Advanced Breast Cancer
Project PINK BLUE is on a journey to change the way Africans think about cancer.
WHAT IS ADVANCED BREAST CANCER?
Breast cancer begins when abnormal cancerous cells in the breast grow and multiply without stopping, creating a tumor. Breast cancer usually starts in the ducts or lobules of the breast.
Advanced breast cancer usually refers to metastatic breast cancer, also called Stage IV breast cancer or secondary breast cancer. Breast cancer that has spread locally in the area of the breast, but not to distant organs and tissues, is often referred to as “locally advanced breast cancer,” or Stage III breast cancer. Given these various and sometimes inconsistent terms, if you or a loved one is diagnosed with advanced breast cancer, it’s important to discuss with your doctor specifically what stage it is and its other characteristics (eg, biology and where the cancer has spread). Knowing these details of a diagnosis can help you to understand important treatment decisions.
“Advanced cancer” in general often means that the cancer is “metastatic” ie, has spread from where it started to distant parts of the body.
Breast Cancer is the most common cancer in women with nearly 1.7. million new cases diagnosed each year worldwide.
In Nigeria, cancer leads to 72,000 deaths per annum. This number is set to increase given that there are 102,000 new cases of cancer every year. The mortality incidence ratio for breast cancer is 0.51 (51%); this is partly because about 70% of these cancer patients present late stages (III & IV) with few patients having access to the limited treatment facilities and over 70% have pain.
HOW IS BREAST CANCER STAGED?
Breast cancer is divided into five main stages, 0 through IV. The stages are based on wether the cancer is invasive or not, the size of the tumor, the number of lymph nodes involved, and if the cancer has spread to other parts of the body.
Stage 0 is used to describe non-invasive breast cancers, such as DCIS (ductal carcinoma in situ). In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or getting through to or invading neighboring normal tissue.
Stage I describes invasive breast cancer (cancer cells are breaking through to or invading normal surrounding breast tissue).
Stage II describes invasive breast cancer with 2-5 cm and or invasion in 1-3 axillary lymphnodes
Stage III describes invasive breast cancer in which either: no tumor is found in the breast or the tumor may be any size; cancer is found in 4 to 9 axillary lymph nodes or in the lymph nodes near the breastbone (found during imaging tests or a physical exam) or the tumor may be any size and has spread to the chest wall and/or skin of the breast and caused swelling or an ulcer and there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast and the cancer has spread to 10 or more axillary lymph nodes.
Stage IV describes invasive breast cancer that has spread beyond the breast and nearby lymph nodes to other organs of the body, such as the lungs, distant lymph nodes, skin, bones, liver, or brain.
You may hear the words “advanced” “secondary” and “metastatic” used to describe stage IV breast cancer. Cancer may be stage IV at first diagnosis or it can be a recurrence (distant recurrence) of a previous breast cancer that has spread to other parts of the body.
WHAT IS METASTASIS AND HOW DOES IT HAPPEN?
Metastasis means the spread of cancer cells to other parts of the body. Cancer cells can break away from a primary tumor and enter the bloodstream or lymphatic system (the system that produces, stores, and carries the cells that fight infections). This is how cancer cells spread to other parts of the body.
When cancer cells spread and form a new tumor in a different organ, the new tumor is a metastatic tumor. The cells in the metastatic tumor come from the original tumor. This means, for example, that if breast cancer spreads to the lungs, the metastatic tumor in the lung is made up of cancerous breast cells (not lung cells). In this case, the disease in the lungs is metastatic breast cancer (not lung cancer).
The most common sites of metastasis from solid breast cancer tumors are the lungs, bones, and liver. However, cancer can spread to other parts of the body as well.
Under a microscope, metastatic breast cancer cells generally look the same as the cancer cells in the breast, so you should consult an oncologist who specializes in the treatment of breast cancer regardless of where the cancer has spread. Sometimes after this first appointment and if there is a need for a special treatment of metastasis in particular organs the breast cancer specialist can ask for advice to a neurosurgeon or an orthopedic surgeon about surgery in a brain or bone metastasis that will benefit from surgery.
HOW DOES A DOCTOR KNOW WHETHER A CANCER IS PRIMARY OR METASTATIC TUMOR?
