BREAST CANCER REVIEW 

Breast Cancer in the U.S.

Anatomy and Pathology

Risk Factors

Detection and Screening

Diagnosis and Staging

Treatment Options

Breast Reconstruction

Follow-Up Care and Support

Treatment Options

Introduction

Five main types of therapies are available for the treatment of breast cancer: surgery, radiation therapy, chemotherapy, hormone therapy, and most recently, biological therapy. Most patients are treated with surgery in combination with one or more additional therapies for optimal cancer management. Individual approaches vary based on the type, size and location of the cancer; the stage of the cancer; and, the characteristics of the cancer cells as determined by laboratory and pathology tests. A woman's characteristics, including age, menopausal status, and overall health are also key considerations. Finally, appropriate treatment will take into account the personal preferences of a patient who has been fully informed of all her options.

Surgery

The primary treatment for breast cancer is surgery to remove the cancer. The type of surgical procedure depends upon a number of factors, including the size and location of the tumor, the type and stage of the breast cancer, the size of the breast, and a woman's personal preference. In most cases, the choice is between breast conserving surgery and mastectomy. For patients with invasive breast cancer, surgery is usually paired with an axillary lymph node dissection or sentinel node biopsy for pathological staging, and to help guide additional treatment decisions.

Breast Conserving Surgery

Breast conserving surgery (BCS) removes the cancer and a surrounding margin of normal breast tissue, while saving most of the breast. Lumpectomy is the most common term used for this procedure, however, it may also be called wide local excision, tylectomy or quadrantectomy.

The goal for all breast conserving procedures is to remove the entire breast cancer with a margin that is free of tumor invasion while saving as much of the breast as possible. If the margin shows evidence of cancer, a second surgery is required. This will usually be a repeat lumpectomy (also called a re-excision), or in some cases, a mastectomy.  For patients with invasive breast cancer, BCS is almost always followed with radiation therapy.

A patient is usually eligible for BCS if she has a single area of cancer, a breast tumor less than 5 cm in diameter, and, is willing to undergo follow-up radiation therapy. The lumpectomy, including any possible re-excisions, must be able to remove all of the cancer. Women ages 70 and older may be able to forego radiation therapy under certain circumstances.¹ For women with early-stage breast cancer, clinical studies have demonstrated similar survival rates with BCS plus radiation therapy as for mastectomy but with better cosmetic results.² BCS is usually performed as an outpatient procedure under general or local anesthesia.

Mastectomy

Mastectomy is a surgical procedure that removes the entire breast. It is usually recommended for women with more advanced breast cancer or for women who otherwise do not meet criteria for breast conserving surgery. Women with early stage breast cancer also have the option of selecting a mastectomy. In addition, mastectomy for the purpose of preventing breast cancer (i.e., prophylactic mastectomy) is available to women who have not been diagnosed with breast cancer but are at increased risk due to a strong family history or known genetic predisposition.

The radical mastectomy, once very common, is rarely performed today. Also called the Halsted mastectomy, this procedure involved the removal of the breast, all surrounding lymph nodes, and the underlying chest muscles. The most common type of mastectomy performed today is the total mastectomy. The procedure involves the removal of the breast, nipple, areola, and a variable amount of the skin of the breast. The total mastectomy has been proven equally effective for treating breast cancer and is less disfiguring. It also maintains the function of the chest wall muscles.

The skin-sparing mastectomy preserves most of the skin of the breast (not including the nipple and areola) and is used in preparation for reconstruction. All women undergoing a mastectomy should be informed of their options for breast reconstruction prior to surgery, which can usually be performed at the same time, or, if the patient prefers, at a later date. Most mastectomies require short hospital stays; more than 2 days are rare.

The healthcare provider is an important resource for locating support groups and/or mental health professionals to help a woman and her family adjust to losing a breast. The American Cancer Society (ACS) offers a Reach to Recovery program that relies on carefully selected, trained survivors to help women cope with treatment-related issues. For more information about this program, please visit the ACS web site, or call 1-800-ACS-2345.

