Breast Cancer Recurrence and Advanced Disease: Comprehensive Expert Guidance

Overview

At age 42, Barbara L. Gordon was diagnosed with Stage II breast cancer. Two years later, it appeared that the cancer had metastasized. Along with her oncologist and other experts, Gordon has written the book that she wished she had as she faced late-stage breast cancer and the prospect of dying from the disease. Filled with information and advice, and designed to enable informed decisions and improved quality of life, this comprehensive guide gathers in one place authoritative medical information about recurrence...

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Breast Cancer Recurrence and Advanced Disease: Comprehensive Expert Guidance

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Overview

At age 42, Barbara L. Gordon was diagnosed with Stage II breast cancer. Two years later, it appeared that the cancer had metastasized. Along with her oncologist and other experts, Gordon has written the book that she wished she had as she faced late-stage breast cancer and the prospect of dying from the disease. Filled with information and advice, and designed to enable informed decisions and improved quality of life, this comprehensive guide gathers in one place authoritative medical information about recurrence and late-stage breast cancer, and it addresses the practical, emotional, spiritual, and interpersonal aspects of dying and death.

Types of recurrence, their symptoms, and ways of minimizing the chance of a recurrence

Diagnostic tests, potential surgeries, and treatments to manage late-stage cancer

Complementary therapies, nutrition, and integrative health centers

Clinical trials, patients' rights, and medical expenses

Cessation of treatment and what one may experience as the disease progresses

End-of-life issues such as handling financial and legal matters, communicating with loved ones and hospice workers, and planning memorial services

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Editorial Reviews

From the Publisher
Breast Cancer Recurrence and Advanced Disease provides a lot of relevant information to women with the condition. It discusses tools and resources to deal with a scary diagnosis, is practical and easy to read, and is written in an objective manner about medicine, daily living, and dying. Women struggling with the condition will find strength and guidance in this book.”—Helena Chang, M.D., Ph.D., Director of the Revlon/UCLA Breast Center

“This book is a wonderful resource for women diagnosed with a recurrence of breast cancer. It explains both the medical and the emotional implications of a second diagnosis of breast cancer and offers women practical information on treatment, as well as on matters such as finding funds to pay for treatment. It also gives excellent advice on wills, durable powers of attorney, advanced medical directives, and other issues people tend not to consider soon enough. The pros and cons of complementary and alternative approaches for this condition are clearly laid out.”—Terry and Joe Graedon, The People’s Pharmacy

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Product Details

  • ISBN-13: 9780822347637
  • Publisher: Duke University Press
  • Publication date: 7/31/2010
  • Pages: 388
  • Sales rank: 1,255,365
  • Product dimensions: 9.10 (w) x 6.10 (h) x 1.00 (d)

Meet the Author

Barbara L. Gordon, Ph.D., is Associate Professor of English at Elon University in North Carolina. Heather S. Shaw, M.D., was a breast oncology clinician, from 1999 to 2009, and Assistant Professor of Medicine at Duke University Medical Center in the Multidisciplinary Breast Program of the Duke Comprehensive Cancer Center. She is pursuing a Master of Public Health degree at the University of North Carolina, Chapel Hill. David J. Kroll, Ph.D., is Professor and Chair of Pharmaceutical Sciences at North Carolina Central University, Adjunct Associate Professor of Medicine at Duke University, and Adjunct Associate Professor in the Division of Pharmacotherapy and Experimental Therapeutics at the University of North Carolina, Chapel Hill. Brooke Ratliff Daniel, M.D., is a private practice medical oncologist at Chattanooga Oncology and Hematology Associates in Tennessee.
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Table of Contents

