by information and knowledge so that each woman can make the best decisions concerning her care. Optimally, these issues are best discussed with the patient’s doctor on an individual basis. What follows is a review of information on breast cancer intended to aid patients and their families in their navigation through the vast ocean of breast cancer
WHO IS AT RISK FOR BREAST CANCER?
Currently, one in every eight women in the United States develops breast cancer. The exact cause of breast cancer is not known and most likely involves many factors, including genetic, environmental, nutritional and hormonal. Breast cancer is more common in higher socioeconomic groups, unmarried women, urban areas and Jewish women.
The most prominent risk factors for breast cancer are age and gender. Men can develop breast cancer, but women are 200 times more likely to develop breast cancer than men. Breast cancer is four hundred times more common in women who are 50 years old as compared to those who are 20 years old. Seventy-five percent of women who develop breast cancer have no risk factors other than age.
A family history of breast cancer will increase the risk of developing breast cancer in a woman by three to five times. Recently, a breast cancer gene (BR CA 1) has been identified. If a woman has this gene present in her chromosomes, there is an 85% chance of developing breast or ovarian cancer, or both in her lifetime. Fifty percent of these cancers will occur before the age of fifty. This gene is felt to be responsible for only two to four percent of all breast cancer cases. Currently, the test for this gene is available only at certain research centers, and though it is highly predictive of some breast cancers, it is still not clear how best to use this information in treating and counseling patients.
Women who started their menstrual periods before age 12, those who delayed menopause until after age 55, and those who had their first pregnancy after age 30 have a mildly increased risk of developing breast cancer (less than two times the normal risk). Pregnancy and breast feeding have a protective effect in preventing breast cancer. Some studies show that hormone replacement therapy and birth control pills cause a small increased risk of breast cancer, but this has not been confirmed in all studies.
When a breast biopsy demonstrates the development of abnormal cells that are not yet cancerous, called atypical hyperplasia, there is a moderately increased risk of developing breast cancer in the future.
Dietary factors such as high-fat diets and alcohol consumption have been implicated as increased risk factors for breast cancer in some studies. More recent studies have disproven high-fat diets as increasing the risk for breast cancer. Cigarette smoking, caffeine intake, and stress do not appear to increase the risk of breast cancer.
HOW IS BREAST CANCER DIAGNOSED?
Currently, mammography and breast examination serve as the foundation in screening for breast cancer. Mammography is an x-ray examination of the breast. It has the ability to detect a cancer in the breast when it is quite small, long before it may be felt by breast examination. Eighty-five to 90% of all breast cancers are detectable by mammography. Approximately 10 to 15 percent of breast cancers are not visible on mammography, but can be felt on physical examination of the breast.
Since a percentage of breast cancers is not seen on mammography, it is extremely important for a woman to have regular breast examinations as well as mammograms in order to most fully ensure she has no evidence of breast cancer. Breast examination can be performed by the woman’s health professional during the routine physical checkup. It should also be performed monthly by the woman herself using the technique of breast self- examination. It is best to do breast self-examination 3 days after the menstrual period has stopped. Any detected change from the usual appearance or feel is reported to the health professional.
An ultrasound is a test that uses sound waves to visualize structures inside the body. It is often used to distinguish between cysts and solid tumors in the breast. Fluid within cysts can be aspirated (withdrawn with a needle and syringe) for analysis in the laboratory.
If an area of the breast is suspicious for a cancer, a biopsy (removal of a piece of tissue to analyze under the microscope) is usually performed to confirm or deny the diagnosis. Eighty percent of biopsies are not cancerous.
HOW IS THE BREAST DESIGNED?
Breast cancer is not just one disease, but rather is a general term used to describe a number of different types of cancers which occur in the breast. Each different type of breast cancer behaves differently and has a different prognosis. Before describing the different cancers and how they are treated, some background information may be helpful.
The breast is an organ of the body designed to produce milk. The breast contains glands called lobules which produce breast milk. There are also tubes or channels called ducts which transport the milk from the glands to the nipple. The majority of breast cancers begins in either the ducts or the lobules and cancer names are based on their site of origin (i.e., ductal carcinoma of the breast or lobular carcinoma of the breast). The lobules and ducts are supported in the breast by surrounding fatty tissue and ligaments.
