Health

Understanding a Breast Cancer Diagnosis

Written by Dr Karen Tedesco. Posted in Health.

Breast Cancer Surviving Diagnosis
Receiving a breast cancer diagnosis can be overwhelming.  In the United States up to 1 in 8 women will receive a breast cancer diagnosis in her lifetime and despite those odds, many women who do not have a family history of breast cancer, are shocked when they receive their breast cancer diagnoses.  In addition to the obvious immediate concerns about prognosis, treatment side effects, and managing other components of one’s work and personal life, there also comes a deluge of new information, new terminology, multiple doctor visits and a multitude of advice; both the solicited and unsolicited varieties. To complicate matters further, breast cancer is a very heterogeneous groups of disorders, meaning that every breast cancer is different due to many features about the breast cancer itself and  the patient that are taken into account when assessing prognosis and potential treatment options.   Fortunately, there are often many options available to treat breast cancer and each patient can receive a treatment strategy that is individualized.  

When a patient meets with an oncologist to review a breast cancer diagnosis, staging will be discussed.  Breast cancer staging is determined by tumor size and involvement of nearby structures such as skin and chest wall,  whether and to what extent lymph nodes under the arm or in the chest are involved by tumor, and whether the cancer has spread, or metastasized, to areas of the body outside of the breast and lymph nodes.   This is called TNM staging (Tumor, Nodes, Metastasis).  Most other types of cancer have a similar type of staging system.  The breast cancer stage can range from 0 (precancerous) to IV (metastatic to sites outside of the breast and nearby lymph nodes).  The stage is often not known at an initial evaluation and additional imaging, surgery, or further biopsy is frequently required before this information is known with certainty.  The stage of breast cancer is important in determining prognosis and treatment options including whether and what types of surgery, radiation, and drug therapies will be appropriate.

Beyond the information used in determining stage, an oncologist will speak with a newly diagnosed breast cancer patient about pathologic features of the tumor and molecular testing done on the tumor. Breast cancers are assigned a grade by the pathologist depending on how the breast cancer cells look when examined under a microscope.  The breast cancer grade is often expressed as 1 (well differentiated), 2 (moderately differentiated), or 3 (poorly differentiated) depending on how similar or dissimilar the breast cancer cells look compared to non-cancerous breast cells.  This feature can help predict the biological behavior or aggressiveness of a breast cancer and may be useful in choosing drug therapy.   The pathologist may describe other features about the breast cancer cells that may be helpful in predicting their propensity to divide and spread.  

An oncologist will also review receptor status of a breast cancer with a newly diagnosed patient. The main receptors that are measured are 2 hormone receptor; estrogen receptor (ER) and progesterone receptor (PR) and HER2 or HER2-neu.  The hormone receptor status is assessed by staining techniques done on the tumor by a patholgoist.  About 70% of breast cancers will test positive for hormone receptors; some will be strongly positive and others weakly positive.  Patients who have hormone receptor positive cancers of any stage may be eligible for hormonal therapy treatments for their breast cancer management.  Many of the hormonal therapies are pills and are often taken for prolonged periods of time.

Tumors that are strongly hormone receptor positive may have a natural history that includes a slower pattern of growth.  Her-2 status can be determined by a pathologist by either assessing overexpression of the Her-2 protein on breast cancer cell surface or by measuring the number of copies of the Her-2 gene present in breast cancer cells.  About 15% of all breast cancers will test positive for Her-2.  Her-2 over-expression has been shown to be associated with higher risk of breast cancer growth and spread; however, with the development of several drugs that target the Her-2 protein, such as herceptin, the natural history of this type of breast cancer has dramatically improved.  Patients who develop Her-2 positive breast cancer now have many more treatment options and better prognosis than people who were diagnosed before the advent of these type of Her-2 “targeted” drugs.  Breast cancers can be both hormone receptor positive and Her-2 positive, hormone receptor positive and Her-2 negative, hormone receptor negative and Her-2 positive, or both hormone receptors and Her-2 can be negative, which is sometimes called “triple negative”.  Many clinicians don’t care for that term because it implies that all tumors that are hormone receptor negative and Her-2 negative can be viewed as a homogeneous group, when in fact,  “triple negative” breast cancers have been found to be a heterogeneous group themselves in terms of what is driving the cancer and what therapies work best.  Some subtypes of “triple negative” breast cancer can have a propensity for rapid growth and spread.

