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Breast Cancer: The Complete Guide

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Fifth Edition

Written by Yashar HirshautAuthor Alerts:  Random House will alert you to new works by Yashar Hirshaut and Peter PressmanAuthor Alerts:  Random House will alert you to new works by Peter Pressman
Foreword by Jane BrodyAuthor Alerts:  Random House will alert you to new works by Jane Brody

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On Sale: January 20, 2009
Pages: | ISBN: 978-0-553-90685-1
Published by : Bantam Bantam Dell
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ABOUT THE BOOK ABOUT THE BOOK
ABOUT THE AUTHOR ABOUT THE AUTHOR
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Synopsis|Excerpt

Synopsis

Written by two renowned authorities who specialize in the treatment of breast cancer, a surgeon and an oncologist, this lucid step-by-step guide has established itself as the indispensable book women need to make informed decisions about the care that is right for them.

Breast cancer will strike one out of every eight women in the United States. Because there have been many important changes in the diagnosis and treatment of breast cancer in the last few years, this fully revised Third Edition contains information on the latest developments in the field, including:

• new diagnostic procedures
• changes in the treatment of in situ cancer
• improved surgical techniques
• gene testing
• sequencing radiation and chemotherapy
• HER-2Neu (Herceptin)
• tamoxifen for prevention
• bone marrow and stem cell transplants
• and more

Excerpt

How do I know which type of surgery is right for me?


Our basic job is to get rid of the cancer and prevent its spread and recurrence, if possible while preserving the breast. In order to accomplish that task, we have to understand the nature or pathology of the malignancy; its stage, including its size and how much it has spread; its location in the breast; and the size of the breast itself. We also have to give serious consideration to what you yourself prefer.

The following sections describe the general circumstances under which each type of surgery is appropriate.


Stage 0 Cancer


Stage 0 cancers are noninfiltrating cancers confined to the lobules and ducts.

Lobular carcinoma in situ (LCIS), generally speaking, requires no surgery after the biopsy. It should, however, be very carefully watched. Mammography and a physical examination by a doctor should be regularly scheduled because this in situ cancer is what we call a marker of great risk. Twenty percent of women with this symptom develop infiltrating cancers over a twenty-year period and there is a likelihood that both breasts are at risk.

In the past, duct cell carcinoma in situ (DCIS) was usually discovered after a biopsy for a nipple discharge or ulceration. With the recent improvements in mammography, we are able to pick up very early abnormalities, and now over twenty percent of the women we treat for breast cancer have DCIS.

To treat DCIS, we do a total mastectomy (without lymph node removal) or we do a lumpectomy followed by radiation therapy. Which procedure to choose poses a dilemma. We know that if we treat DCIS with mastectomy, we can achieve close to one hundred percent success. If we preserve the breast with a wide excision and radiotherapy, there is a one-percent-a-year recurrence rate. Of those women who have a recurrence, half can be successfully treated with mastectomy. The other half will have infiltrating disease. Some of them will be cured, but some lives will be lost.

Many women and their doctors say, “If there is any risk of recurrence at all, do a mastectomy.” Others decide that one percent a year is an acceptable risk. They are opting for as wide an excision as can be done to avoid deformity, along with radiation therapy.

As we will see below, invasive cancers are treated with lumpectomy, node removal, and radiation. It seems paradoxical that cases of DCIS — that is, of noninvasive cancer — are often treated with mastectomy because of the one hundred percent cure rate. As one of my patients said, “Is the loss of my breast the reward I get for finding cancer before it has spread?”

There are studies now under way to try to resolve this dichotomy, and to find out whether, in some cases of DCIS, wide excision alone is adequate treatment. In the meantime, if you have an in situ ductal cancer, you and your doctor will have to carefully discuss and weigh your treatment options We are not yet at the point where, as in early lobular cancers, we can monitor and observe and, at least, delay surgery. But treatment for intraductal carcinomas in situ can and should be individualized and the options carefully weighed as to their physical and emotional consequences.

Stage I and Stage II Cancers



The discussion of treatment for these cancers is best begun with a quote from “the horse’s mouth,” a conference convened by the National Institutes of Health (NIH) to evaluate available scientific information and to “resolve safety and efficacy issues related to biomedical technology.” According to the findings of this NIH Consensus Conference on early, invasive breast cancer, in June 1990, “Breast conservation treatment is an appropriate method of primary therapy for the majority of women with Stages I and II breast cancer and is preferable because it provides survival rates equivalent to those of total mastectomy [modified radical] and axillary dissection while preserving the breast.”

