Breast Cancer Care in the Greater Philadelphia Area

At Consultants in Medical Oncology and Hematology, our dedicated team of medical oncologists use the latest breast cancer treatment technologies to create a unique care plan for each patient. They are available to answer questions and guide you through the process of starting a breast cancer treatment plan that is right for you.

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Types of Breast Cancer

Breast cancer is not a single disease but rather a broad term that covers a number of different types of breast cancer. Treatment for one patient may look completely different than another patient’s treatment plan, all because of their specific breast cancer type and stage. 

Breast cancer is broadly classified into two categories based on its relationship to the walls of its origin: invasive and non-invasive.

Invasive Breast Cancer

Invasive (infiltrating) means that cancer has spread into surrounding tissues and/or distant organs. This is the more common type of breast cancer.

Non-Invasive Breast Cancer

Non-invasive (in situ) means that the cancerous cells are confined to their point of origin within the breast lobules or milk ducts. They don't invade or grow into normal tissues beyond or within the breast.

Common Types of Breast Cancer

Most breast cancers are categorized as carcinomas — tumors that start in the cells that line organs and tissues in the body. When carcinomas start in the breast, they’re specifically called adenocarcinoma. Adenocarcinomas start in the milk ducts or the lobules that produce milk.

Certain breast cancers are more common than others. Some specific types of common breast cancer include:

Ductal Carcinoma in Situ (DCIS)

DCIS is a type of non-invasive breast cancer. It's not life-threatening, but when you have this type of cancer, it could increase your risk of invasive breast cancer development later on. Around one in five new breast cancers will end up being DCIS. Almost all women with this early stage DCIS can be cured.

Sometimes when you receive a non-invasive diagnosis, it could mean you're at a greater risk for the development of breast cancer in the future.

Lobular Carcinoma in Situ (LCIS)

Sometimes referred to as intralobular or neoplasia, this type of cancer isn't considered a pre-cancer or cancer since, without treatment, it doesn't become invasive cancer. It actually indicates you could possibly develop breast cancer in the future.

LCIS is typically diagnosed before you experience menopause, usually between the ages of 40 and 50 years old. Less than 10% of women who received an LCIS diagnosis have already experienced menopause. It's very rare in men.

Invasive Ductal Carcinoma (IDC)

This is the most common type of breast cancer, with between 70 and 80% of breast cancer diagnoses in this category, affecting both women and men. Sometimes referred to as infiltrative ductal carcinoma, IDC irregular cancer cells that start forming in your milk ducts begin spreading into other breast tissue areas. Invasive cancer cells also have the ability to spread to other body parts.

Invasive Lobular Carcinoma (ILC)

This type of cancer begins in your lobules (milk-producing glands) and could potentially spread to other body parts. ILC accounts for 10% to 15% of breast cancers and is the next most common type.

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Less Common Types of Breast Cancer

Certain breast cancers are less common than others.

Inflammatory Breast Cancer

Inflammatory Breast Cancer (IBC) is a less common type of invasive breast cancer, accounting for only 1-5% of breast cancers. IBC often appears to be an infection (breast red, swollen and inflamed) but it is actually cancer that is blocking lymphatic vessels in the skin and breast tissue, causing a buildup of fluid (lymph).

Paget Disease of the Nipple

This type of breast cancer starts in the breast ducts and spreads to the skin of the nipple and then to the areola, the dark circle around the nipple. This type of breast cancer only accounts for about 1% of all cases of breast cancer.

Phyllodes Tumor

Phyllodes tumors are rare breast tumors. These tumors develop in the connective tissue (stroma) of the breast and grow in a leaflike pattern. Although phyllodes tumors tend to grow quickly, they rarely spread outside the breast.

Angiosarcoma

Angiosarcoma is a cancer in the inner lining of blood vessels that can occur in any part of the body. This form of cancer rarely occurs in the breast.

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Detecting and Diagnosing Breast Cancer

Since there are very few noticeable symptoms of breast cancer, it’s important to get screened regularly. Doctors recommend that women have regular clinical breast exams and mammograms starting at age 40. The earlier that breast cancer is found, the greater the chances of successful treatment and recovery. Screening is proven to find breast cancers early, when they’re easier to treat.