List of Online Resources xi

Preface xv

Acknowledgments xxiii

Introduction 1

Chapter 1 Local and Distant Recurrence 5

Common Questions about Recurrence 6

Predictors of Recurrence 9

Recurrence Statistics 20

Reducing Chances of Recurrence 24

Local and Regional Recurrence 34

Distant Recurrence/Metastatic Cancer 42

Chapter 2 Immediate Concerns and Best Care 51

Emotional Self-Care 52

Getting the Best Care 56

Researching Your Disease and Treatment 68

Exploring Treatment Options 72

Chapter 3 Medical Treatments 83

Physical and Emotional Considerations in Determining Treatment 84

Local Treatment Aimed at Specific Tumor Sites 89

Treatment Aimed at Cancer Cells throughout the Body-Systemic Treatment 93

Monitoring Treatment 110

Supportive/Palliative Treatment 111

Chapter 4 Understanding Cancer Development, Treatment, and Emerging Therapies 115

Understanding Cancer Development 116

How Current Treatments Fight Cancer 129

How Targeted Therapies Fight Cancer 134

The Future 145

Chapter 5 Complementary, Alternative, and Integrative Care 153

Comparison of CAM and Standard Western Medical Practices 155

Nature's Pharmacy in Cancer Treatment 157

Biologically Based Practices 60

Whole Alternative Medical Systems 168

Exercise and Manipulative Practices 170

Mind-Body Interventions 172

Energy Therapies 173

Considerations in Using a CAM Practice 175

Selecting a Complementary Health-Care Practitioner 180

Chapter 6 Managing Pain and Understanding the Dying Process 185

Pain from Metastatic Cancer 186

Describing and Evaluating Pain 188

Attacking the Causes and Symptoms of Pain 191

Euthanasia and Suicide 196

Choices in Dying 200

How We Die 203

Chapter 7 Practical Matters 211

Medical Rights 211

Paying for and Managing Medical Expenses 219

Final Arrangements: Will, Durable Power of Attorney, Advance Directive, Memorial Service 245

Chapter 8 Emotional and Spiritual Well-Being 263

Responding to Loss 264

Interrelating with Others: Those You See Occasionally 273

Interrelating with Those Closest to You 276

At Ease near life's End 283

Reflections on Death 293

Appendix A Absolute and Relative Risk 297

Appendix B Diet and Breast Cancer 301

Appendix C CAM Centers 311

Glossary of Medical and Scientific Terms 317

References 331

Index 345

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First Chapter

Breast Cancer Recurrence and Advanced Disease

Comprehensive Expert Guidance
By Barbara L. Gordon Heather S. Shaw David J. Kroll Brooke R. Daniel

Duke University Press

Copyright © 2010 Duke University Press
All right reserved.

ISBN: 978-0-8223-4763-7


Chapter One

Local and Distant Recurrence

Do not be anxious about tomorrow; tomorrow will look after itself. —Matthew 6:34

Even cowards can endure hardship; only the brave can endure suspense. —Mignon McLaughlin, A Woman's Notebook

Over millennia the word "cancer" has inspired concern. Humankind has wrestled with its nature, seeking to define, understand, and overcome it. Physicians thousands of years ago in ancient Greece recognized the disease, calling abnormal growths oncos, the origin for our word "oncology." The word "cancer" comes from what the Greeks called solid growths, karkinos, meaning crab, a derivative of the Indo-European word for hard.

You probably know personally how frightening a diagnosis of cancer can be since you are reading this book. You may be among the many millions of people worldwide living with cancer or among the many who care for them. In the United States alone, almost 2.45 million women were living with a diagnosis of breast cancer in 2005, the latest year for which data were available at this writing (1). This number will likely increase as newer treatments extend lives. Though the disease has not significantly altered since it was first identified, our ability to manage it has greatly improved. Increasingly we know more about its workings, and increasingly people have access to advancements in treatment and good care. This book is a part of that care. We bring to you and your loved ones expert information about recurrence and advanced breast cancer. In conjunction with your health-care professionals, what you learn in these pages can empower you to make knowledgeable decisions for your complete well-being—body, mind, and spirit.