Axillary Lymph Node Dissection (ALND) is a procedure for determining whether cancer has spread past the breast and to help guide the course of therapy. It is usually performed at the same time as a lumpectomy or a mastectomy. With ALND, an average of 20 nodes are surgically removed and microscopically examined for evidence of cancer. Although a mainstay of breast cancer treatment for over 30 years, ALND can be associated with a number of chronic side effects including pain, wound infection, limited shoulder motion, numbness and lymphedema (a chronic swelling of the arm caused by an accumulation of lymphatic fluid). Patients with noninvasive breast cancer do not require an ALND. Similarly, patients who have had a sentinel lymph node biopsy (SLNB) in which the sentinel node is negative do not require ALND. The combination of a total mastectomy and an ALND is often called a modified radical mastectomy.

Sentinel Node Biopsy (SNB) is a newer procedure that risks far fewer side effects and offers a possible alternative for some patients. As with ALND, the purpose of SNB is for staging and guiding treatment. However, rather than removing an average of 20 axillary nodes, SNB removes an average of only 3. The procedure is based on the idea that cancer cells spread in an orderly way from the primary tumor to the sentinel lymph node, or nodes, then to other nearby lymph nodes.³ Because SNB involves the removal of fewer nodes, the potential for postsurgical complications is reduced. However, it is not an appropriate procedure for all patients. Women interested in SNB should discuss their options with their cancer treatment team.

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Radiation Therapy

Radiation therapy uses high-energy X-rays or other types of radiation to destroy cancer cells. Radiation therapy is almost always recommended for use after lumpectomy (i.e., adjuvant therapy) to destroy any remaining undetected cancer cells in the breast, chest wall, or axilla. It is less often recommended after mastectomy, although, recent clinical trials indicate that postmastectomy radiation therapy may significantly reduce both 5-year recurrence and 15-year mortality rates for women with early-stage cancer.⁴ Occasionally, radiation therapy is used before surgery (i.e., neoadjuvant therapy) to shrink the size of a tumor. For patients with advanced cancer, it may also be used to relieve pain and other symptoms but without altering the course of the disease (i.e., palliative therapy).⁵

There are two main types of radiation treatment used for cancer treatment: external radiation therapy and internal radiation therapy. The most common type of radiation therapy used for women with breast cancer is external beam radiation.

External Beam Radiation

External radiation delivers high-energy x-rays from an external source. With external beam radiation, a machine targets a precise beam of radiation to the area of the body affected by cancer, with minimal impact on adjacent tissues. The irradiated area usually includes the whole breast. In some cases, it may also include the chest wall and axilla. Beginning about one month after surgery, radiation therapy is usually administered 5 times per week, for 5 to 7 weeks. Treatments are painless and usually last less than 30 minutes.

The most common side effect of radiation therapy is fatigue. Other temporary side effects include swelling or heaviness in the breast, sunburn-like changes in the skin, and loss of appetite. Toward the end of treatment, the irradiated skin may feel moist and sore. In some women, the treated breast may become smaller or firmer. In a small percentage of cases, lymphedema is possible with radiation of the axilla. Most women are able to carry on daily activities while undergoing radiation therapy. It is not used for women who are pregnant.

Advancements in radiation technology have led to the development of a newer technique called three-dimensional conformal radiotherapy (3DRCT). Using 3D computer images to develop complex plans for the delivery of highly focused beams, 3DRCT significantly reduces the amount of radiation to surrounding healthy tissues. Although 3DRCT is not widely available, this technique allows for the treatment of breast tumors considered too close to vital organs and structures for conventional radiation therapy. Another newer approach, called accelerated partial breast irradiation (APBI), also limits the exposure of healthy tissue to radiation, but in addition, APBI greatly reduces the total time commitment required to receive radiation therapy. Methods described as APBI using external radiation are 5-day external beam radiation (5-day EBR) and intraoperative radiation therapy (IORT). Brachytherapy is another type of APBI, however, brachytherapy relies upon internal radiation to deliver treatment.

