(February 10, 2009 - Insidermedicine)
At the 2008 San Antonio Breast Cancer Symposium, we had a chance to speak with Dr. Susan Love, Clinical Professor of Surgery at the David Geffen School of Medicine at UCLA. Dr. Love is the President and Medical Director at the Dr. Susan Love Research Foundation, as well as the Chief Medical Officer at Windy Hill Medical. She is also the author of ‘Dr. Susan Love’s Breast Book.”
If I had metastatic breast cancer…
Dr. Love: Once a woman is diagnosed with metastatic breast cancer, what that means is that we don’t have a way to absolutely cure you. But, we can put you into remission--and that remission can last months and years and, who knows what will come up in that period of time?
A diagnosis of metastatic breast cancer basically means that we shift from a curative intent, to how long can we keep you alive with the absolutely best quality of life.
What are the stages of breast cancer?
Dr. Love: There are four stages of breast cancer and they’re set out by the clinical presentation. Stage 1 is a small cancer, less than 2cm. Stage 2 is a cancer 2-5 cm and/or positive lymph nodes. Stage 3 is a cancer over 5cm and Stage 4 means the cancer has spread to other organs (or, metastatic breast cancer).
Now, we’re at a cusp right now, because those stages are based on the surgical and clinical presentation—how the patient comes to the doctor. And now we’re doing all kinds of molecular things that is probably going to change all that. But that’s the way it is now.
What investigations are used to stage breast cancer?
Dr. Love: The initial staging of breast cancer is based on the clinical examination, usually by the surgeon. So the size is measured by what you can feel; the lymph nodes are measured if you can feel them or not; as well as if there are any other signs.
Then you take the tumor out--and you take some lymph nodes out—and do a pathological staging. This is based on measuring the tumor but pathologically—under the microscope and telling how many nodes are positive having taken some nodes out through either sentinel node [biopsy] or axillary node dissection. It also—in terms of spread to other organs—can mean doing other scanning tests, such as MRI’s and bone scans, to see whether you can find any other disease.
What symptoms would indicate spread of the disease?
Dr. Love: The interesting thing about having your breast cancer spread is that the symptoms are not subtle—so you don’t have to worry. When you’re newly diagnosed, you don’t trust your body anymore: it went and got cancer, so how could you trust it! Every little thing—like your toe hurts, your thumb hurts—makes you think, ‘oh my god there might be breast cancer there!’
That’s not usually what breast cancer does.
Dr. Love: There are certain organs it likes--bones, liver, lungs--and the symptoms are not subtle. You’ll know that there’s something different. For example, a back ache that just doesn’t go away the way your other ones have. Or some pain that doesn’t go away, shortness of breath, fatigue that does not go away. You’ll know. If you have something you’re worried about, get it checked out.
How quickly should I get my symptoms evaluated?
Dr. Love: If you’ve been treated for breast cancer and you’re in remission, and now you have symptoms that you’re worried about—that maybe, might mean recurrence. Psychologically, it might feel like an emergency but in fact, it’s not really an emergency. Breast cancer does not move that fast. So if it takes you a week to get checked out, or even a month, that’s not going to change the outcome.
One of the things we don’t talk about very much is the fact that, once you have disease in other organs big enough for us to see, we can only make the symptoms go away. Treating it early does not give you a better response than waiting until you have other symptoms. There’s no value in doing scans all the time and blood tests all the time to look for signs of recurrence. You really should wait until you have symptoms.
Where does breast cancer commonly spread to first?
Dr. Love: All cancers have certain organs they like. Breast cancer likes to go to bones, lungs, liver and sometimes, the brain. It doesn’t go to one first and then the other. Some cancers, and this is an area of a lot of research, we’re finding that particular kinds of breast cancer like bone better—like the hormone positive ones. Other particular kinds of breast cancer might be more likely to go to the liver. So, it’s hard to say where it will go first, but there are certain places that we look.
How do you treat breast cancer that has spread?
Dr. Love: Once breast cancer has spread, then you need a treatment that cancirculate through you blood stream and get to where it is. Because if there are cancer cells in the bone, there might be microscopic cancer cells other places too that we cannot see yet with scans.
We usually treat metastatic breast cancer with either chemotherapy or hormonal therapy—treatments that can circulate through the bloodstream and get to wherever those cells might be.
What are the complications of that type of therapy?
Dr. Love: Most women, these days, who’ve had breast cancer have undergone chemotherapy or hormone therapy before, so they know what they’re getting into.
Chemotherapy interferes with rapidly dividing cells and it doesn’t discriminate between normal cells and cancer cells. Your blood count will go down, sometimes you’ll have nausea and vomiting, often you’ll lose your hair, you can also have fatigue—the symptoms are really related directly to getting the chemo. So they peak and then they start to get better. And then just when you’re starting to feel good again, we give you some more!
The hormone therapy is less bad to tolerate and it’s usually done over a longer period of time. But you will get hot flashes, you can get some menopausal symptoms—and those are pretty much the same as what you would get when you were initially treated.
How can I protect myself from these complications?
Dr. Love: There are drugs that you can take which can help with some of the side effects of chemotherapy or hormone therapy. That is one way to do it. Another way that a lot of women do it is to use complementary techniques. Acupuncture can help a lot in helping the symptoms. There are Chinese herbs that can help. Exercise actually helps a lot with some of the side effects. And so, I usually recommend looking into complementary things that you can add on to make your life better.
Dr. Love: If I had metastatic breast cancer mthe first thing I would do is change my mindset to, ‘okay, I know I’m probably going to die of breast cancer. What I don’t know is whether it’s ten years, 2 months, 6 months. But I need to think in a different way about my life. We are all going to die, but now I have a name for what’s going to get me.’ And then, I have to think all the time about measuring what I’m going to get out of any potential treatment compared to what it’s going to do to the quality of my life. Since I know that my life is limited, I want to maximize the quality at the same time that I am trying to lengthen my life.