Clinical Breast Exams

During a clinical breast exam, your health care provider — usually a gynecologist — checks your breasts. You may be asked to raise your arms over your head, let them hang by your sides, or press your hands against your hips.

Your health care provider looks for differences in size or shape between your breasts. The skin of your breasts is checked for a rash, dimpling, or other abnormal signs. Your nipples may be squeezed to check for fluid.

If a lump is detected, your doctor will feel its size, shape, and texture. He or she will also check to see if the lump moves easily. Benign lumps often feel different from cancerous ones. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer, but further tests are needed.

Mammograms for Breast Cancer Screening

A mammogram is an x-ray image of the inside of the breast. Mammograms can often show a breast lump before it can be felt. They also can show a cluster of tiny specks of calcium. These specks are called microcalcifications. Lumps or specks can be from cancer, precancerous cells, or other conditions. Further tests are needed to find out if abnormal cells are present.

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The right time to start breast cancer screening depends on your risk level. Here are the latest recommendations for breast cancer screening according to the American Cancer Society:

Women Under 40

Women younger than 40 with risk factors for breast cancer should ask their primary care physician whether to start mammograms and how often to have them

Age 40 - 44

Women between the ages of 40 to 44 have the choice to start yearly mammography

Age 45 - 54

Women aged 45 to 54 are recommended to receive a mammogram every year

Age 55+

Women age 55 and older can switch to having a mammogram every two years or continue yearly screening if they choose

If the mammogram shows an abnormal area of the breast, your doctor will order more detailed images of that area. This could include another mammogram as well as:  

Ultrasound

An ultrasound device sends out sound waves that people can’t hear. The sound waves bounce off breast tissues. A computer uses the echoes to create a picture. The picture may show whether a lump is solid, filled with fluid (a cyst), or a mixture of both. Cysts usually are not cancer. But a solid lump may be cancer.

MRI

MRI uses a powerful magnet linked to a computer. It makes detailed pictures of breast tissue. These pictures can show the difference between normal and diseased tissue.

Breast Biopsy for Cancer Diagnosis

If an abnormal area is found during a diagnostic mammogram or breast MRI, you will likely need a biopsy. A biopsy is the removal of tissue from the breast to determine if the unusual area contains cancer cells. It is the only way to tell for sure if cancer is present. 

The tissue or fluid removed from your breast for cancer cells will be examined by a pathologist who will record the findings in a pathology report. This report determines if cancer cells are found and gives the pathologist information about what type of breast cancer it is.

Lab Tests With Breast Tissue

If you are diagnosed with breast cancer, your doctor will order special lab tests on the breast tissue that was removed, including:

Hormone Receptor Tests

Some breast tumors grow more quickly due to hormones. These tumors have receptors for the hormones estrogen, progesterone, or both. If the hormone receptor tests show that the breast tumor has these receptors, then hormone therapy is most often recommended as a treatment option.

HER2 test

HER2 is a protein found in or on some breast cancer cells that fuels growth and can make breast cancer spread quicker. If the test shows you are HER2 positive, a special drug targeting the HER2 protein is recommended.

All of these diagnostic tests may not happen at once, and it might take several weeks to get the results. This does not mean your treatment will be put on hold. In most cases, oncologists recommend a treatment plan that begins shortly after diagnosis to begin the process of shrinking the breast tumor. 

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Hormone Status and Breast Cancer

Some breast cancer cells are fueled by estrogen and some by progesterone (the naturally occurring hormones in the female body) because of special proteins inside the tumor cells, called hormone receptors. When hormones attach to hormone receptors, the cancer cells grow.

 

Breast cancer patients are given a hormone receptor status that is either hormone receptor (HR) positive or hormone receptor (HR) negative:

Hormone Receptor-Positive

Hormone receptor-positive breast cancer cells have either estrogen (ER) or progesterone (PR) receptors. These breast cancers can be treated with hormone therapy drugs that lower estrogen levels or block estrogen receptors. HR-positive cancers tend to grow more slowly than those that are HR-negative. HR-positive cancers are generally more common in women after menopause.