After the first visit with a medical oncologist, the overall treatment plan is generally not fully elucidated.  Depending on presumed stage, receptor status, and symptoms, additional imaging, biopsies or further testing done on the tumor itself may be indicated. In particular tests to assess expression of various genes within the tumor itself may be helpful in predicting prognosis and responsiveness to various medical therapies. Many  presumed early stage breast cancer patients see the medical oncologist prior to completing definitive surgery, so will need to see the surgeon again and potentially a radiation oncologist.  If patients have advanced or metastatic breast cancer the main treatment will be drug therapy, which is selected based on factors such as receptor status, availability of clinical trials and patient/ physician preference.  For patients with early stage breast cancer, most commonly patients have definitive surgery first, followed by chemotherapy if indicated.  Then radiation therapy starts if indicated, based on extent of tumor and type of surgery that was done.  Hormonal therapy can start at the same time as radiation or after it is completed, when indicated.  In some cases drug therapy can be given before definitive breast surgery.  A couple of common reasons for this approach include need to shrink a tumor so that surgery is possible or as part of participation in a clinical trial evaluating a new therapy.  

It has also become a more typical practice for Her-2 positive breast cancers that are either larger than 2cm or have at least one involved lymph node.  For that situation, there are combinations of chemotherapy and Her-2 targeted drugs that are currently FDA approved for use prior to surgery but not after.

Second opinions should be sought any time that is desired by the patient or the initial physicians.  If you obtain a second opinion at a large academic cancer center that will often involve multi-disciplinary review of your case, including not only a surgeon, medical oncologist and radiation oncologist but can also include a pathologist reviewing of the material obtained at biopsy or definitive surgery and a radiologist reviewing the imaging studies.  Patients often don’t think of getting additional opinions from radiologists or pathologists since those are often doctors that patients never meet.  However, having accurate interpretations and clear reporting of findings that need to be used by other physicians is absolutely imperative to receiving the best possible care.  Alert your oncologist that you would like to get another opinion.  The initial physician can be very helpful in recommending another reputable facility and can assist in getting all of the necessary scans, pathology slides, and reports to the site where the second opinion will be done.  Also, the initial doctor will want to know who you are seeing so the various physicians can work together to coordinate care if applicable.

If not specifically addressed by your oncologist, I recommend asking if there are clinical trials or research studies available that are evaluating new therapies with a goal of improving outcomes compared to current standards of care.  I also suggest asking about whether there are features about your family history, ethnicity or tumor type that make you a candidate for genetic testing for a familial cancer syndrome.  This could have implications for your immediate care and for the health of family members.  All patients should speak with their doctors about lifestyle interventions, including diet and exercise strategies that can be helpful in improving outcomes from  breast cancer.  Finally all breast cancer patients should seek support, be that from family, friends, clergy, or support groups per their own individual needs and believes, as they go through your uniquely challenging journey.