There are also blood vessels and lymphatics present in the breast. Lymphatics are small thin channels similar to blood vessels. They do not carry blood, but collect and carry tissue fluid. This fluid ultimately re-enters the blood stream. Breast tissue fluid drains through the lymphatics into the axillary lymph nodes, located in the underarm. Lymph nodes are small glands through which lymphatic channels enter. They filter the lymph fluid and can serve as a barrier to the further spread of bacteria or cancer cells that may have entered the lymph fluid. Lymph nodes are not completely effective in filtering out cancer cells and may spread to other parts of the body despite their presence. Once cancer cells have gained access to either the lymph channels or the blood stream, they have the potential to spread to any area of the body. In breast cancer, these areas are typically the bone, the lungs, the liver and the brain.
Breast cancer is also categorized as invasive (infiltrating) or non-invasive (in-situ). Invasiveness, as it relates to cancer, refers to the cancer’s ability to spread to other parts of the body (metastasize). If a cancer is invasive, it has the capability of growing directly into other parts of the body, or traveling in the blood or lymph fluid to these areas. Non-invasive cancers (in situ cancers) are those cancers which are defined by microscopic criteria as lacking the ability to spread to other parts of the body.
WHAT ARE THE TYPES OF BREAST CANCERS?
The majority of breast cancers can be classified into one of the following categories; infiltrating ductal carcinoma, infiltrating lobular carcinoma, ductal carcinoma in situ, lobular carcinoma in situ, inflammatory carcinoma, Paget’s disease, and cystosarcoma phyllodes. There are other tumors of the breast, such as angiosarcoma, squamous cell cancer and lymphoma, but they are quite rare. These categories are based on the microscopic appearance of the breast tissue obtained with a biopsy sample.
* INFILTRATING DUCTAL CARCINOMA
* INFILATRATING LOBULAR CARCINOMA
* DUCTAL CARCINOMA IN SITU (DCIS)
* LOBULAR CARCINOMA IN SITU (LCIS)
* INFLAMMATORY CARCINOMA
* PAGET’S DISEASE
* CYSTOSARCOMA PHYLLODES
INFILTRATING DUCTAL CARCINOMA
Infiltrating Ductal Carcinoma begins in the cells forming the ducts of the breast. It is the most common form of breast cancer, comprising about 65-85% of all cases. On a mammogram, invasive ductal carcinoma is usually found as an irregular mass, or as a group of small white irregular dots called microcalcifications, or a combination of both. It may also appear as a lump in the breast. On physical examination, this lump usually feels much harder or firmer than other benign causes of lumps in the breast.
INFILATRATING LOBULAR CARCINOMA
Infiltrating Lobular Carcinoma comprises 5 to 10 percent of breast cancers. This type of breast cancer can appear similar to infiltrating ductal carcinoma on mammography, but on examination of the breast there is usually not a hard mass, but rather a vague thickening of the breast tissue. Lobular carcinoma can occur in more than one site in the breast (multicentric) or in both breasts simultaneously (bilateral).
DUCTAL CARCINOMA IN SITU (DCIS)
Ductal Carcinoma In Situ (DCIS) is a pre-invasive form of breast cancer. It is commonly seen in association with an invasive breast cancer. If it occurs without an invasive cancer there is usually no lump associated with it. On mammography, there may be fine microcalcifications which can signal its presence. DCIS is frequently multifocal, meaning it is located in more than one area of the breast. Approximately one-third of DCIS cases are multifocal. If DCIS is treated with biopsy alone, about 40% of women will ultimately develop an invasive cancer of that breast in the future.
LOBULAR CARCINOMA IN SITU (LCIS)
Lobular Carcinoma In Situ (LCIS) is usually encountered as an incidental finding in a breast biopsy. It has no symptoms, and has no characteristic pattern on mammography. It has been found to occur in multiple sites in the same breast in 40 to 90% of cases. In 50% of the cases, it may also occur in the opposite breast. The risk of developing an invasive cancer of the breast with LCIS is approximately 1% per year. The invasive cancer that develops has about an equal chance of being in either breast regardless as to which breast the LCIS was initially found. A large percentage (38%) of women with LCIS may not develop an invasive cancer until more than 20 years after the initial diagnosis.
INFLAMMATORY CARCINOMA
Inflammatory carcinoma of the breast is a subtype of infiltrating ductal carcinoma, but is named for its typical clinical presentation. The breast becomes red, swollen, and warm, and the skin becomes quite thickened. The breast appears as if it were infected. This appearance is due to the rapid growth of the cancer which blocks the lymphatics in the breast, causing it to swell and appear infected. The cancer has already spread to the lymph nodes in 90% of the cases at the time of diagnosis. The prognosis for this cancer is very poor, and is fortunately relatively uncommon.