Hormone Receptor-Negative

Hormone receptor-negative breast cancers do not have estrogen or progesterone receptors. These types of cancers will not benefit from hormone therapy drugs and typically grow faster than HR-positive cancers. HR-negative cancers are more common in women who have not yet gone through menopause.

 

Hormone Receptor Categories of Breast Cancer

Your doctor will run tests and give you at least one of the following hormone receptor categories:

Estrogen-Receptor Positive or Negative (ER+/-)

The breast cancer cells may or may not have receptors for the hormone estrogen. ER+ results suggest that the cancer cells may receive signals from estrogen that could promote their growth.

Progesterone-Receptor Positive or Negative (PR+/-)

The breast cancer cells may or may not have receptors for the hormone progesterone. PR+ results mean that the cancer cells may receive signals from progesterone that could promote their growth.

HER2 Status in Breast Cancer

HER2 (human epidermal growth factor receptor 2) is a protein that appears on the surface of some breast cancer cells and plays a role in how a healthy breast cell grows, divides, and repairs itself.

What does it mean to be HER2- negative or positive?

HER2-Negative

HER2-negative breast cancers do not have excess HER2 and will therefore not respond to therapies that specifically target HER2 receptors.

HER2-Positive

HER2-positive breast cancers have too much HER2 protein or extra copies of the HER2 gene, which usually makes the tumor grow faster. HER2-positive breast cancer treatment typically includes targeted therapy drugs that slow the growth and kill these cancer cells.

Knowing both your hormone receptor and HER2 status will help the oncologists at Consultants in Medical Oncology and Hematology create the best treatment plan for you.

 

Triple Negative Breast Cancer

This is an invasive breast cancer, accounting for 10-15% of all breast cancers. It grows faster and spreads faster than other types of breast cancer. Because it doesn’t have receptors for hormones, like estrogen or progesterone, and it does not make too much HER2 protein, the best method of treatment is less decisive.

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Breast Cancer Staging & Lymph Node Involvement

Staging is a way of describing how extensive the breast cancer is. Knowing the stage is an important part of planning your breast cancer treatment. 

The stage of your breast cancer is based on several factors, such as: 

  • The size and location of the primary tumor
  • Whether the cancer has spread to nearby lymph nodes or other parts of the body
  • Tumor grade

 

The Role of Lymph Nodes In Breast Cancer

One of the first places breast cancer can spread and start to grow is in the nearby lymph nodes. 

Multiplying breast cancer cells can enter the lymphatic vessels that are located in breast tissue. These cells are then carried throughout the body by lymph fluid. The closest lymph nodes, usually in the underarm area, are often the first place that breast cancer will start to grow outside of the breast.

When the surgeon removes the tumor, they will also evaluate the lymph nodes and run a test to find the closest lymph nodes so they can be removed and tested for cancer cells. This is called a sentinel lymph node biopsy.

Stages of Breast Cancer

The TNM staging system is a classification system developed by the American Joint Committee on Cancer for describing the extent of disease progression in cancer patients. It is the most common tool that doctors use to describe the breast cancer stage. It is used to answer the following questions: 

  • Tumor (T): How large is the primary tumor in the breast? What are its biomarkers?
  • Node (N): Has the tumor spread to the lymph nodes? If so, where, what size, and how many?
  • Metastasis (M): Has the cancer spread to other parts of the body?

T Categories for Breast Cancer

T followed by a number from 0 to 4 describes the primary tumor's size and if it has spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.

TX: The primary tumor cannot be evaluated.

T0 (T zero): There is no evidence of cancer in the breast.

Tis: Refers to carcinoma in situ. The cancer is confined within the ducts of the breast tissue and has not spread into the surrounding tissue of the breast. There are 2 types of breast carcinoma in situ:

  • Tis (DCIS): DCIS is a non-invasive cancer, but if not removed, it may develop into an invasive breast cancer later. DCIS means that cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began.
  • Tis (Paget’s disease): Paget's disease of the nipple is a rare form of early, non-invasive cancer that is only in the skin cells of the nipple. Sometimes Paget's disease is associated with invasive breast cancer. If there is an invasive breast cancer, it is classified according to the stage of the invasive tumor.