To clarify, lumpectomy with axillary dissection and radiation therapy is the preferable treatment for small infiltrating cancers of either the lobules or the ducts.

There are, however, circumstances where mastectomy is the treatment advised for Stage I and Stage II cancers:

• More than one cancerous tumor in the breast

• Multiple areas of microcalcification (see page 77) in the breast

• A relatively large tumor in a small breast or a tumor in or near the center of the breast

• Considerable axillary lymph-node involvement

In addition, some physicians consider mastectomy the preferred treatment in the following circumstances:

• Extensive intraductal cancer in situ within and adjacent to the primary tumor

• An infiltrating cancer plus a considerable amount of intraductal cancer

Under certain circumstances, we may recommend a bilateral mastectomy when there is lobular cancer in situ:

• If there have been recurrent lumps that required biopsy

• If mammograms show calcifications that are difficult to interpret

• If there is an extremely strong family history of breast cancer

Stage III Cancers



We have, up until now, been discussing early, relatively small cancers. As we saw in Chapter Three, some women come for treatment with more advanced disease. In such cases, the cancer may be in the skin of the breast, it may be of the inflammatory type, it may be accompanied by extensive lymph-node involvement, or the tumor may be over five centimeters (about two inches) in size.

For Stage III cancers, chemotherapy (see Chapter Ten) is the first treatment. It is used to treat inflammatory cancer and also to shrink a large tumor to operable size. Surgery, usually a modified radical mastectomy, is performed after the tumor has shrunk.

Stage IV Cancers



Stage IV cancers have spread beyond the breast and the axillary lymph nodes to other places in the body. They are treated primarily with chemotherapy. Surgery — lumpectomy or modified radical mastectomy — or radiation therapy may sometimes be used to assist in local tumor control.

It is important to say here that I have patients in my practice who came to me with a large tumor and who have done well, usually with chemotherapy followed by surgery. In a few instances, where the tumor was inoperable, some women have survived for many years on long-term chemotherapy.

Cancer in Pregnancy


As we saw in Chapter Three, breast cancer in pregnant women tends to be discovered at a later stage than cancer in other women. Our general approach is to “abort the cancer, not the baby.” However, when cancer is discovered during the first trimester, women usually choose to terminate the pregnancy and then to promptly seek the most appropriate treatment for the disease.

During the second trimester or later, a mastectomy can be safely performed. We do not use radiation with pregnant women so as not to risk the well-being of the fetus. Chemotherapy may be started only in the very last weeks of pregnancy.

Treatment Options



To summarize the sequence of treatment that may be recommended for all stages of breast cancer:

STAGE 0

LOBULAR CARCINOMA IN SITU
1. Biopsy
2. Observation
3. Possible hormone therapy
or
1. Bilateral mastectomy
2. Breast reconstruction

DUCTAL CARCINOMA IN SITU
1. Biopsy
2. Mastectomy
or
1. Wide excision with observation only (experimental)
or
1. Wide excision plus radiation

STAGE I
1. Biopsy
2. Partial (lumpectomy) or modified radical mastectomy
3. Axillary dissection
4. If mastectomy, possible breast reconstruction
5. If lumpectomy, radiation therapy
6. Possible hormone therapy or chemotherapy

STAGE II
1. Biopsy
2. Lumpectomy or modified radical mastectomy
3. Axillary dissection
4. If mastectomy, possible breast reconstruction
5. If lumpectomy, radiation therapy
6. Hormone therapy or chemotherapy

STAGE III
1. Biopsy
2. Course of chemotherapy
3. Modified radical mastectomy
4. Continued chemotherapy
5. Radiation therapy

STAGE IV
1. Biopsy
2. Course of chemotherapy
3. If appropriate, lumpectomy
or
Modified radical mastectomy
4. Continued chemotherapy
Yashar Hirshaut|Peter Pressman|Jane Brody|Author Q&A

About Yashar Hirshaut

Yashar Hirshaut - Breast Cancer: The Complete Guide
Yashar Hirshaut is a medical oncologist specializing in the treatment of breast cancer. A graduate of the Albert Einstein College of Medicine, he completed his oncology training at the National Cancer Institute in Bethesda, Maryland, and at the Memorial Sloan-Kettering Cancer Center in New York. Form 1970 to 1986 he served as an attending physician at Memorial Sloan-Kettering on the Clinical Immunology Service and an associate professor of medicine at the Cornell University Medical College. He was also head of the Laboratory for Immuno-diagnosis at Sloan-Kettering. In addition to being in private practice, he is currently associate clinical professor of medicine at Cornell University, adjunct professor of biology at Yeshiva University, and an attending physician at Mount Sinai Medical Center and Beth Israel and Lenox Hill Hospitals in New York City.