Internal Radiation

Internal radiation places a radioactive source inside the body. Also called brachytherapy, this delivery method implants radioisotopes directly into the breast tissue close to the site of the surgical removal or into the tumor mass. Compared with conventional external beam radiation, brachytherapy allows for higher doses of radiation to be administered within a much shorter time span (usually 5 days). Other advantages include less irritation to breast tissues and skin, and a shorter delay for patients requiring subsequent chemotherapy. Although brachytherapy is not yet considered a standard method for treating breast cancer, it is available for some women. Interested patients should ask their doctors whether it is an appropriative form of treatment in their case.

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Chemotherapy

Chemotherapy uses cytotoxic drugs to kill and prevent the growth of cancer cells. It can be used as a form of adjuvant, neoadjuvant, or palliative therapy. Chemotherapy may also be used as the primary treatment for managing metastatic or recurrent breast cancer. In contrast to radiation therapy and surgery, which are local therapies, chemotherapy is a systemic mode of treatment that affects tissues and organs throughout the entire body. It is the role of the medical oncologist to determine which combination of drugs will be used, and what will be their order, dose, and frequency.

The different types of chemotherapy drugs used to treat breast cancer are broadly described as alkylating agents, anthracyclines, antimetabolites, and taxanes. Each drug is categorized according to their effect on the cell cycle and cell chemistry.

Chemotherapy is usually given as a combination of drugs, which has been shown to be more effective than any one single drug. The specific combination is tailored to the individual patient. A women's age, medical history, overall health, and tumor characteristics will factor into the planning of her specific regimen.

The most commonly used combination of chemotherapy drugs for treating breast cancer are as follows:⁶

• cyclophosphamide, methotrexate, and fluorouracil [abbreviated CMF]
• cyclophosphamide, doxorubicin, and fluorouracil [abbreviated CAF]
• doxorubicin and cyclophosphamide [abbreviated AC]
• doxorubicin and cyclophosphamide followed by paclitaxel or docetaxel [abbreviated ACT] or docetaxel concurrent with AC [abbreviated TAC]
• doxorubicin, followed by CMF
• cyclophosphamide, epirubicin, and fluorouracil with or without docetaxel

For women with advanced breast cancer, other chemotherapy drugs may be used, such as vinorelbine (Navelbine), gemcitabine (Gemzar), and capecitabine (Xeloda).

Most often, chemotherapy is delivered intravenously through a catheter placed into a vein on the hand or lower arm; it can also be delivered by IV through ports and pumps. Chemotherapy drugs may be injected into the muscle (intramuscularly) or under the skin (subcutaneously). In addition to these delivery methods, some chemotherapy drugs are given orally.

Chemotherapy is administered in cycles, with each cycle of treatment usually followed by a 1 to 3 week rest period. A complete course of treatment may include from 4 to 12 cycles, lasting for a total time of roughly 3 to 6 months. Administration can take from a few minutes to a few hours. Most patients receive their treatment as an outpatient.

The side effects of chemotherapy depend on the types of drugs used, the dosages, and the duration of treatment. Most of the side effects associated with chemotherapy are temporary. Common side effects are nausea and vomiting, hair loss (alopecia), and fatigue (sometimes due to low red blood cell counts). Other side effects include oral ulcerations, flu-like symptoms after treatment, bruising or bleeding after minor cuts (from lower blood platelets), and/or infection (from lower white blood cells), among others. Permanent side effects can include early menopause and infertility. In addition, many women report having problems with memory and/or mental clarity after having had chemotherapy. This condition, also known as "chemo brain," can linger for varying lengths of time after the course of chemotherapy is completed.

There are a number of excellent medicines for managing side effects from chemotherapy. The American Cancer Society (ACS) web site offers a helpful section to which providers may refer their patients for learning about various methods for Managing Side Effects of Chemotherapy. Knowing what to expect before treatment begins will help patients through the experience.