In this chapter on recurrence, we introduce important concepts in the diagnosis and treatment of breast cancer. The common questions that are posed in the following section form the basic outline of topics in this chapter. For those of you who have metastases at the time of diagnosis, some of the material on recurrence may be less helpful. However, the discussion of the diagnosis of cancer will give you a good working knowledge of breast cancer to aid in reading your medical reports and in understanding the therapeutic options available to you.

Common Questions about Recurrence

What Is a Recurrence?

Nearly everyone who has been treated for breast cancer worries about cancer returning or, in other words, worries about having a recurrence. Many do not realize that a breast cancer recurrence refers to a number of different conditions. Though any recurrence is scary, some are far less life threatening than others. Recurrences are of various types and differ significantly in terms of treatment and prognosis. A recurrence can be local, meaning that cancer has reappeared in the same breast or scar area; regional, meaning that cancer has reappeared in nearby lymph nodes, such as those under the collarbone or in the chest wall; or distant, meaning that cancer has reappeared in an organ in the body such as in a bone, a lung, the liver, or the brain.

Recurrences are usually caused by a return of cancer cells from the original tumor, cells that remained despite prior surgery, chemotherapy, and radiation. Most often a local recurrence occurs in the mastectomy or lumpectomy scar. Following the original surgery, the breast cancer cells at the edges (margins) of the removed areas of the breast may have been too few or too far apart to be seen by a pathologist looking at tissue through a microscope. These cells can lie dormant, and though radiation, chemotherapy, and hormonal therapies may have been used to destroy them, occasionally some survive and reappear. It is also possible, though less likely, that a local recurrence is the result of the original cancer circulating in the body and reappearing in the breast; this is a more serious condition. Cancer that recurs or is discovered in a distant site is called metastatic cancer.

What Is My Chance for Recurrence?

Your oncologist may use a number of sources of information to determine your risk of cancer recurrence. A computer program called Adjuvant! Online can give general estimates of chances of recurrence based on the size, grade, and estrogen-receptor status of your tumor, in combination with the number of lymph nodes with metastases. These factors are discussed under "Predictors of Recurrence." The estimate calculated with Adjuvant! Online is not highly specific; it does not distinguish between distant and local recurrences, nor does it currently take HER2—an important indicator of a tumor's response to certain drugs as well as its potential aggressiveness—status into account. Newer tests that look at a gene signature may soon more accurately predict the risk of distant recurrence.

How Can I Prevent a Recurrence?

Depending on your specific cancer, chemotherapy, hormonal therapy, and/or radiation may be, or may have been, recommended to reduce the chances of a recurrence. Exercise and a healthy diet appear to prevent recurrences, and specific recommendations are discussed below under "Reducing Chances of Recurrence."

How Is a Recurrence Detected?

Some recurrences are easy to see, such as those that occur in the skin. These can be diagnosed with a simple skin punch sample or biopsy. Recurrences in the lymph nodes, such as those in the armpit (axilla) or around the collarbone (clavicle), are usually found as hard lumps that can be sampled with a needle to confirm a recurrence. Recurrences in other sites, such as the lung, liver, or bone, are detected with scans such as a CT scan or bone scan. Areas of concern must also be sampled with a needle to confirm a recurrence. This is further discussed in "Detecting a Local or Regional Recurrence" and "Detecting and Confirming a Metastatic Recurrence."

How Can Recurrence Be Treated?

Depending on the site and type of recurrence, combinations of hormonal therapy, chemotherapy, immunotherapy, radiation therapy, and surgery can be used. Further discussion of local and regional recurrence can be found in this chapter under "Treatment of Local or Regional Recurrence," and a more extended discussion of treatments, particularly for distant (metastatic) recurrence, can be found in chapter 3.

What Does It Mean to Have a Distant Recurrence?

A distant recurrence is the reappearance of cancer in an organ away from the site of the original cancer, such as the bone or lung. A distant recurrence signals that initial treatment did not destroy all the malignant cells. At the time of this writing, no treatment can guarantee the eradication of all cancer cells.