About Peter Pressman

Peter Pressman - Breast Cancer: The Complete Guide
Peter I. Pressman is a surgical oncologist who specializes in the treatment of breast cancer. A graduate of Columbia College and the Columbia University College of Physicians and Surgeons, he trained at Presbyterian Hospital and the Columbia Division of Bellevue Hospital in New York City. Dr. Pressman has been in private practice in New York for over thirty-five years and is Clinical Professor of Surgery at the Weill Medical College of Cornell University. He was attending surgeon at Beth Israel Medical Center and Lenox Hill Hospital.

About Jane Brody

Jane Brody - Breast Cancer: The Complete Guide
Jane Brody writes a weekly personal health column for The New York Times, which is syndicated in scores of other newspapers around the country. She is the author of several books, including Jane Brody's Guide to the Great Beyond, Jane Brody’s Good Food Book, Jane Brody’s Nutrition Book, and Jane Brody’s Good Seafood Book. She has also written many magazine articles and frequently lectures on health issues to audiences both lay and professional. She has appeared on hundreds of radio and television shows and has received numerous prestigious awards for journalistic excellence.

Author Q&A


Most people know that October is Breast Cancer Awareness month. As experts in the field, what would you say is the #1 thing for women, and men, to be aware of in preventing or treating breast cancer?

Research continues to confirm that eating well, being physically active and following screening recommendations is the best advice. Mammography continues to be the most effective tool available to protect women from breast cancer. If there is breast cancer in the family, earlier screening and intervention are increasingly effective in disease prevention and cure. A family history of breast or ovarian cancer should motivate genetic testing.

The new research into the role that genetics plays in cancer occurrence is fascinating. Can you tell us more about some of the recent findings and breakthroughs, and inform the readers of Breast Cancer: The Complete Guide how this informs the new edition?


The impact of genetic discoveries on breast cancer is just starting to be felt. Today, the two genes which in their abnormal forms have already been identified as causes of familial breast cancer, BRCA1 and BRCA2, account for as many as 5% of all new breast cancers. Learning more about how these genes work will help us discover what genetic changes lead to non-familial breast cancers as well. It is now so important that in Breast Cancer: The Complete Guide, 5th Edition, there is an entire separate chapter devoted to GENETICS. The surgical and medical approaches to preventing breast and ovarian cancers are outlined in the PREVENTION chapter.

Many breast cancers have abnormal genes or abnormal amounts of specific genes. The best known of these genes, HER-2, affects the growth rates of tumor cells and their response to hormone and drug treatments. Knowledge of the role of HER-2 resulted in the development of a drug that has reduced the risk of recurrence of HER-2 positive tumors by 52%. Recent developments in identifying other such gene targets and preparing drugs against them are presented in the new edition. Attacking multiple abnormal gene targets is one way in which advanced breast cancer may be cured or converted to a chronic non-life threatening illness.

Finally, research has identified abnormal sets of genes which are associated with the likelihood of recurrence. One of these gene sets now available is the Oncotype test. A randomized clinical research trial is now underway to see if Oncotype results can tell us whom to treat with chemotherapy and who can avoid such treatment. In the book we explain such tests and the potential contributions they can make to tailoring treatments to the needs of individual patients.

There is a familiar saying: “Knowledge is Power.” How will Breast Cancer: The Complete Guide empower patients?

Discovering one has cancer is very frightening and at least temporarily disabling. It is a new and dangerous world about which most people know something—but not enough to make the important decisions that suddenly confront them. An informed patient is best positioned to receive the best treatment. Breast Cancer: The Complete Guide can be read in its entirety at once, but, it is designed to take each person step by step through the journey from discovery through diagnosis and treatment. Our book provides the information she (or he) needs in a well-organized, clearly explained and reassuring form. It is a companion that they can rely on at every step of the journey to restored good health.

In many communities, the local medical expert is the authority. How can another doctor use this book to augment her/his support throughout a patient’s experience? Why would a trained medical professional benefit from reviewing this new edition?

