Questions on breast cancer
Question: I have just had a lump removed from my breast and the doctor says it is cancer. Does this mean I am going to die?
Answer: It certainly doesn't mean that you are going to die from breast cancer as many women are alive and well 25 years onwards. However, some cancers are more aggressive than others and to decide on the best available treatment, the doctors need to know as much about your cancer as possible.
Question: How can they do that?
Answer: To decide how nasty or malignant a cancer is, there are certain characteristics of the tumour which give you clues as to whether the tumour is likely to come back or spread to other parts of the body. These clues include the size of the tumour and what the cells look like under the microscope.
They also look for other evidence that a tumour or cancer will respond to a specific type of treatment. This is done by looking for things on the cancer cell surface which as receivers of signals to grow rapidly. These signal receivers are called receptors and once they are stimulated they pass the message into the cell telling it to grow and divide. The end result of this is the tumour gets bigger.
The most common two receptors that are looked for on the cancer cell are the oestrogen receptor which is turned on by the female hormone oestrogen. There is another receptor (Her2) which is turned on by another growth factor.
Different tumours have differing amounts of these receptors on the surface. The tumour for example may be reported as having no oestrogen receptors, a moderate number of oestrogen receptors or many oestrogen receptors.
This helps the doctor decide which treatment is best for you as if your tumour has a moderate or large number of oestrogen receptors then it more likely to respond to a treatment that blocks the oestrogen from reaching its receptor, resulting in the cancer cell not being stimulated to grow. If the tumour has no oestrogen receptors on its surface then there is no point in giving you a treatment that blocks oestrogen receptors.
Why do some women have their whole breast removed (mastectomy) while others only have the lump removed (lumpectomy)?
Answer: There can be a number of reasons for this. Some breast tumours are too big to remove the lump and therefore the surgeon has no option but to remove the whole breast. Other tumours may be present in more than one region of the breast so mastectomy is the only real option. Some women especially with those with a strong family history of breast cancer prefer to have a mastectomy in the knowledge that the tumour can't come back in that breast.
Question: After I had the lump removed, I need to have radiotherapy to the same area. Why is this?
Answer: When the surgeon removes the lump, it is impossible to know if a few tumour cells are left behind as when there are only a few of them it is difficult to tell them apart from normal breast tissue. So to stop local recurrence, an X-ray beam is targeted at the area from where the lump was removed to kill any remaining tumour cells.
Question: The doctors also took samples of lymph nodes under my arm. Why did they do this?
They are looking to see if some of the cancer cells have escaped from the main tumour and are trying to reach other parts of the body. They do this in two different ways either by draining into lymph nodes nearest the breast which are usually in the armpit or they can enter the blood stream directly
The purpose of the lymph nodes normally is a surveillance unit to look out for dangerous bacteria and viruses that have managed to enter the body. The function of the white cells in your body is to kill these bugs. However, sometimes they have difficulty killing them on their own. Therefore they carry the bugs or part of a killed bug to the lymph node which specifically drains an area such as the breast. Here, other different types of white cells are there to help them.
Cancer cells also can travel down the same channels to the lymph nodes but because they don't appear to be a bacteria or virus and therefore no obvious danger, the white cells in the lymph nodes ignore them. These tumour cells depending on how aggressive they are can then spread to other lymph nodes close by and then eventually they can pass into channels which join the main blood stream.
The knowledge of how many of the lymph nodes have tumour in them gives the doctor an understanding of how aggressive the tumour is. As a result of this, the cancer specialist will decide on what treatment is best in your individual case.
Question: Does that mean if many lymph nodes are invaded by the cancer, then the cancer has spread to other parts of my body?
Answer: No, not necessarily. The tumour cells may have spread as far as the lymph nodes but not yet made their way into the blood stream. So even if the majority of lymph nodes are invaded it still does not mean that the tumour has spread any further.
However, logically there is a greater chance it may have spread further but absolutely no cancer specialist knows if it has or hasn't. As a result of this, the specialist has to guess or estimate the chances that a particular type of tumour has spread but in reality there is no sure answer.
Question: I have seen other women who have swollen arms following removal of all the lymph glands in their armpit. Why does that happen and will it happen to me?
Answer: Women with mastectomy often had swollen arms because the removal of all the lymph nodes in the armpit led to all the lymph fluid in the arm not having anywhere to drain to. When the fluid reached the position of where the lymph glands used to be they reached a dead end and therefore had to try another way to get back to the blood. Unfortunately, there are no other channels so the lymph fluid was forced into the surrounding tissue resulting in those tissues filling up and becoming swollen.
These days the surgeons don't remove all the glands in the armpit but only the ones draining the breast so the chances of developing a swollen arm are much reduced. They know which ones these are by injecting a dye into the breast tissue and watching which lymph glands the dye drains to. This first lymph node is called a sentinel lymph node and this is examined for the presence of tumour cells.
Question: I am not keen on taking chemotherapy unless I really have to. Are there any further tests that can be done?