T1: The tumor in the breast is 20 millimeters (mm) or smaller in size at its widest area. This is a little less than an inch. This stage is then broken into 4 substages depending on the size of the tumor:

  • T1mi is a tumor that is 1 mm or smaller.
  • T1a is a tumor that is larger than 1 mm but 5 mm or smaller.
  • T1b is a tumor that is larger than 5 mm but 10 mm or smaller.
  • T1c is a tumor that is larger than 10 mm but 20 mm or smaller.

T2: The tumor is larger than 20 mm but not larger than 50 mm.

T3: The tumor is larger than 50 mm.

T4: The tumor falls into 1 of the following groups:

  • T4a means the tumor has grown into the chest wall.
  • T4b is when the tumor has grown into the skin.
  • T4c is cancer that has grown into the chest wall and the skin.
  • T4d is inflammatory breast cancer.

N Categories for Breast Cancer

N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are involved.

NX: The lymph nodes cannot be assessed.

N0: No sign of cancer in the lymph nodes, or tiny clusters of cancer cells not larger than 0.2 millimeters in the lymph nodes

N1: Cancer is described as one of the following:

  • N1mi: cancer has spread to the axillary (armpit area) lymph nodes and is larger than 0.2 millimeters but not larger than 2 millimeters.
  • N1a: cancer has spread to 1 to 3 axillary lymph nodes, and the cancer in at least one of the lymph nodes is larger than 2 millimeters.
  • N1b: cancer has spread to lymph nodes near the breastbone on the same side of the body as the primary tumor, and the cancer is larger than 0.2 millimeters and is found by sentinel lymph node biopsy. Cancer is not found in the axillary lymph nodes.
  • N1c: Cancer has spread to 1 to 3 axillary lymph nodes, and the cancer in at least one of the lymph nodes is larger than 2 millimeters. Cancer is also found by sentinel lymph node biopsy in the lymph nodes near the breastbone on the same side of the body as the primary tumor.

N2: Cancer is described as one of the following:

  • N2a: cancer has spread to 4 to 9 axillary lymph nodes, and the cancer in at least one of the lymph nodes is larger than 2 millimeters.
  • N2b: cancer has spread to lymph nodes near the breastbone, and imaging tests found the cancer. Cancer is not found in the axillary lymph nodes by sentinel lymph node biopsy or lymph node dissection.

N3: Cancer is described as one of the following:

  • N3a: cancer has spread to 10 or more axillary lymph nodes, and the cancer in at least one of the lymph nodes is larger than 2 millimeters, or cancer has spread to lymph nodes below the collarbone.
  • N3b: cancer has spread to 1 to 9 axillary lymph nodes, and the cancer in at least one of the lymph nodes is larger than 2 millimeters. Cancer has also spread to lymph nodes near the breastbone, and imaging tests found the cancer;
    OR
    ​cancer has spread to 4 to 9 axillary lymph nodes and cancer in at least one of the lymph nodes is larger than 2 millimeters. Cancer has also spread to lymph nodes near the breastbone on the same side of the body as the primary tumor, and the cancer is larger than 0.2 millimeters and is found by sentinel lymph node biopsy.
  • N3c: Cancer has spread to lymph nodes above the collarbone on the same side of the body as the primary tumor.

M Categories for Breast Cancer

M0: There is no sign that cancer has spread to other parts of the body.

M1: Cancer has spread to other parts of the body, most often the bones, lungs, liver, or brain. If cancer has spread to distant lymph nodes, the cancer in the lymph nodes is larger than 0.2 millimeters. The cancer is called metastatic breast cancer.

Breast Cancer Stage Grouping

The breast cancer stage is assigned by combining the T, N, and M classifications, the tumor grade, and the results of ER/PR and HER2 testing. It is usually expressed as a number on a scale of 0 through IV — with stage 0 describing non-invasive cancers that remain within their original location and stage IV describing invasive cancers that have spread outside the breast to other parts of the body. 