Dr Karen TedescoDr. Tedesco earned her MD from SUNY Health Science Center in Syracuse, NY and graduated magna cum laude. She completed an Internal Medicine residency at University of Michigan Medical Center and  her Hematology and Oncology fellowship at Vanderbilt University Medical Center.  Dr. Tedesco is board certified in Internal Medicine, Hematology, and Oncology and a member of many professional societies including AOA medical Honor Society, AMA, ASCO, and ASH.
Dr. Tedesco has been an attending physician with NY Oncology Hematology since completing fellowship in 2004.  She has been Vice President of the NYOH Board of Directors since 2011.  She is the program director for the NYOH Hereditary Cancer Risk Assessment Program and completed the Intensive Course in Cancer Risk Assessment through the City of Hope Division of Clinical Cancer Genetics.   Dr. Tedesco is a member of the US Oncology Genetic Risk Evaluation and Testing (GREAT) program Steering Committee and member of the GREAT program research committee. She is director NYOH Physician Mentoring Program.  Dr. Tedesco is a member of the USON Breast Cancer Research Committee and local PI for many breast cancer clinical trials.  She has served as co-director of the NYOH/Albany Medical College annual Translational Research Symposium and regularly teaches medical students and residents.  Dr. Tedesco is a member of the NYOH Pharmacy and Therapeutics Committee and participates in USON breast cancer pathways/guidelines development and compliance.  She has completed training as an Advance Care Planning facilitator.   Dr. Tedesco practices general Hematology and Oncology with a particular interest in breast cancer.  She is regularly involved in community based education and outreach events.  
 