High-dose chemotherapy is based on the idea that drugs used to kill cancer are more effective if given at higher doses. Yet, high doses of anti-cancer drugs are very toxic to the bone marrow and interfere with the body's ability to form new blood cells. High-dose chemotherapy with autologous stem cell support addresses this issue by replacing blood-forming cells destroyed by higher doses of chemotherapy with stem cells harvested from the patient's blood or bone marrow prior to treatment. However, studies have shown that high-dose chemotherapy followed by stem cell transplant is no more effective than standard chemotherapy in the treatment of breast cancer. It may also be associated with serious adverse effects, including death.⁷

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Hormone Therapy

Hormone therapy (also called endocrine therapy) is a cancer treatment that either removes hormones or blocks their action in order to stop cancer cells from growing. This form of therapy is based upon the recognition that estrogen and progesterone stimulate the growth of breast cancer cells. When this action is interrupted, the cancer cells that depend upon these hormones stop growing and die. As such, hormone therapy is only effective in treating women whose cancers are estrogen and/or progesterone receptor positive.

Hormone therapy may be used in addition to surgery and radiation therapy. It may also be used with chemotherapy. In addition, women at high risk of developing breast cancer may be offered hormone therapy as an effective method of risk reduction. Hormonal medicines may be given alone, in combination, or sequentially. There are several types of hormone therapies used in the treatment of breast cancer. They are known as selective estrogen receptor modulators, estrogen receptor downregulators, aromatase inhibitors, ovarian ablation, and progestins.

Selective estrogen receptor modulators (e.g., tamoxifen (Nolvadex), raloxifene (Evista)) are a type of antiestrogen that work by binding to estrogen receptors selectively, stimulating or inhibiting the estrogen receptors of different target tissues. Tamoxifen is a selective estrogen receptor modulator (SERM). It is used for treating breast cancer with both pre- and post-menopausal women, in early and advanced disease, and with invasive and noninvasive types of breast cancers. For the past 30 years, it is the most widely used hormone therapy in the treatment of breast cancer. Tamoxifen is also used effectively for decreasing the likelihood of breast cancer in women at high risk. However, side effects associated with tamoxifen can be serious, including increased risk for uterine cancer, blood clots, strokes and cataracts. Clinical research (i.e., STAR trial) has found that raloxifene, also a SERM, is an effective alternative to tamoxifen for postmenopausal women at increased risk, but with fewer side effects.⁸ However, it is not a breast cancer treatment, only a preventive agent in postmenopausal women. As of May 2007, raloxifene had not yet received FDA approval for breast cancer prevention.

Selective estrogen-receptor downregulators (e.g., fulvestrant (Faslodex)) refers to a newer type of antiestrogen. Similar to SERMs, selective estrogen-receptor downregulators (SERDs) bind to the estrogen receptors of cells and interfere with the process of cell proliferation. However, while SERMs block most estrogen activity, SERDs block estrogen in all tissues. Currently, fulvestrant is the only FDA-approved SERD for treatment with breast cancer. It is frequently used to treat postmenopausal women with advanced cancer who no longer respond to tamoxifen. Compared with tamoxifen, fulvestrant is well tolerated although it is associated with some side effects, including nausea and fatigue.

Aromatase inhibitors (e.g., letrozole (Femara), anastrazole (Arimidex), and exemestane (Aromasin) prevent the formation of estrogen by inhibiting the action of the aromatase enzyme which converts androgens into estrogens by a process called aromatization. Aromatase inhibitors eliminate all of the body's estrogen in postmenopausal women. (In premenopausal women, this group of drugs is ineffective since most of their estrogen is produced from the ovaries.) Aromatase inhibitors (AIs) are used for treating postmenopausal women, either as initial therapy or after tamoxifen. Side effects associated with AIs are generally mild and include joint and muscle pain. Long term use, however, may lead to osteoporosis.

Ovarian ablation (e.g., goserelin (Zoladex) stops the ovaries from producing estrogen. Also called ovarian suppression, this form of therapy is used with premenopausal women, in whom ovaries are the main source of the body's estrogen. Traditionally, ovarian ablation involves surgery (oophrectomy) or radiation, but ovarian produced estrogen can now be suppressed by drugs called luteinizing hormone-releasing hormone (LHRH) agonists, such as goserelin. Hormone agonists work by inhibiting the signaling of LHRH, so that the body's production of estrogen is reduced. Possible side effects include hot flashes, decreased sexual desire, absence of menstruation, vaginal dryness, and breast swelling or tenderness.