If the Cancer Comes Back in My Bone/Lung/Liver, Is It Bone/ Lung/Liver Cancer or Breast Cancer?

If the original cancer reappears in your bone or in another organ, it is not bone or another type of cancer, but breast cancer that has spread (metastasized) to the bone or that organ. Regardless of the organ to which breast cancer has metastasized, it is still breast cancer and keeps the features of breast cancer.

Does It Matter How Quickly a Recurrence Is Detected? Why Doesn't My Doctor Get Scans on Me Routinely?

It improves chances of survival to detect a local or regional recurrence as early as possible. This fact guides the recommendation for monthly breast self-examination; annual mammograms; and regular follow-up appointments with a physician after diagnosis. (See "Conducting a Breast Self-Exam" resource box in this chapter.) Unfortunately, detecting a distant recurrence early, such as seeing cancer on a CT or bone scan, does not significantly improve chances of survival. Once a tumor has spread outside the local or regional area, it is no longer curable. It is, however, treatable, as will be discussed. Many women with metastatic breast cancer have a good quality of life and live many years.

Current surveillance guidelines from major cancer organizations do not include routine scans other than mammography or other breast imaging on an annual basis. The American Society of Clinical Oncology (ASCO) recommends physical examinations every three to six months for the first three years after diagnosis, every six to twelve months for years four and five, and annually thereafter. Yearly mammographic evaluation should also be performed. The National Comprehensive Cancer Network (NCCN) recommends annual mammograms and physical examinations every four to six months for the first five years after diagnosis and annual exams after five years. Neither ASCO nor NCCN recommends tumor markers or other blood tests as part of surveillance.

Is the Diagnosis of Recurrence Going to Affect How Long I Will Live?

If your cancer has spread locally, then your risk for distant metastases increases. If you have distant metastases, then most likely breast cancer will shorten your life. Where the metastases are; how well your cancer responds to therapy (chemotherapy, hormonal therapy, radiation therapy, and/or immunotherapy); your age; and your underlying health will all affect how long you will live. Women with metastatic breast cancer are now living longer than ever with new treatments. This is further discussed in this chapter under "Prognosis of Distant Metastasis."

Predictors of Recurrence

Oncologists and pathologists can estimate the risk of your cancer returning in various ways. In general, your type of cancer is compared to similar types of cancer. The number of times out of one hundred that type of cancer was seen to have returned in the past is estimated as your chance of recurrence. Estimates can be made based on the size and spread of the cancer (stage of cancer), the way the cancer looks under the microscope (pathologic type), the types of proteins present on the cancer, and (most recently) a specific gene "signature." Estimates of recurrence will likely continue to become more personalized such that risk will be determined for each individual's specific tumor, not simply her tumor type.

Cancer Staging

Cancer staging is a means of indicating the amount of cancer present in the body when the disease is first diagnosed. It is also the best means at this time for predicting your risk of recurrence, although this is changing as newer molecular tests are being developed. The system most often used to describe the extent of breast cancer is the TNM staging system of the American Joint Commission on Cancer (AJCC). In TNM staging, information about the tumor (T), spread to nearby lymph nodes (N), and distant metastases (M) is combined, and a stage is assigned to specific TNM groupings. The TNM stage groupings are described using Roman numerals from 0 to IV.

The clinical stage is determined by what the doctor learns from the physical examination and imaging tests. The pathologic stage includes the findings of the pathologist after surgery. Most of the time, the pathologic stage is the most important since involvement of the lymph nodes can be accurately determined only by examining them under a microscope.

TNM Staging System of the American Joint Commission on Cancer (AJCC)—Categories of TNM

T Categories: T categories are based on the size of the breast cancer and whether it has spread to nearby tissue.

Tis: T is used only for carcinoma in situ (noninvasive breast cancer), such as ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS).

T1: The cancer is less than or equal to 2 cm in diameter (about 3/4 inch).

T2: The cancer is more than 2 cm but not more than 5 cm in diameter.