To determine whether a tumor is primary or metastatic, a pathologist (a doctor who identifies diseases by studying cells and tissues under a microscope) examines a sample of the tumor. In general, cancer cells look like abnormal versions of cells in the tissue where the cancer first appeared. Using specialized diagnostic tests, a pathologist is often able to tell where the cancer cells came from. Doctors may determine the primary site of cancer in a few ways. They may look for markers, which are a diagnostic indication that disease may develop. They may also look for antigens, a substance that causes the immune system to have a specific immune response.
Metastatic cancer may be found before or at the same time as the primary tumor, or months or years later. When a new tumor is found in a patient who has been treated for cancer in the past, it is more frequently a a metastasi
WHAT ARE THE SYPTOMS OF A METASTATIC BREAST CANCER?
Some people with metastatic cancer do not have symptoms. Their metastases may be found by X-rays and other tests. These tests include magnetic resonance imaging (MRI), computed tomography (CT scan), and positron emission tomography (PET scan), which are performed usually when patients have specific complaints during follow-up appointments.
When symptoms of metastatic cancer occur, the type and frequency of the symptoms will depend on the size and location of the metastasis. For example, cancer that spreads to the bones can cause pain and can lead to bone fractures. Shortness of breath may be a sign of lung involvement. Abdominal swelling or jaundice (yellowing of the skin) can indicate that cancer has spread to the liver.
Sometimes a person’s primary cancer is discovered only after the metastatic tumor causes symptoms.
WHAT IS RERCURRENCE?
Recurrent breast cancer is cancer that has come back in the same or opposite breast or chest wall after a period of time when the cancer couldn’t be detected – this is called a local recurrence. When then cancer returns in the lymphnodes of the axilla or around the collarbone it is called a regional recurrence. When the cancer spreads to other parts of the body, it is called a distant recurrence or metastatic breast cancer. Almost everyone who had cancer fears that one day the cancer will come back, or recur. Keep in mind that a local or locorregional recurrence of breast cancer has treatment and even a distante recurrence – metastatic (advanced) disease is NOT hopeless. Many women continue to live long, productive lives with breast cancer after recurrences. It is also likely that your experience with treatment this time will be somewhat different from last time. There are so many options for your care and so many ways to chart your progress as you move through diagnosis, treatment, and beyond.
When you had surgery to remove the original breast cancer, your surgeon removed all the cancer that could be seen and felt. But tests for cancer aren’t sensitive enough to detect a tiny group of single cancer cells. These isolated cells may survive radiation therapy and chemotherapy aimed at preventing recurrence. Even a single cell that escaped treatment may be able to spread and grow into a tumor.
Being diagnosed with recurrent or metastatic breast cancer can be overwhelming. Women experiencing a recurrence may find themselves back on the emotional rollercoaster they thought they got off of after initial treatment. Other women may be angry, scared, stressed, outraged, and depressed. Some may question the treatments they had or may be mad at their doctors or themselves for not being able to beat the disease. Still other women may deal with diagnosis of recurrent or metastatic breast cancer in a matter-of-fact way. There is no right or wrong way to come to terms with the diagnosis. You need to do and feel what is best for you and your situation.
There are two important things to remember about diagnoses of recurrent and “metastatic” advanced breast cancer:
- You are not alone. More and more people are living life to the fullest while being treated for advanced-stage cancer.
- You can have confidence that there are a wide variety of available treatment choices. There are many treatment options for advanced breast cancer, and new medicines are being tested every day. While recurrent or metastatic breast cancer may not go away completely, treatment may control it for a number of years. If one treatment stops working, there usually is another you can try. The cancer can be active sometimes and then go into remission at other times. Many different treatments — alone, in combination, or in sequence — are often used. Breaks in treatment can make a big difference when the disease is under control and you are feeling good.
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GLOBOCAN. 2012 Breast Cancer Incidence and Mortality Worldwide. Available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx. Accessed on January 12, 2015.
Adenipekun, A., Onibokun, A. Elumelu, T.N., Soyannwo, O.A. (2005). Knowledge and Attitudes of Terminally Ill Patients and Their Family To Palliative Care and Hospice Services in Nigeria. Nigeria Journal of Clinical Practice, June 2005, 8 (1): 19-22.
Report of workshop of National Headquarters of cancer Registry on National Cancer Control Programme (NCCP) for Nigeria, Dec 1992; 7-11.
Acknowledgement: Thanks to our Scientific Committee for compiling this handbook and Special Thanks to Union for International Cancer Control (UICC) & Pfizer Oncology whose support brought this handbook to you.