Breast Cancer. Patient Resources. Classification of Breast Cancer YOUR GUIDE TO

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1 YOUR GUIDE TO Breast Cancer Classificatin f Breast Cancer Treatment Optins Fllw-up Patient Resurces Patient Resurces Natinal Cancer Centre Cancer Helpline Tel: Breast Cancer Fundatin Tel: Singapre Cancer Sciety Tel: This pamphlet cntains general infrmatin and advice regarding yur cnditin and is designed t prvide yu with a guide n hw best t safeguard yur health. Hwever, it is nt intended t cntain exhaustive instructins. In specific cases yu may receive different/additinal instructins frm yur dctr. Yu are advised t fllw any specific written r ral instructins given t yu by yur dctr r healthcare wrker. Please seek clarificatin if in dubt. Classificatin f Breast Cancer Breast cancer is the abnrmal grwth f the cells that line the ducts and lbes f the breast. The mst cmmn types f breast cancers are: Ductal carcinma in situ (DCIS): This is a cnditin als called Stage 0 breast cancer. It is nninvasive and is cnfined t the ducts. Infiltrating (invasive) ductal carcinma (IDC): This cancer starts in a milk duct, breaks thrugh the wall f the duct and invades the fatty tissue f the breast. It can spread t ther parts f the bdy. Infiltrating (invasive) lbular carcinma (ILC): This cancer starts in the milk glands (lbules) and can spread t ther parts f the bdy. Tumur prperties Tests are dne n the tumur cells t guide treatment and it can predict patient utcme Estrgen receptr (ER) and Prgesterne Receptr (PR) status (type f hrmne receptrs in breast cancer cells). Human epidermal grwth factr type 2 receptr (HER2) r cerbb2 status Spread f cancer Ndal status - the presence f cancer cells in glands r lymph ndes in the armpit n the same side (which means tumur has spread via the lymphatic system t lymph ndes in the armpit); if present, hw many. Metastasis - the spread f cancer int ther distant tissues, mst cmmn sites are the lungs, bnes, r liver.

2 STAGE OF BREAST CANCER STAGE III BREAST CANCER This determined by the tumur type and size, lymph nde spread as well as distant spread. STAGE 0 BREAST CANCER (DCIS) Tumurs are mre than 5 cm with lymph nde invlved Tumurs 0-5 cm with 4-9 invlved r fixed lymph nde invlved Tumurs that have invlved the skin and/r chest wall Tumurs with mre than 9 lymph ndes invlved Ductal carcinma in-situ (DCIS) is an early nninvasive cnditin in which cancer cells are fund in the lining f a breast duct, and have nt spread utside the duct t ther tissues in the breast. STAGE I BREAST CANCER Tumurs are 0-2 cm N lymph nde invlved r small clusters f cancer cells (frm 0.2 mm - 2 mm) STAGE II BREAST CANCER Tumurs are 0-2 cm with small clusters f cancer cells in lymph ndes (frm 0.2 mm - 2 mm) Tumurs 2-5 cm with mvable r up t 3 lymph ndes invlved Tumurs mre than 5 cm but n lymph nde invlved STAGE IV BREAST CANCER Advanced cancer in which the cancer cells have spread (metastasized) t ther parts f the bdy, mst ften the lungs, bnes, r liver. Treatment: The gal in stage IV disease is t stabilize the disease. Systemic therapy (treatment that ges thrughut the entire bdy) such as chemtherapy and targeted therapies may be used. Hrmne therapy is used fr ER-psitive tumurs Tumur may be treated with radiatin therapy. Tumur is surgically remved where pssible, especially in cases where symptms must be alleviated.

3 Treatment Optins The current treatment f breast cancer invlves cmbinatin therapies which include surgical treatment f the breast and the axillary lymph ndes as well as ther therapies. 1. SURGERY This is cnsidered in 2 parts: a. Breast: Lumpectmy - remval f the tumur with a margin f nrmal tissue. Generally smaller breast tumurs can be managed with a lumpectmy, in which case the tumur is remved but the rest f the breast is left intact. This is usually fllwed with raditherapy f the remaining breast. Mastectmy- remval f the whle breast. Patients with tumurs that are larger, arund the nipple, multi-centric tumurs (i.e., multiple tumurs in different parts f the breast) will need a mastectmy; r when raditherapy is cntraindicated. b. Axillary lymph ndes: Sentinel lymph nde bipsy (SLNB) - a surgery that takes ut lymph nde tissue t lk fr cancer. Patients with invasive tumurs less than 5 cm and n palpable lymph ndes may have sentinel lymph nde bipsy. This requires an injectin f a blue dye r special tracer substance befre surgery. If cancer is fund in the sentinel lymph nde at the time f surgery, mre surgery will be needed t remve additinal the lymph ndes in the armpit (axillary clearance). SLNB is als perfrmed fr patients with DCIS underging mastectmy. Axillary clearance a mre extensive surgery where additinal lymph are remved frm the armpit. c. Breast recnstructin This may be cnsidered fr patients underging mastectmy: Immediate breast recnstructin - dne in the same sitting with the mastectmy Delayed breast recnstructin - dne after initial mastectmy and cmpletin f ther treatments such as chemtherapy and raditherapy Cmmn side effects may include: Pain after the peratin. This is well managed with painkillers Serma (tissue fluid) cllectin beneath the skin Wund infectin Tightness r discmfrt ver the chest that reslve ver time Stiffness f the shulder which will recver with physitherapy Lymphedema: a build-up f lymphatic fluid that may cause swelling ften in the arm n the same side as the affected breast. This may ccur in patients with axillary surgery.

