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Breast Cancer: Better Treatments Save More Lives
By Carol Lewis
Star Community Newspapers – August 27, 2003

    Two different women. The same deadly disease. One thought she couldn’t get it. The other was told she didn’t have it. Both opinions were wrong. In 1994, one week before turning 35, Cathy Young received the devastating news. ”I thought you had to be in their 50s to get cancer,” the Oak Grove Mo., resident says “And then it happened to me.”
     Linda Hunter, 42, recalls that in 1995, her mammogram results came back normal. But skin changes in one of her breasts compelled her to seek a second, third and fourth opinion – all of which supported the initial mammogram findings. Her tenacity paid off when the fifth doctor she visited detected a rare form of the disease.
    Every three minutes, a woman in the United States learns she has breast cancer. It is the most common cancer among women, next to skin cancers, and is second only to lung cancer in deaths in women. Only 5 to 10 percent of breast cancers occur in women with a clearly defined genetic predisposition for the disease! The overall risk for developing breast cancer increases as a woman gets older.
     Although treatment is initially successful for many women, The American Cancer Society (ACS) says that breast cancer will return in about 50% of these cases.
      "It’s hard to say that things are back to normal when one survives breast cancer,” says Young, “because a survivor always has the fear that one day the cancer will return.”
     New drugs, new treatment regimens and better diagnostic techniques have improved the outlook for many, and are responsible, according to the ACS, for breast cancer death rates going down.
     Women have greater options in breast treatment compared to a decade ago,” says Harman Eyre, M.D., chief medical officer at the ACS. New drugs and procedures open up a whole new era of effective treatment.”
      Breast cancer can be treated with surgery, radiation, and drugs (chemotherapy and hormonal therapy). Doctors may use one of these or a combination, depending on factors such as the type and location of the cancer, whether the disease has spread, and the patient’s overall health.
    Most women with cancer will have some kind of surgery, depending on the stage of the breast cancer. The least invasive, lumpectomy (breast conserving surgery), removes only the cancerous tissue and a surrounding margin of normal tissue. Removal of the entire breast is called a mastectomy. A modified radical mastectomy includes the entire breast and some of the underarm lymph nodes. The very disfiguring radical mastectomy, in which the breast, lymph nodes, and chest wall  muscles under the breast are removed, is rarely performed today because doctors believe that a modified radical mastectomy is just as effective.
    While removing underarm lymph nodes after surgery is important in order to determine if the cancer has spread, this procedure may add chronic arm swelling and restricted shoulder motion to the discomfort of the overall treatment. But a new method, sentinel node biopsy, allows physicians to pinpoint the first lymph node into which the tumor drains ( the sentinel node), and remove the only nodes most likely to contain cancer cells.
     To locate the sentinel node, the physician injects a radioactive tracer in the area around the tumor before the mastectomy. The tracer travels the same path to the lymph nodes that the cancer cells would take, making it possible for the surgeon to determine the one or two nodes most likely to test positive. The surgeon will then remove the one or two nodes most likely to be cancerous.
     Radiation therapy is treatment with high-energy rays or particles given to destroy cancer. In almost all cases, lumpectomy is followed by six or seven weeks of radiation, an integral part of breast-conserving treatment. Although radiation therapy damages both normal and cancerous cells, most of the normal cells are able to repair themselves and function properly.
     Radiation therapy can cause side effects such as swelling and heaviness in the breast, sunburn-like skin changes in the treated area, and lymphodema (swelling of the arm due to fluid buildup) if the underarm lymph nodes were treated after a node dissection.

Drug Options Expanded
     Drugs are used to reach cancer cells that have spread beyond the breast -- in many cases even if no cancer is detected in the lymph nodes after surgery.
     Doctors once believed that the spread of breast cancer could be controlled with extensive surgery. Now, they believe that cancer cell may break away from he primary tumor and spread hrough the bloodstream, even in the earliest stages of the disease. These cells cannot be felt by examination or seen on x-rays or other imaging methods, and they cause no symptoms. But they can establish new tumors in other organs or bones. The goal of drug treatment , even if there's no detectable cancer after surgery, is to kill these cells. This treatment, known as adjuvant therapy, is not needed by every patient. Doctors will make recommendations regarding specific types of therapy based on he stage of the breast cancer.
     The Food and Drug Administration has approved several new drugs and new uses of older drugs in recent years that improve the chances of successfully treating breast cancer. These drugs include Herceptin (trastuzumab), which binds to HER2 and kills the excess cancer cells, theoretically leaving the healthy cells alone, Novadex (temoxifen citrate), used for breast cancer risk reduction in high-risk women, Xeloda (capectabine), for the treatment of breast cancer that has spread to other parts of the body (metastasized) in its resistance to both paclitaxel and an anthracycline-containing regimen and Taxotere (docetaxel) to treat patients whos locally advanced or metastasized breast cancer has progressed despite treatment with other drugs.
     In addition to these drugs, combinations of the anti-cancer drugs Cytoxan (cyclophosphamide) and Adriamycin (doxoribicin), with or without Adrucil (fluorouacil) , may be used to treat breast cancer.
     Chemotherapy (drug Treatment) is given in cycles, with each period of treatment followed by a recovery period. The total course of chemotherapy can last 3 to 6 months, depending on the drugs and how far the cancer has spread.
    Kelly Munsell of Tuscon, Ariz., took the combination Adriamycin and Cytoxan in six cycles, spaced 3 weeks apart, after doctors diagnosed her breast cancer in 1996 at age 27.

"Chemo for me was torture," Munsell recalls, describing profuse vomiting  and severe weight gain as two serious side effects. But despite the discomfort, Munsell, whose mother and grandmother died of breast cancer, is glad she underwent the grueling treatment two years ago. "My recent battery of tests came back negative for cancer," she says.
    In addition to the drugs, actually battling the disease, there also is help for patients in severe pain from cancer. FDA approved Actic (oral transmucosal fentanyl citrate) in November 1998 as a treatment specifically for cancer patients with severe pain that breaks through their regular narcotic therapy. A narcotic more potent than morphine, Actic is in the form of a flavored lozenge that dissolves slowly in the mouth.

Looking Ahead
It is important for every woman to consider herself at risk for breast cancer, the ACS says, simply because she is female. At the same time, however, studies continue to uncover lifestyle factors and habits that can alter the risk, and many new chemotherapy drugs and combinations continue to be developed and tested in clinical trials. Drugs and procedures currently under investigation include bisphosphonates (a group of drugs routinely used to treat osteoporosis), monoclonal antibodies (similar to Herseptin), and angiogenesis inhibitors (drugs that block the development of blood vessels that nourish cancer cells). "While death rates for breast cancer are falling, and while there are a number of new strategies being developed," says Dr. Michael A. Friedman, a former FDA deputy commissioner and cancer research specialist, "we recognize that a great deal more needs to be done."

Mammography: A Lifesaving Step  
The ACS says that the best strategy for successfully beating breast cancer is to follow guidelines for early detection. Currently, the most effective technique for early detection is screening mammography, an x-ray procedure that can detect small tumors and breast abnormalities up to two years before they can be felt and they are most treatable. (See "FDA Sets Higher Standards  For Mammography" in the January-February 1999 FDA Consume.)
     Studies show regular screening mammograms can help decrease the chance of dying of breast cancer. Finding a breast tumor early may mean that a woman can choose breast saving surgery. Furthermore, she may not have to undergo chemotherapy.

To find a certified mammography facility near you, go to on FDA's Website, or call the National Cancer Institute at 1-800-4-CANCER (1-800-4226237).

Carol Lewis is a staff writer for FDA Consumer.

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