Doctors who must counsel patients with newly discovered breast cancer can use our book as a tool to help patients understand what they are confronting and how to deal effectively with the challenges they may face along the way. Breast cancer treatment now involves so many specialties that most doctors cannot know all the information presented in the book. It is a repository of the most up to date and comprehensive information on chemotherapy, hormone therapy, and targeted therapy as well as diagnostic procedures, surgery, radiation therapy and new directions in research and clinical trials.

In the foreword to your book noted “Personal Health” columnist for The New York Times, Jane Brody, states “Now is the time to replace fear with facts…. No more ‘one size fits all’ [treatments].” What are the facts that can replace the fear? And what are a few of the factors that have changed treatment options, for a more individualized approach?

Most women who develop a breast cancer will live long and productive lives. In the 1960s the five-year survival rate was 62%. At present, the five year survival is 88.5%. More and more people are being cured.

In addition, as treatment options improve, women no longer have to fear that the cure will be worse than the disease. Oncoplastic surgery, which combines techniques for optimal removal of tumor with those that provide the best cosmetic results, offers many women a chance to retain attractive breasts while having the surgery they need. Lumpectomies are more frequently done than mastectomies. For some women, particularly where there is a gene mutation, mastectomies may be advised but for others immediate breast reconstruction can retain a near-normal appearance. The fear of arm swelling after lymph node removal has markedly diminished because of the use of the sentinel node biopsy procedure.

Changes continue: is there something (a treatment, new information) on the horizon that brings even greater hope to women and men everywhere?



This is the Fifth Edition of Breast Cancer: The Complete Guide. Starting with the Second Edition (in 1996) we have changed about one third of the book with each edition. That speaks to the rapid progress that is being made in our understanding and treatment of breast cancer.

Promising progress is being made in our understanding of the causes of breast cancer. As noted earlier, the study of genes is the perfect example. Knowing about a gene mutation makes it possible to reduce the risk of developing a cancer. The use of MRI in screening has also made it possible to discover earlier cancers and institute preventive programs. It is also very important that we are learning more about how genes interact with each other in groups providing the intricate web of functions that are needed to keep a cell normal. At the same time we are learning about the influence of environmental factors on gene stability. This is known as the field of epigenetics.

Delving into the perilous art of predicting the future, the next major advance in our efforts to cure breast cancer is likely to come from the discovery of a number of drugs that can target genetic or epigenetic pathways; these would be protocols and combinations used as we now use combined treatments in the long-term control of AIDS–in some ways a much more insidious disease. The ultimate aim in our focus on genetics is to identify an abnormality and correct it with an injection.

As authors (in addition to being respected doctors) what do you hope a reader gains from Breast Cancer: The Complete Guide, 5th Edition?

Many of our patients have told us this book has helped them along the journey to regained health. We set out to create a book that would serve the breast cancer patient very much like the way Benjamin Spock’s book has served new mothers for many decades–instilling a sense of security in our readers, and the confidence to know how to select doctors, and to ask questions, and to make intelligent decisions about their individual care.

To meet our obligations we have worked hard with each edition to revise the book to provide the most recent information in a comprehensive way while keeping the language clear and the contents reader friendly. The Fifth Edition represents our greatest effort yet to provide our readers with what they need to know.

Praise

Praise

“It should be required reading for everyone who is touched by the disease, whether personally or through a family member, friend, colleague, employee, or a patient diagnosed with breast cancer.... I can’t recommend it enough.”— Today’s OR Nurse

“These experts demystify breast cancer in understandable and compassionate terms.... Should help hundreds of thousands of women.”— James F. Holland, M.D. Chairman, Department of Neoplastic Diseases, Mount Sinai Medical Center

“Both timely and current — [It] discusses the most common cancer in women in a precise, clear, and positive way, providing essential information in a warm, supportive fashion in a readable and understandable format.”— Journal of the National Cancer Institute

“Comprehensive, up-to-date, and highly detailed ... From selecting the best doctors to describing procedures and treatments, the authors answer all possible questions in a calm, rational manner.... Highly recommended.”— Library Journal

“Every woman is touched by the reality of breast cancer — by the fear of it or the fact of it.... Drs. Pressman and Hirshaut have written the essential guide, one that should be required reading for every woman.”— Barbara Gordon author of I’m Dancing as Fast as I Can

“This is a humane, compassionate book which nonetheless manages to be straightforward and comprehensive; the authors have succeeded in addressing the many questions (and the fears) of breast cancer patients, and have done a thorough and sensitive job.”— Share

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