T3: The cancer is more than 5 cm in diameter.

T4: The cancer is any size and has spread to the chest wall, skin, or both. This category includes inflammatory breast cancer. To learn more about inflammatory breast cancer, see "Inflammatory Breast Cancer" at the end of this section.

N Categories: The N category is based on which of the lymph nodes near the breast, if any, are affected by the cancer.

NØ Clinical: The cancer has not spread to lymph nodes, based on clinical exam.

NØ Pathological: The cancer has not spread to lymph nodes, based on examining them under the microscope.

N1 Clinical: The cancer has spread to lymph nodes under the arm on the same side as the breast cancer. Lymph nodes are not attached to one another or to the surrounding tissue.

N1 Pathological: The cancer is found in 1–3 lymph nodes under the arm.

N1 Clinical: The cancer has spread to lymph nodes under the arm on the same side as the breast cancer, and lymph nodes have attached to one another or to the surrounding tissue. Alternatively, the cancer can be seen to have spread to the internal mammary lymph nodes (next to the breastbone) but not to the lymph nodes under the arm.

N2 Pathological: The cancer has spread to 4–9 lymph nodes under the arm or to the internal mammary lymph nodes.

N3 Clinical: The cancer has spread to lymph nodes above (supraclavicular) or just below (infraclavicular) the collarbone on the same side as the breast cancer and may or may not have spread to lymph nodes under the arm. Alternatively, the cancer has spread to the internal mammary lymph nodes or the superclaviclular and axillary lymph nodes under the arm, both on the same side as the cancer.

N3 Pathological: The cancer has spread to ten or more lymph nodes under the arm or also involves lymph nodes in other areas around the breast.

M Categories: The M category depends on whether the cancer has spread to any distant tissues and organs.

MØ: No distant cancer spread.

M1: Cancer has spread to distant organs.

Once the T, N, and M categories have been assigned, the information is combined to assign an overall stage of 0, I, II, III, or IV. The stages identify tumor types that have a similar outlook and thus are treated in a similar way. For a further look at staging, use the link in the following resource box.

Inflammatory Breast Cancer

Inflammatory breast cancer is a special type of breast cancer that is given its own T designation, T4d. A breast involved with inflammatory breast cancer is red, swollen, and warm, and the condition can be easily confused with an infection of the breast. These symptoms do not go away with antibiotic treatment, unlike in an infected breast. Often the skin of the breast resembles the peel of an orange, called "peau d'orange." Frequently these skin changes are found without a lump that can be felt (a palpable mass), and a mammogram may show only skin thickening. A skin biopsy performed on an affected area shows tumor cells in the lymph channels of the skin, the dermal lymphatics. These cancers are particularly aggressive, and spread to the local lymph nodes is common. Distant disease is present at initial diagnosis more often than in other types of cancer, and a CT scan and a bone scan are usually performed soon after diagnosis. With newer presurgical (neoadjuvant) chemotherapy and targeted treatment for HER2 overexpressing tumors, long-term survival from this cancer has significantly improved.

Pathology Reports for Diagnosis and Prognosis

The staging of a cancer relies heavily on a pathology report. In addition to noting physical evidence, such as the size of a tumor and the amount of lymph node involvement, pathology reports note the histological type of cancer (how the cancer cells look under the microscope), the aggressiveness of the cancer in terms of how rapidly the cells appear to be dividing, and the extent cancer cells have invaded surrounding tissue. Last, pathology reports include biomarkers, special features of a tumor that can reveal what may have contributed to the growth of a particular cancer. These pathology indicators help physicians determine the treatment to which a cancer may respond and predict both the chances of a recurrence and the chances of a normal life span.

(Continues...)



Excerpted from Breast Cancer Recurrence and Advanced Disease by Barbara L. Gordon Heather S. Shaw David J. Kroll Brooke R. Daniel Copyright © 2010 by Duke University Press. Excerpted by permission of Duke University Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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