Stage 0

Stage zero (0) describes a disease that is only in the ducts of the breast tissue and has not spread to the surrounding tissue of the breast. It is also called non-invasive or in situ cancer (Tis, N0, M0).

Stage I

Stage IA:
The tumor is small, invasive, and has not spread to the lymph nodes (T1, N0, M0).

Stage IB:
Cancer has spread to the lymph nodes and the cancer in the lymph node is larger than 0.2 mm but less than 2 mm in size. There is either no evidence of a tumor in the breast or the tumor in the breast is 20 mm or smaller (T0 or T1, N1mi, M0).

Stage II

Stage IIA:
Any 1 of these conditions:

  • There is no evidence of a tumor in the breast, but the cancer has spread to 1 to 3 axillary lymph nodes. It has not spread to distant parts of the body (T0, N1, M0).
  • The tumor is 20 mm or smaller and has spread to 1 to 3 axillary lymph nodes (T1, N1, M0).
  • The tumor is larger than 20 mm but not larger than 50 mm and has not spread to the axillary lymph nodes (T2, N0, M0).

Stage IIB:
Either of these conditions:

  • The tumor is larger than 20 mm but not larger than 50 mm and has spread to 1 to 3 axillary lymph nodes (T2, N1, M0).
  • The tumor is larger than 50 mm but has not spread to the axillary lymph nodes (T3, N0, M0).

Stage III

Stage IIIA:
The tumor of any size has spread to 4 to 9 axillary lymph nodes or to internal mammary lymph nodes. It has not spread to other parts of the body (T0, T1, T2, or T3; N2; M0). Stage IIIA may also be a tumor larger than 50 mm that has spread to 1 to 3 axillary lymph nodes (T3, N1, M0).

Stage IIIB:
The tumor has spread to the chest wall or caused swelling or ulceration of the breast, or it is diagnosed as inflammatory breast cancer. It may or may not have spread to up to 9 axillary or internal mammary lymph nodes. It has not spread to other parts of the body (T4; N0, N1, or N2; M0).

Stage IIIC:
A tumor of any size that has spread to 10 or more axillary lymph nodes, the internal mammary lymph nodes, and/or the lymph nodes under the collarbone. It has not spread to other parts of the body (any T, N3, M0).

Stage IV (metastatic)

The tumor can be any size and has spread to other organs, such as the bones, lungs, brain, liver, distant lymph nodes, or chest wall (any T, any N, M1).

Recurrent

Recurrent cancer is cancer that has come back after treatment and can be described as local, regional, and/or distant. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Breast Cancer Tumor Grade

Breast tumor grade is a measurement of how much the cancer cells look like healthy cells. Tumor grading will give the oncologist a better idea of how quickly the cancer is likely to grow and spread.

If the cancer looks similar to healthy tissue and has different cell groupings, it is called "well-differentiated" or a "low-grade tumor." If the cancerous tissue looks very different from healthy tissue, it is called "poorly differentiated" or a "high-grade tumor."

The three grades are as follows:

  • Grade 1 (well-differentiated): total score of 3 to 5
  • Grade 2 (moderately differentiated): total score of 6 to 7
  • Grade 3 (poorly differentiated): total score of 8 to 9
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Breast Cancer Treatment Options

There are many treatment options for women with breast cancer and what’s best for one woman may not be best for another. Breast cancer treatment may include one or a combination of the following treatments:

Breast Cancer Surgery

Surgery is a common part of breast cancer treatment. Your CMOH oncologist and breast surgeon will discuss your options to compare the benefits and risks of each, and describe how each will change the way you look:

Breast-Sparing Surgery

Also called breast-conserving surgery or a lumpectomy, this operation removes the cancer and some surrounding tissue rather than the entire breast. 

Mastectomy

This procedure removes the entire breast (or as much of the breast tissue as possible) and possibly some of the lymph nodes. There are several types of mastectomies: 

  • Total (simple) mastectomy:
    The whole breast is removed. Some lymph nodes under the arm may also be removed.
  • Skin-sparing mastectomy:
    The surgeon removes as little skin as possible so that an implant can be inserted in the future. In some cases, the nipple can be kept intact (nipple-sparing surgery).
  • Modified radical mastectomy:
    The surgeon removes the whole breast and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A small chest muscle also may be taken out to make it easier to remove the lymph nodes.