PAGET’S DISEASE
Paget’s disease of the breast accounts for about one to four percent of all breast cancers. It occurs typically as a crusting and scaling of the nipple. It can be mistaken for a benign skin condition unless there is a high index of suspicion.
CYSTOSARCOMA PHYLLODES
Cystosarcoma Phyllodes is a firm tumor that resembles a benign fibroedenoma. This cancer is very different than other cancers of the breast. It seldom spreads to the lymph nodes, but can metastasize to other parts of the body by way of the bloodstream.
WHAT TREATMENTS ARE USED FOR INVASIVE BREAST CANCER?
Currently, when breast cancer is detected it is already an invasive cancer in the majority of cases. The treatment of invasive breast cancer is similar, whether it be invasive ductal or invasive lobular carcinoma.
The treatment plans are divided into local therapy and systemic therapy. Local therapy is designed to remove or kill the cancer cells in the breast and adjacent lymph nodes. If the cancer has not spread outside these areas, the patient can be cured by local therapy alone. Unfortunately, breast cancer can metastasize or spread to other areas of the body even though the primary cancer is quite small and there is no evidence of cancer spread to the lymph nodes. Breast cancer does not always follow a predictable pattern of growth. From many studies, estimates of the risk of metastasis and recurrence of the cancer are given based on factors, such as tumor size, cell type, lymph node status, and hormone receptors. But in any individual woman, an outcome (or prognosis) cannot be predicted with certainty. Due to this uncertainty, a systemic therapy is incorporated to treat the potential and actual risk of cancer cells spreading elsewhere. This systemic therapy is called chemotherapy, and utilizes drugs to kill cancer cells.
Local therapy involves surgery, radiation, or both. There are many terms used in connection with breast cancer surgery. Mastectomy is a general term for removal of the breast. A modified radical mastectomy involves removal of the breast and the axillary lymph nodes. A simple mastectomy removes the breast, but not the lymph nodes. Lumpectomy, partial mastectomy, and quadrentectomy refer to removing only a portion of the breast. An axillary dissection means removal of a portion of the lymph nodes under the arm.
Radiation therapy is the use of special high energy x-ray beams to kill rapidly growing cells, such as cancer cells. It is a generally a painless treatment and is given in an outpatient setting without the need for hospitalization.
A woman who has developed an invasive breast cancer usually has several surgical options for treatment. A modified radical mastectomy or removal of the entire breast, nipple complex and lymph nodes, is one well established option. This is inherently quite a physically deforming operation and less disfiguring treatments for breast cancer now exist. Breast conservation treatment for invasive breast cancer consists of lumpectomy (removal of the breast cancer and a surrounding rim of normal tissue), axillary dissection (removal of a portion of the lymph nodes under the arm), and radiation therapy to the remaining breast tissue. This maintains the majority of a woman’s breast and often the shape is not altered significantly. Many studies have compared these two techniques of therapy and both are equally effective in the treatment of invasive breast cancer. The survival rates at 5 and 10 years for both these therapies are the same. Neither therapy can guarantee a cure of the breast cancer as approximately 25-30% of women will ultimately die from their disease.
The choice of breast conservation therapy or modified radical mastectomy is usually an option available to most women with breast cancer. There are some conditions which pose relatively higher risks with breast conservation therapy. These include multiple sites of invasive breast cancer in the same breast, multiple sites of associated ductal carcinoma in situ, a primary breast cancer that was not detected on mammography, a breast that is difficult to evaluate on physical examination or by mammography, the inability to obtain margins that are clear of cancer at the time of lumpectomy, and cancers that are large in comparison to the breast size, which when removed, would lead to severe breast deformity. These conditions tend to have either a higher risk of local recurrence or make the early detection of a local recurrence in the conserved breast difficult if treated with breast conservation therapy. The risk of local recurrence with breast conservation therapy is about 5-7%. The local recurrence rate following modified radical mastectomy is 1-2%.
If modified radical mastectomy is chosen by a woman as the treatment of her breast cancer, then reconstructive surgery to recreate the breast mound can be done either at the time of mastectomy or at a later time. There are several operations that can be performed to reconstruct the breast. Reconstruction can be done with a woman’s own tissue (autologous reconstruction) or a prosthetic implant can be placed.
A prosthetic implant is usually inserted beneath the pectoralis muscle of the chest. There is usually not enough skin left after a mastectomy to place an adequately sized implant. Therefore, a tissue expander is commonly used. This is a balloon- shaped silicone implant which when initially inserted is flat. The tissue expander can be then filled with fluid externally by means of a small valve under the skin. The implant is filled over a period of several months after the operation. This enlarges the tissue expander and stretches the skin until an appropriately sized permanent implant can be placed which simulates the size of the opposite breast.