Progestins (e.g., megestrol (Megace)) are sometimes used as a second- or third-line treatment in women with advanced breast cancer when treatment with tamoxifen or an aromatase inhibitor has failed. Common side effects are fluid retention and weight gain.

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Biological Therapy

Biological therapy is directed at specific targets in the body (cellular receptors, proteins and enzyme systems) to help fight cancer. Other terms used for this type of therapy are biological response modifier therapy and targeted therapy. Such therapies include monoclonal antibodies and small molecules.

Many biological therapies are still considered experimental for treating breast cancer. However, trastuzumab (Herceptin), a monoclonal antibody, has been used since 1998 to treat certain cases of advanced breast cancer by targeting cancer cells that make excessive amounts of the protein HER-2/neu. Approximately 20% to 30% of breast cancers test positive for the overexpression of HER-2/neu.

Most recently, trastuzumab has been found to be very effective if used earlier in the course of treatment. In May, 2005, two large clinical trials reported that trastuzumab, used in addition to standard chemotherapy in women with early-stage breast cancer (that expresses the protein HER2/neu), lowers the risk of recurrence by as much as 52% after 3 years, compared with chemotherapy alone. Moreover, trastuzumab with chemotherapy was found to lower the risk of death by 33% after 3 years. These findings represent a significant advance in breast cancer treatment and are expected to change the standard of care for a significant number of patients.⁹  Trastuzumab, however, is not without potentially serious side effects, including heart muscle damage and allergic reactions.

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Treatment Options by Stage

Treatment options for breast cancer vary depending on the stage of disease, as summarized below.¹⁰

*Treatment of lobular carcinoma in situ (Stage 0) may include the following:

• Biopsy to diagnose the LCIS followed by close observation (i.e., regular clinical exams, regular screening mammography, monthly breast self-exam).
• Hormone therapy (i.e., tamoxifen).
• Bilateral prophylactic mastectomy, without axillary node dissection. (Most surgeons believe that this is a more aggressive treatment than is needed.)
• Clinical trials testing cancer prevention drugs.

*Lobular carcinoma in situ (LCIS) is not a cancer but rather a marker that identifies women at increased risk for subsequent development of invasive breast cancer.

Treatment of ductal carcinoma in situ (Stage 0) may include the following:

• Breast-conserving surgery and radiation therapy, with or without hormone therapy.
• Total mastectomy with or without hormone therapy.
• Clinical trials testing breast-conserving surgery and hormone therapy, with or without radiation therapy.

Treatment of Stage I, Stage II, Stage IIIA , and operable Stage IIIC breast cancer may include the following:

• Breast-conserving surgery followed by lymph node dissection and radiation therapy.
• Modified radical mastectomy, with or without breast reconstruction surgery.
• A clinical trial evaluating sentinel lymph node biopsy followed by surgery.

  Adjuvant therapy may include the following:

• Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.
• Chemotherapy with or without hormone therapy.
• Hormone therapy.
• A clinical trial of trastuzumab (Herceptin) combined with chemotherapy.

Treatment of Stage IIIB and inoperable Stage IIIC breast cancer may include the following:

• Chemotherapy.
• Chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.
• Clinical trials testing new anticancer drugs, new drug combinations, and new ways of giving treatment.

(Treatment of inflammatory breast cancer is similar to the treatment of Stage IIIB or inoperable Stage IIIC breast cancer.)

Treatment of Stage IV may include the following:

• Hormone therapy and/or chemotherapy, with or without trastuzumab (Herceptin).
• Radiation therapy and/or surgery (for relief of pain and other symptoms).
• Clinical trials testing new chemotherapy and/or hormone therapy.
• Clinical trials of new combinations of trastuzumab (Herceptin), with anticancer drugs.
• Clinical trials testing other approaches, including high-dose chemotherapy with stem cell transplant.
• Bisphosphonate drugs (to reduce bone disease and pain when cancer has spread to the bone).

Treatment of recurrent breast cancer in the breast or chest wall may include the following:

• Surgery (radical or modified radical mastectomy), radiation therapy, or both.
• Chemotherapy or hormone therapy.
• A clinical trial of trastuzumab (Herceptin) combined with chemotherapy.