The surgeon usually does a sentinel lymph node biopsy at this time to see if there may be lymph node involvement.

You may choose to have breast reconstruction, which involves using plastic surgery to rebuild the shape of the breast. It may be done at the same time as the cancer surgery or later. If you’re considering breast reconstruction, you may wish to talk with a plastic surgeon before having cancer surgery.

Radiation Therapy for Breast Cancer

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. It is given by a specialist called a radiation oncologist. 

There are two standard types of radiation therapy that oncologists use to treat breast cancer. Depending on your situation, you may receive both types, which include:

External Beam Radiation Therapy

The radiation comes from a large machine outside the body. Treatments will be given at a hospital or clinic for treatment and last five days a week for four to six weeks. This is the most common type of radiation therapy used for breast cancer.

Internal Radiation Therapy (Brachytherapy)

An applicator is placed inside the breast, pointed at the area where there was cancer. Over the course of a few days, radioactive seeds (or pellets) are placed in the applicator tubes, left for a short period of time, and then removed. This is repeated several times throughout the treatment period. At the end of the treatment, the device with the tubes is removed. This treatment is typically only used after surgery for early-stage breast cancers.

Hormone Therapy for Breast Cancer

If the breast cancer is hormone-receptor positive, then hormone therapy may be used to reduce the amount of hormones in the body that can fuel the cancer’s growth. Hormone therapy slows the production of hormones, or blocks their action and stops cancer cells from growing.

The type of hormone therapy given depends on whether or not the patient has gone through menopause. Hormone therapy is usually given along with other therapies (adjuvant) and may be recommended for several years after your other breast cancer treatments are complete.

Chemotherapy for Breast Cancer

Chemotherapy drugs kill cancer cells. They are usually given through a vein (intravenous) or as an injection under the skin (subcutaneous) for breast cancer. If chemotherapy is part of your treatment plan, you will probably receive a combination of drugs based on the type, stage, and grade of breast cancer you have.

This can be given before surgery, after surgery, or both depending on the type of breast cancer and its stage.

Targeted Therapy for HER2-Positive Breast Cancer

Another breast cancer treatment approach is targeted therapy. It involves taking medicines that “target” specific proteins and genes that are already known to promote breast cancer growth in the body. For example, targeted therapy may block the action of the HER2 protein that stimulates the growth of breast cancer cells.

Immunotherapy for Breast Cancer

Immunotherapy uses the body's natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells. When breast cancer cells disguise themselves as healthy cells, their checkpoints don’t work correctly to attack the cancer. Immunotherapies called checkpoint inhibitors make it so the body can recognize the cancer cells, thus allowing the immune system to do its job and attack the unhealthy cells. Immunotherapy has been found to be helpful for patients with triple-negative breast cancer when combined with chemotherapy.

Clinical Trials for Breast Cancer

Every breast cancer treatment goes through a period of clinical trials before it’s approved by the FDA for use with all patients who have the same type of cancer. During various phases of the trials, a new drug, or a new combination of drugs, is made available to patients who meet specific study requirements. Your outcomes are followed carefully by the cancer care team to understand the effectiveness of the new therapy. 

At CMOH we offer our patients access to clinical trials that make new breast cancer treatments available before they can be offered to all patients with the same type of cancer. Your oncologist will review your specific type of breast cancer, past history, etc. and may suggest a study that you qualify for. Participation is always voluntary. Feel free to discuss the pros and cons about being in a clinical trial with your cancer care team.

Learn more about Breast Cancer Clinical Trials
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Find a Breast Cancer Specialist in Eastern Pennsylvania

The breast cancer specialists at Consultants in Medical Oncology and Hematology work with you to ensure you have the most effective breast cancer treatment plan. Contact us today at one of our convenient locations in Broomall and Glen Mills, Pennsylvania. We also offer second opinions on diagnosis and treatment plans for breast cancer. 

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