In autologous reconstruction, the woman’s own tissue is used to reconstruct the breast. A transverse rectus abdominis myocutaneous flap (TRAM flap) or a latissimus dorsi myocutaneous flap are currently the most used. The TRAM flap uses a portion of the abdominal muscles, fat and skin to reconstruct the breast. The latissimus dorsi myocutaneous flap uses a muscle of the upper back along with its overlying skin to reform the breast.
Nipple reconstruction can also be done in conjunction with any of the reconstructive breast procedures.
WHAT HAPPENS AFTER THE SURGICAL PROCEDURE?
Once the surgical procedure has been completed, whether it has been a breast conservation technique or a modified radical mastectomy, the status of the lymph nodes will be known. The presence or absence of cancer in the lymph nodes plays an important role in determining further treatment. If the cancer has spread to the lymph nodes, the risk of the cancer recurring is much higher and the addition of chemotherapy and/or hormonal therapy is usually indicated.
Chemotherapy and hormonal therapy, used in addition to surgery, is known as adjuvant systemic therapy. The purpose of this therapy is to eradicate microscopic deposits of breast cancer cells which still may be present in other areas of the body. The risk of these metastatic cancer cells roughly increases with the size of the original tumor, whether or not there is spread to the lymph nodes, the number of lymph nodes involved, and the microscopic characteristics of the cancer. There are no tests currently available which can tell doctors precisely whether there is microscopic spread of breast cancer. This is important because even when the cancerous tumor is small and there is no evidence of spread to the lymph nodes, there may be reasons to use adjuvant systemic therapy, since approximately 10%-15% of women in this group will still develop metastatic breast cancer.
Chemotherapy in adjuvant breast cancer treatment usually involves using a combination of drugs, typically, cyclophosphamide (CYTOXAN or NEOSAR), methotrexate, and 5-flourouracil (CMF), or cyclophosphamide, doxorubicin (ADRIAMYCIN, RUBEX) and 5-flourouracil. Currently, six cycles of chemotherapy which encompasses about six months of therapy is standard.
Breast cancer tissue is also tested for estrogen and progesterone receptors, or the so-called hormone receptors. A certain percentage of breast cancers will have molecular sites in their cells to which these hormones will attach. The hormones have a role in promoting the growth of cancerous cells. If these hormone receptors are present, the use of an anti-estrogenic agent called tamoxifen can be used. In older, post-menopausal women it can decrease the risk of recurrent breast cancer similar to the decrease seen with the use of chemotherapy. This avoids many of the side effects of chemotherapy which may include nausea, vomiting, hair loss, loss of energy, susceptibility to infection, and heart toxicity. Tamoxifen, however, can increase the risk of uterine cancer. Tamoxifen can also be given following the completion of chemotherapy because in certain women it can decrease the risk of cancer recurrence even further than with just chemotherapy alone. The optimal duration of treatment with tamoxifen is not known and most regimens range from two to five years. There are ongoing studies to help answer this question.
Inflammatory cancer of the breast is a rapidly growing cancer which has often metastasized at the time of diagnosis. A combination of surgery, radiation therapy and chemotherapy is currently now used. Mastectomy is not performed first as is typically the case in breast cancer. Rather, chemotherapy is started immediately. Radiation therapy to the breast follows and surgery is performed subsequently. This sequencing of treatment has shown to provide the best survival statistics compared to other regimens.
Paget’s disease of the breast is treated similarly to other forms of invasive breast cancer. A modified radical mastectomy is the usual treatment of choice. Lumpectomy which includes removing the nipple complex, followed by radiation therapy is sometimes used.
Cystosarcoma phyllodes cancer of the breast spreads somewhat differently than other breast cancers. It is rare for this cancer to ever spread to the lymph nodes, but it does spread through the blood stream. Since it does not involve the lymph nodes, treatment does not involve removing the lymph nodes, even if the tumor is quite large. Treatment consists of removing the tumor with a rim of normal breast tissue or simple mastectomy (removal of the entire breast, but without removing the axillary lymph nodes).
WHAT TREATMENTS ARE USED FOR NON-INVASIVE BREAST CANCER?
The management of non-invasive breast cancer, ductal carcinoma in situ and lobular carcinoma in situ, is much different than with invasive cancer of the breast. Treatment options are less clear cut in non- invasive cancer of the breast.