Receiving a breast cancer diagnosis can be overwhelming.  In the United States up to 1 in 8 women will receive a breast cancer diagnosis in her lifetime and despite those odds, many women who do not have a family history of breast cancer, are shocked when they receive their breast cancer diagnoses.  In addition to the obvious immediate concerns about prognosis, treatment side effects, and managing other components of one’s work and personal life, there also comes a deluge of new information, new terminology, multiple doctor visits and a multitude of advice; both the solicited and unsolicited varieties. To complicate matters further, breast cancer is a very heterogeneous groups of disorders, meaning that every breast cancer is different due to many features about the breast cancer itself and  the patient that are taken into account when assessing prognosis and potential treatment options.   Fortunately, there are often many options available to treat breast cancer and each patient can receive a treatment strategy that is individualized.   When a patient meets with an oncologist to review a breast cancer diagnosis, staging will be discussed.  Breast cancer staging is determined by tumor size and involvement of nearby structures such as skin and chest wall,  whether and to what extent lymph nodes under the arm or in the chest are involved by tumor, and whether the cancer has spread, or metastasized, to areas of the body outside of the breast and lymph nodes.   This is called TNM staging (Tumor, Nodes, Metastasis).  Most other types of cancer have a similar type of staging system.  The breast cancer stage can range from 0 (precancerous) to IV (metastatic to sites outside of the breast and nearby lymph nodes).  The stage is often not known at an initial evaluation and additional imaging, surgery, or further biopsy is frequently required before this information is known with certainty.  The stage of breast cancer is important in determining prognosis and treatment options including whether and what types of surgery, radiation, and drug therapies will be appropriate.      Beyond the information used in determining stage, an oncologist will speak with a newly diagnosed breast cancer patient about pathologic features of the tumor and molecular testing done on the tumor. Breast cancers are assigned a grade by the pathologist depending on how the breast cancer cells look when examined under a microscope.  The breast cancer grade is often expressed as 1 (well differentiated), 2 (moderately differentiated), or 3 (poorly differentiated) depending on how similar or dissimilar the breast cancer cells look compared to non-cancerous breast cells.  This feature can help predict the biological behavior or aggressiveness of a breast cancer and may be useful in choosing drug therapy.   The pathologist may describe other features about the breast cancer cells that may be helpful in predicting their propensity to divide and spread.   An oncologist will also review receptor status of a breast cancer with a newly diagnosed patient. The main receptors that are measured are 2 hormone receptor; estrogen receptor (ER) and progesterone receptor (PR) and HER2 or HER2-neu.  The hormone receptor status is assessed by staining techniques done on the tumor by a patholgoist.  About 70% of breast cancers will test positive for hormone receptors; some will be strongly positive and others weakly positive.  Patients who have hormone receptor positive cancers of any stage may be eligible for hormonal therapy treatments for their breast cancer management.  Many of the hormonal therapies are pills and are often taken for prolonged periods of time.  Tumors that are strongly hormone receptor positive may have a natural history that includes a slower pattern of growth.  Her-2 status can be determined by a pathologist by either assessing overexpression of the Her-2 protein on breast cancer cell surface or by measuring the number of copies of the Her-2 gene present in breast cancer cells.  About 15% of all breast cancers will test positive for Her-2.  Her-2 over-expression has been shown to be associated with higher risk of breast cancer growth and spread; however, with the development of several drugs that target the Her-2 protein, such as herceptin, the natural history of this type of breast cancer has dramatically improved.  Patients who develop Her-2 positive breast cancer now have many more treatment options and better prognosis than people who were diagnosed before the advent of these type of Her-2 “targeted” drugs.  Breast cancers can be both hormone receptor positive and Her-2 positive, hormone receptor positive and Her-2 negative, hormone receptor negative and Her-2 positive, or both hormone receptors and Her-2 can be negative, which is sometimes called “triple negative”.  Many clinicians don’t care for that term because it implies that all tumors that are hormone receptor negative and Her-2 negative can be viewed as a homogeneous group, when in fact,  “triple negative” breast cancers have been found to be a heterogeneous group themselves in terms of what is driving the cancer and what therapies work best.  Some subtypes of “triple negative” breast cancer can have a propensity for rapid growth and spread. After the first visit with a medical oncologist, the overall treatment plan is generally not fully elucidated.  Depending on presumed stage, receptor status, and symptoms, additional imaging, biopsies or further testing done on the tumor itself may be indicated. In particular tests to assess expression of various genes within the tumor itself may be helpful in predicting prognosis and responsiveness to various medical therapies. Many  presumed early stage breast cancer patients see the medical oncologist prior to completing definitive surgery, so will need to see the surgeon again and potentially a radiation oncologist.  If patients have advanced or metastatic breast cancer the main treatment will be drug therapy, which is selected based on factors such as receptor status, availability of clinical trials and patient/ physician preference.  For patients with early stage breast cancer, most commonly patients have definitive surgery first, followed by chemotherapy if indicated.  Then radiation therapy starts if indicated, based on extent of tumor and type of surgery that was done.  Hormonal therapy can start at the same time as radiation or after it is completed, when indicated.  In some cases drug therapy can be given before definitive breast surgery.  A couple of common reasons for this approach include need to shrink a tumor so that surgery is possible or as part of participation in a clinical trial evaluating a new therapy.  It has also become a more typical practice for Her-2 positive breast cancers that are either larger than 2cm or have at least one involved lymph node.  For that situation, there are combinations of chemotherapy and Her-2 targeted drugs that are currently FDA approved for use prior to surgery but not after. Second opinions should be sought any time that is desired by the patient or the initial physicians.  If you obtain a second opinion at a large academic cancer center that will often involve multi-disciplinary review of your case, including not only a surgeon, medical oncologist and radiation oncologist but can also include a pathologist reviewing of the material obtained at biopsy or definitive surgery and a radiologist reviewing the imaging studies.  Patients often don’t think of getting additional opinions from radiologists or pathologists since those are often doctors that patients never meet.  However, having accurate interpretations and clear reporting of findings that need to be used by other physicians is absolutely imperative to receiving the best possible care.  Alert your oncologist that you would like to get another opinion.  The initial physician can be very helpful in recommending another reputable facility and can assist in getting all of the necessary scans, pathology slides, and reports to the site where the second opinion will be done.  Also, the initial doctor will want to know who you are seeing so the various physicians can work together to coordinate care if applicable. If not specifically addressed by your oncologist, I recommend asking if there are clinical trials or research studies available that are evaluating new therapies with a goal of improving outcomes compared to current standards of care.  I also suggest asking about whether there are features about your family history, ethnicity or tumor type that make you a candidate for genetic testing for a familial cancer syndrome.  This could have implications for your immediate care and for the health of family members.  All patients should speak with their doctors about lifestyle interventions, including diet and exercise strategies that can be helpful in improving outcomes from  breast cancer.  Finally all breast cancer patients should seek support, be that from family, friends, clergy, or support groups per their own individual needs and believes, as they go through your uniquely challenging journey.
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