4 Numbness ver the skin f the chest r upper arm 2. CHEMOTHERAPY Chemtherapy is treatment with medicatin that ges thrughut the bdy t kill cancer cells and t imprve the chance f cure. Chemtherapy is usually given as a cmbinatin f drugs t treat breast cancer. Many types and dsages f drugs are used depending n the situatin. Chemtherapy may be used after surgery in an attempt t kill remaining cancer cells. The use f chemtherapy in this setting is called adjuvant chemtherapy and is designed t be an utpatient prgram. It may als be used in Stage III t dwnsize the cancer befre surgery, knwn as neadjuvant chemtherapy and IV Breast Cancer t treat tumurs and manage symptms knwn as palliative chemtherapy. Cmmn side effects may include: Tiredness, hair lss, and a lw white bld cell cunt (neutrpenia) Less cmmn side effects may include nausea, vmiting, diarrhea, muth sres, pr appetite, allergic reactins, easy bruising r bleeding, an increased chance f develping infectin and decreased sensitivity in the arms and legs (neurpathy) 3. RADIATION THERAPY Radiatin therapy uses high-energy X-rays t destry cancer cells. Treatment is usually dne fr five days a week fr a few minutes a day fr apprximately 5-6 weeks. Radiatin therapy usually begins abut 4-6 weeks after surgery r after chemtherapy if chemtherapy is recmmended. Radiatin therapy may be given fr advanced cancer t treat the tumur in the breast r distant sites t relieve symptms. Radiatin treatments are usually painless. Cmmn side effects may include: Tiredness Red, itchy r flaky skin where the radiatin is applied Breast swelling and nipple tenderness Less cmmn side effects include nausea 4. HORMONAL THERAPY This is targeted twards preventing estrgen frm acting as a tumur grwth factr. It acts by either blcking the prductin f estrgen r the effects f estrgen n cancer cells (receptr blcker). It is given fr tumurs which are ER and/r PR psitive and is generally fr 5 years. The chice f drug is dependent n several patient factrs including menstrual status, cntraindicatins f any f the drugs and side effects. Hrmnal treatments include: Estrgen receptr mdulatrs: E.g., tamxifen which blck estrgen's actin at the tumur (in pre and pstmenpausal wmen). Its side effects are well tlerated including ht flushes, weight gain and vaginal

5 dryness. Hwever, it is assciated with a small increased risk f venus thrmbtic disease, endmetrial hyperplasia and cancer. Armatase inhibitrs: these blck estrgen prductin by tissue ther than the varies (in pstmenpausal wmen). This has shwn t be gd and better than tamxifen in sme cases. It is assciated with increased bne fractures in patients with steprsis (thin bnes). 5. TARGETED THERAPY This is a type f treatment that uses drugs that attack specific cancer cells withut harming nrmal cells. Trastuzumab (Herceptin) is a mnclnal antibdy that blcks the effects f the grwth factr prtein HER2 and is given t patients with tumurs with HER2 gene ver expressin. This has cardiac side effects and needs mnitring. Fllw Up Carrying n Althugh cancer is a chrnic disease, less than half f all patients will have their cancer recur. It is imprtant t cntinue nrmal activities after treatment. Recurrence The risk f breast cancer recurring depends n its initial stage and the effectiveness f its treatment. Lcal recurrences (at r near the riginal cancer site) ften prduce the same signs as the initial disease, such as a lump in the breast r armpit. Treatment is usually further surgery (a mastectmy if lumpectmy was dne), radiatin therapy (if it was nt previusly given) and apprpriate systemic therapy. Metastasis (recurrences elsewhere in the bdy) may appear anywhere and may cause pain at the site f recurrence. Treatment varies and may include chemtherapy, hrmne therapy, radiatin therapy, psychlgical supprt, and smetimes surgery. Breast Screening Annual mammgraphy is recmmended fr new and recurrent breast cancer after breast cnservatin and ppsite breast cancer