Ductal carcinoma in situ is a pre-invasive cancer. Its treatment is based on the risk of this disease evolving into an invasive cancer which is then life- threatening. Treatment options for ductal carcinoma in situ include lumpectomy, lumpectomy combined with radiation therapy, and simple mastectomy. A simple mastectomy is an operation which removes the entire breast, but does not remove the axillary lymph nodes as is done in a modified radical mastectomy.
If the area involved with ductal carcinoma is quite small (one centimeter or less) then simply removing this area alone may suffice. If the area of breast involved is larger, then further therapy is usually indicated, because the risk of the breast cancer recurring is reasonably high over the ensuing years. When the cancer recurs, 50% of the time the cancer is invasive. If a simple mastectomy is used to treat carcinoma in situ, the cure rate is 98-99%. Since all the remaining breast tissue is removed, there is no further breast tissue that remains in which a breast cancer can form. Why isn’t the cure rate 100%? This is due to the fact that a microscopic analysis of the cancer can miss a small area of invasive cancer. Therefore, there is a chance that the cancer can metastasize. Secondly, even with the best surgical technique, some breast tissue may remain after a mastectomy.
If a woman wishes to pursue breast conservation therapy and not mastectomy, then lumpectomy and radiation therapy to the remaining breast tissue is used. Data does not yet exist which confirms that this form of therapy is as effective as a simple mastectomy. The results of clinical trials which compare these two forms of therapy should be available within the next several years. Most doctors expect lumpectomy and radiation to compare quite favorably to mastectomy as it does with invasive cancer. There are some forms of ductal carcinoma in situ that are resistant to radiation therapy. The treatment for carcinoma in situ must be individualized in each woman’s case and she should be made aware of the relative risks and benefits of each treatment modality.
Lobular carcinoma in situ is not a pre-invasive cancer as is ductal carcinoma in situ. Rather, it represents a high risk potential for the development of invasive breast cancer. This risk is estimated to be approximately one percent per year. This risk is for both breasts because 50% of the time the invasive cancer will occur in the opposite breast in which the lobular carcinoma in situ was found. Additionally, lobular carcinoma in situ is multifocal (it occurs in many places or throughout the breast).
Since the risk of developing an invasive cancer is acceptably low to most women and their doctors, the usual recommendation is to perform yearly mammograms and to have a breast examination every six months for life. If a more aggressive approach is taken, the only logical choice that exists at this time is the removal of both breasts (bilateral simple mastectomy). This approach is sometimes justified in a woman with a strong family history of breast cancer, and/or the woman who is young at the time of the diagnosis. This is because the cumulative 1% per year risk of developing invasive cancer can be substantial after many years.
Lumpectomy with or without radiation does not significantly decrease the risk of developing an invasive breast cancer with lobular carcinoma in situ. A single mastectomy does not seem to be the answer either, since the invasive cancer can occur in either breast. This is yet another area of breast disease that requires more research and knowledge to optimize management and offer treatment options.
CAN WOMEN HELP THEMSELVES ADDRESS BREAST CANCER ISSUES?
As can be seen, the management of breast cancer is quite varied and complex. The subtleties of each case make it most important for each woman to discuss her options with the health professionals involved in her care.
The best chance of eliminating breast cancer is prevention. However, we currently do not have the knowledge to prevent breast cancer. The capability of diagnosing breast cancer in a much earlier stage than in previous years does exist. Early diagnosis of breast cancer can be achieved with routine mammography and early biopsy of suspicious lesions. The earlier a breast cancer is found, the better the chances of a cure.
Current American Cancer Society guidelines for mammography recommend that a woman should have a baseline mammogram between the ages of 35 and 40. She should have a mammogram every other year between the ages of 40 and 50. Beyond the age of 50, a woman should have a yearly mammogram.
The more the community is educated about breast cancer issues, the greater the likelihood of controlling this deadly disease.
BREAST CANCER AT A GLANCE
* One in every eight women in the United States develops breast cancer.
* The causes of breast cancer are not yet fully known although a number of risk factors have been identified.
* Breast cancer is diagnosed with self- and physician- examination of the breasts, mammography, ultrasound testing, and biopsy.
* There are many types of breast cancer that differ in their capability of spreading (metastasize) to other body tissues.
* Treatment of breast cancer depends on the type and location of the breast cancer, as well as the age and health of the patient.
* The American Cancer Society recommends that a woman should have a baseline mammogram between the ages of 35 and 40 years. Between 40 and 50 years of age mammograms are recommended every other year. After age 50 years, yearly mammograms are recommended.
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