Breast and Cervical Cancer Prevention and Treatment Act of 2000

The Breast and Cervical Cancer Prevention and Treatment Act of 2000 gives states the option to provide treatment through Medicaid to eligible women who were screened for and found to have breast or cervical cancer, including precancerous conditions, through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). All 50 states and the District of Columbia have approved this Medicaid option.¹¹  

For Californian's diagnosed with breast cancer, free treatment is available to all who qualify through the Breast and Cervical Cancer Treatment Program. Information on this program is available on Medi-Cal's web site or call 1-800-824-0088 to speak with an eligibility specialist.

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Clinical Trials

Clinical trials are research studies that test new medical approaches with volunteer patients. They are the means by which the safety and efficacy of new treatments and methods are evaluated before becoming a part of standard medical protocol. All aspects of breast cancer management - screening, prevention, diagnosis, and treatment - are researched in clinical trails. Patients who participate in these studies not only obtain expert care from a leading medical facility but may also gain access to potentially more effective therapies. They are also helping others by contributing to research that may lead to significant medical advances. While once considered appropriate for patients only with advanced disease, the National Institute of Cancer explains that patients with "common cancers often choose to receive their first treatment in a clinical trial."¹²

There are three phases of clinical trials in which a treatment or method is studied before it can be approved by the FDA for widespread use.

• Phase I trials test an experimental drug or treatment in a small group of people (20-80) for the first time to evaluate its safety, determine a safe dosage range, and identify side effects.
• Phase II trials study the drug or treatment with a larger group of people (100-300) to determine whether it is effective and to further evaluate its safety.
• Phase III trials study the drug or treatment with large groups of people (1,000-3,000) to confirm its effectiveness, monitor side effects, compare it to standard treatments, and collect information that will allow the experimental drug or treatment to be used safely.¹³ 

Each clinical trial is unique. When talking with patients about the potential benefits and risks of participation, health providers should thoroughly explain the purpose of the trial, the type of tests and treatments involved, and how these compare with the standard approaches. Patients considering participation will also need to know how long the trial will last, how often and where treatments will be administered, who will be in charge of their care during the trial, and what will be the long-term follow-up. If financial costs are involved, patients need to know whether or not such costs are covered by insurance, and if not, whether financial aid is available. Most important, patients will want to know if the experimental treatment is working. What will they be told about this and when?

Many patients with breast cancer will learn about clinical trials from their oncologists, surgeons, radiologists, and other medical specialists on their cancer care team. Primary care providers can also help connect the patient with appropriate clinical trial information by knowing about several key registries available Online.

NCI's Clinical Trials Registry contains more than 4,000 open protocols and over 15,000 abstracts of clinical trials that have been completed or closed. Most studies within the database are sponsored by NCI but the registry also includes trials sponsored by pharmaceutical companies, medical centers, and other groups from around the world. Clinical trials can be found using either the basic or advanced search form.

ClinicalTrials.gov provides regularly updated information about federally and privately supported clinical trials. Cancer trials registered in PDQ will automatically be registered in ClinicalTrials.gov and vice versa but users may prefer the unique search features of one source over the other.

The Coalition of National Cancer Cooperative Groups (CNCCG) is network of cancer clinical trials specialists, which includes cooperative groups, cancer centers, academic medical centers, community hospitals, physician practices, and patient advocacy groups. The TrialCheck®! search tool on the CNCCG web site uses answers to 9 questions to return a matched listing of CNCCG-affiliated clinical trials.

The American Cancer Society Clinical Trial Matching Service is designed with a user-friendly question and answer format for patients and their caregivers. The data base contains over 3,000 clinical trials. Registration is required, however, all information is held confidential and the matching service is free of charge. At the patient's request, an ACS Information Specialist will contact the patient by phone or by email with additional information about one or more trials.

