The different types of breast cancer
Although there is some controversy regarding noninvasive cancer, there is ample evidence that noninvasive cancer can evolve into invasive cancer with time. Noninvasive cancer is generally treated similarly to invasive cancer with regards to surgery and radiation. Chemotherapy is never given for noninvasive cancer. The controversy lies in how likely the noninvasive cancer is to become invasive cancer and how aggressively it should be treated. Until we have better tools to predict an individual’s likely course, we tend to be aggressive in all cases.
Treatment of Paget’s disease depends upon any associated tumors discovered. Generally treatment involves removal of the nipple with radiation therapy of the remaining breast. Plastic surgery can fashion a new nipple with excellent cosmetic result. A total mastectomy may be indicated in some cases. The nipple-areola complex and breast is completely removed with or without reconstruction. The prognosis depends upon associated tumors but is generally excellent.
Ductal Carcinoma In Situ (DCIS)
Lobular Carcinoma In Situ (LCIS)
Treatment generally involves close surveillance including frequent breast exam, mammogram and MRI. If a patient has multiple other risk factors for breast cancer, in addition to LCIS, the likelihood that she may develop the disease warrants more aggressive preventative treatment. This may include removing both breasts as a preventive measure. This is a highly personal decision that requires serious discussion with a breast specialist. Removal of the affected breast is not adequate protection, as LCIS predicts a higher risk of getting breast cancer in EITHER breast.
Invasive Ductal Carcinoma
Usually treatment involves lumpectomy, in which the cancer is removed with a rim of normal tissue (margin), and an axillary lymph node biopsy. This determines whether the cancer has spread to the armpit nodes. This is followed by radiation and chemotherapy and an anti-hormone pill. Radiation is recommended in all patients who undergo breast preserving surgery to minimize recurrence of the cancer in the breast. Thirty percent of women treated with lumpectomy with clear margins (areas of normal tissue around the cancer) but who do not receive radiation, will recur within 10 years.
Chemotherapy is given to those patients whose tumors have a high likelihood of spreading outside of the breast even after surgery. Chemotherapy consists of drugs that are given by mouth or vein and go throughout the body to kill any cancer cells that may have gotten away. Anti-hormone pills target hormone sensitive tumor cells and this dramatically reduces the risk of those cancers returning in the breast or body. Anti-hormone pills do not decrease the risk of hormone-negative cancers from recurring or spreading.
Invasive Lobular Carcinoma
Invasive lobular cancer tends to grow in sheets rather than lumps and may be difficult to discover by a physical exam or imaging studies such as mammogram. Once identified, the tumor size may be underestimated preoperatively which requires re-operation to ensure the entire tumor is removed with clear margins (distance of normal tissue surrounding the cancer). Invasive lobular carcinoma has a higher risk of occurring in the opposite breast; as high as 50 percent in some studies. Removing both breasts (bilateral mastectomies) should be considered and discussed in all cases of invasive lobular cancer. Personalized treatment is then tailored to the individual. Post surgical treatment depends upon the final pathology and may include radiation (in all breast preserving procedures), chemotherapy and/or anti-hormone therapy.