You've been diagnosed with breast cancer. Now what?

A breast cancer diagnosis can be devastating for many women. Nearly 12.4 percent of women will develop invasive breast cancer in their lifetimes, according to breastcancer.org.

One of the first questions they will have is about treatment. Dr. Katherine H.R. Tkaczuk, professor of medicine at the University of Maryland School of Medicine and director of the breast evaluation and treatment program at the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, talks about what women can expect after finding out they have breast cancer.

After a woman is diagnosed with breast cancer what will determine if she needs radiation?

Breast radiation therapy is recommended to all women with stages 1, 2 and 3 breast cancer who have breast conservation (lumpectomy surgery). Additionally, some women at higher risk for recurrence such as women with stage 3 breast cancer may receive radiation therapy after mastectomy surgery.

What will determine if she needs chemotherapy?

The need for adjuvant chemotherapy in early stage breast cancer (stage 1-3) is based on many factors, such as tumor stage (tumor size, number of lymph nodes involved) and estrogen, progesterone, HER2 expression and tumor grade. Those with HER2 positive breast cancer have a protein that feeds the growth of cancer cells.

Women who have stage 3 breast cancer will almost always be considered for chemotherapy. Women with triple-negative or HER2-positive cancers will more often be considered for chemotherapy. Women with HER2-positive breast cancers will always receive “HER2 blockers” — antiHER2-agents, such as Trastuzumab with or without Pertuzumab with chemotherapy.

In some cases when the cancer is estrogen and progesterone-receptor positive, and HER2-negative, oncologists may order additional tumor tests to assess if chemotherapy will be beneficial. When these tests show that the tumor has low or intermediate risk of recurrence, hormonal therapies, such as aromatase inhibitors or Tamoxifen, will be recommended.

What are some of the side effects women may experience after treatment?

During chemotherapy, women may experience many side effects such as fatigue, low blood counts, increased risk of infections, anemia, hair loss, nausea, vomiting and neuropathy symptoms. These side effects typically are temporary and are expected to resolve after chemotherapy is completed. The majority of women are able to continue to work and carry on their daily activities, however, we do recommend rest, shorter working hours and intermittent work schedules, if needed.

Hormonal therapies, which block estrogen production or block estrogen receptors, are recommended for patients with estrogen or progesterone positive breast cancers and may cause symptoms and side effects that resemble menopausal symptoms, such as hot flashes and sweats. Additionally, drugs known as aromatase inhibitors can cause joint and muscle aches and pains and also can accelerate postmenopausal bone loss.

Women with HER2-positive breast cancer will receive antiHER2 therapy, initially with chemotherapy and then by itself to complete 12 months of antiHER2 therapy. These treatments can cause minor reactions such as fever or chills and rarely may contribute to decrease in heart function.

What determines if a woman will have her breasts removed and will need reconstruction surgery?

The majority of women with early stage breast cancer do not need to have mastectomy surgery. Several large randomized clinical trials have shown that breast conservation surgery (lumpectomy) with radiation therapy is as effective as mastectomy for treatment of early stage breast cancer. In some cases, if the breast tumor is very large, or there are several tumors in different quadrants of the breast, mastectomy is recommended.

Breast cancer patients should carefully consider their surgical options and discuss them with their breast surgeons. When mutations are present in genes known as BRCA 1 or 2, women may consider having prophylactic mastectomy surgery, or the removal of one or both breasts, due to significantly increased risk of developing additional breast cancers in their lifetime.

Most women with early stage breast cancer who are planned for mastectomy can have breast reconstruction; at the University of Maryland Breast Evaluation and Treatment Program we recommend plastic surgery consultations to all patients who are undergoing mastectomy surgeries.

What are some of the things women are surprised about living with breast cancer?

Although the majority of women presenting with early stage breast cancer will be cured, they are often surprised that we recommend postoperative treatment, such as hormonal therapies, for up to 10 to 15 years.

Some doctors are starting to rethink whether they are overtreating some women with breast cancer. Why is that and how does a woman know if she is being overtreated?

The concept of overtreatment of cancer has evolved in recent years; cancer doctors tend to utilize more aggressive chemotherapy treatment approaches for certain subtypes of breast tumors such as triple-negative or HER2-positive breast cancers. One of the major recent advances in the treatment of early stage breast cancer is the ability to better define who needs chemotherapy and recognize that patients with certain estrogen receptor positive, HER2-negative tumors that have not spread to the lymph nodes, are considered low risk and do not need chemotherapy. New genomic tumor tests such as OncotypeDx or Mammaprint can better define who will benefit from chemotherapy.

Once a women's treatment is completed what are some of the after effects they should be aware of?

After completion of treatments, most women recover to their baseline; women with estrogen positive breast cancer will remain on oral hormonal therapies for five to 15 years, and some do experience muscle and joint aches and hot flashes with these treatments. For all breast cancer patients we recommend continuing to follow up with their cancer doctors every four to six months for five years, then annually. Screening mammograms are recommended every 12 months, with the exception of the initial short-term, six-month follow-up after completion of surgery and radiation.

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