Notes

²National Cancer Institute. Mastectomy No Better Than Lumpectomy for Women with Small Breast Tumors (Oct. 23, 2002). Retrieved Jun. 21, 2006 at: http://www.cancer.gov/clinicaltrials/results
/mastectomy -versus- lumpectomy1002

³National Cancer Institute. Sentinel Lymph Node Biopsy: Questions and Answers (Apr. 27, 2005). Retrieved Jun. 22, 2006 at: http://www.cancer.gov/cancertopics/factsheet/therapy/ sentinel-
node-biopsy

⁴National Cancer Institute. Survival Improved by Radiation After Breast Cancer Surgery (Jan. 27, 2006). Retrieved Jun. 22, 2006 at: http://www.cancer.gov/clinicaltrials/results/ postsurgical
-radiation0106

⁵Adjuvant therapy is treatment that is given after the primary treatment (e.g., radiation therapy after surgery). Neoadjuvant therapy is treatment that is given before the primary treatment (e.g., hormone therapy before surgery). Palliative therapy is used to relieve symptoms and reduced suffering caused by cancer, but without altering the course of disease.

⁶American Cancer Society. Breast Cancer: Chemotherapy (revised, Sep. 2, 2005). Retrieved Jun. 22, 2006 at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Chemotherapy_5.asp?
sitearea=

⁷National Cancer Institute.Treatment Option Overview (Jun. 22, 2005). Retrieved Jun. 24, 2006 at: http://www.cancer.gov/cancertopics/pdq/treatment/breast/Patient/page5

⁸National Cancer Institute.Study of Tamoxifen and Raloxifene (STAR) Trial  (updated, Apr. 26, 2006). Retrieved Jun. 24, 2006 at: http://www.cancer.gov/star

⁹Herbst, RS, Bajorin, DF, Bleiberg, H, et al. Clinical Cancer Advances 2005: Major Research Advances in Cancer Treatment, Prevention, and Screening—A Report From the American Society of Clinical Oncology (Jan. 1, 2006). Retrieved Jun. 24, 2006 at: http://www.jco.org/cgi/content /full/24/1/190

¹⁰Treatment by stage information was compiled from patient and health professional versions of the National Cancer Institute's (NCI) Breast Cancer Treatment (PDQ®) summaries (last modified, Jun. 22, 2005 & Feb. 14, 2006, respectively). Retrieved Jun. 24, 2006 at: http://www.cancer.gov
/cancertopics/ pdq/treatment/ breast/Patient and http://www.cancer.gov/cancertopics
/pdq/treatment/breast/ HealthProfessional. (PDQ is NCI's comprehensive cancer database containing peer-reviewed, evidence-based summaries on the major types of cancer in adults.) For more information on this topic, see the National Comprehensive Cancer Network's (NCCN) Clinical Practice Guidelines in Oncology™publications, available on the NCCN web site.

¹¹Centers for Disease Control and Prevention. Breast and Cervical Cancer Prevention and Treatment Act of 2000. Retrieved Aug. 28, 2006 at: http://www.cdc.gov/cancer/nbccedp/legislation/
law106-354.htm

¹²National Cancer Institute. Taking Part in Clinical Trials: What Cancer Patients Need to Know (May, 1998). Retrieved Jun. 25, 2006 at: http://www.cancer.gov/PDF/a559d304-f6d9-492a-ab1b-875644f29be2/whatcancerpatients.pdf

¹³ClinicalTrials.gov. Understanding Clinical Trials. Retrieved Dec. 1, 2007 at: http://www.clinicaltrials.gov/ct2/info/understand

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All external links are provided as a service to our visitors for information purposes only. No endorsement is made or implied.

References updated: February 4, 2009.

The Breast Cancer Review is sponsored by the The California Department of Public Health (CDPH), Cancer Detection Section (CDS), with the goal of providing healthcare professionals a general reference for breast cancer screening, diagnosis, and treatment. The Breast Cancer Review is not an expression of medical opinion, diagnosis, prognosis or treatment recommendation for any particular patient. It should be used for informational purposes only. The Cancer Detection Section does not dispense clinical advice or patient care consultation. Links to other web resources are offered as a courtesy; no endorsement is made or implied.  While every care has been taken in their selection, CDS makes no claims as to the validity, quality, or viability of their content.

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