Answer: It is possible to look at the tumour cells in more detail. In every cell, the decision of whether that cell may spread to another part of the body depends upon the activation of certain genes in the 'brain' or nucleus of the cell. If certain genes are found to be turned on then there is an increasing likelihood that the tumour will be the type to spread. However, these tests are not foolproof yet but using them can help you make a decision on treatment.
There are two tests that look at these genes but only the first from the USA is commercially available. This test looks at 21 genes to see if they are turned on or not. The second test from Holland looks at 72 genes but is not commercially available.
Question: A friend of mine who also has breast cancer is on treatment different from mine because she has reached the menopause. Why is this?
Answer: Before you reach the menopause, most of the oestrogen that can stimulate a breast tumour is produced in the ovaries but a small amount comes from another organ called the adrenal gland which sits on top of the kidneys.
When you reach the menopause, your ovaries no longer produce any oestrogen so you only have to block the small amounts produced by the adrenal gland. Drugs such as tamoxifen and anastrozole block the effects of oestrogen through different mechanisms.
If you haven't reached the menopause then your ovaries are producing large amounts of oestrogen which can't be blocked by using the above drugs alone. Therefore in addition a hormone treatment (known as LHRH agonists) is given that tells the brain to send messages to the ovaries to turn off oestrogen production.
Question: Will I definitely lose all my hair on chemotherapy and if so is there any way to prevent it?
Answer: Not all chemotherapy leads to loss of hair although it is a common side effect with the following drugs: Doxorubicin (daunorubicin), etc. However your hair will grow back after you have completed the treatment but for some strange reason it may become curly to begin with.
Cold caps are a method used to try and prevent hair loss. They work by cooling the scalp and therefore reduce the blood flow through it . The less blood flow means the less chemotherapy carried to that area so the hair cells are less likely to die.
Some people worry that a few tumour cells could be lurking in these cooled areas and therefore avoid being killed but there is no proof either way if this happens or not. It is extremely rare to get a secondary tumour to the scalp.
Question: I am worried about the short term side effects of chemotherapy. What effects could these be?
Answer: Each drug has its own particular side effects which can vary depending on the dose of the chemotherapy you are given. Unfortunately, chemotherapy today is not very specific. It tends to kill any cell that is dividing whether it is a tumour cell or not. The cells that most rapidly divide in our bodies are those that line the whole of the gut and those that produce white cells to protect us from getting infections. As these cells get destroyed, the side effects on the damaged gut lining vary from a sore mouth to vomiting and abdominal pain and diarrhoea. Damage to the white cells can lead to inability to fight infections and for this reason further doses of chemotherapy are not given until your white cells have recovered from the previous dose of chemotherapy.
It is important that the cancer specialist is aware of any heart or lung problems you have as these can be made worse with chemotherapy and a close eye will need to be kept on their functioning. If you need a combination of treatment that involves the use of herceptin and doxorubicin (daunorubicin) or epirubicin, this is especially true.
Other drugs can result in rashes which usually resolve once the chemotherapy has been completed.
Question: Are there any long term risks of chemotherapy?
Answer: Yes, but fortunately they are rare. The most important ones are the chances of developing another malignancy and for the younger woman who has not completed her family, infertility may result.
Question: Is there anything else I can do to stop the cancer coming back?
Answer: There are many factors associated with the development of breast cancer which can be divided into those which you can do nothing about which means the genes you have inherited from your parents and environmental effects which you can alter to a degree which are discussed below
Question: What environmental effects can be changed?
Answer: Studies have shown that those women who exercise more are less prone to develop breast cancer. Even in women who have inherited a gene that makes them more likely to develop breast cancer, the combination of exercise and not being overweight appears to put off the development of breast cancer to later in life.
No one understands why exercise or not being overweight makes you less likely to develop breast cancer just as no one understands why drinking excess alcohol also predisposes you to breast cancer. The relationship of smoking to breast cancer is not clear but in view of all the other malignancies associated with smoking, common sense says to give it up.
Hormone replacement therapy is also associated with the development of breast cancer and thus should be avoided with the exception of women who reach an early menopause for other reasons.
Good nutrition is equally important. Remember the saying 'you are what you eat'. Many alternative doctors or nutritionists may recommend numerous vitamin supplements but it is difficult to know if they do any good or worse, any harm. Eat plenty of fresh vegetables and fruit as well as nuts as these have been the normal staple diet for the last thousand years and our bodies have adapted to them over this period of time. Studies have shown for example that taking vitamin C tablets do not have as good anti-oxidant effects as taking fruit containing the same amount of vitamin C which suggests that there are other compounds in foodstuffs that work alongside vitamin C to enhance its anti-oxidant effects.
The other problem with many of the modern foodstuffs is the use of chemicals or hormones to increase food production. Unfortunately, we do not really know what effect if any these are having on our body and immune system and until we have better insight it is common sense to limit these in our diet as much as possible.
Other people such as Jayne Plant are convinced that milk products are not good for you and the fact that her recurrent breast cancer has not returned since sticking to a milk free diet suggests that in her particular case milk products were having an effect. Some women have found no benefit from this diet which is not really surprising as each tumour is different and is likely to respond to different stimuli. However, it may work for you.