Metaplastic breast cancer is a rare type of breast cancer that is very different from the typical ductal or lobular breast cancer. Metaplastic breast cancer starts in cells that provide the supporting structure for the glandular breast tissue. Since the cells that give rise to metaplastic breast cancer are not part of the normal breast gland, they are always ER- and PR-negative. Metaplastic carcinoma is a term that is used to describe cancer that begins in cells that have changed into another cell type. For example, a squamous cell of the esophagus changes to resemble a cell of the stomach. Metaplastic carcinoma of the breast describes a range of cancers of mixed epithelial cells (cells that line the breast) and mesenchymal cells (the connective tissue of the breast). Most cases of metaplastic carcinoma of the breast start in the epithelial cells, and then change into nonglandular (squamous) cells. Metaplastic carcinoma metastasizes (spreads) through the blood vessels, frequently invading the lungs.
The breast is mainly composed of fatty tissue. Within this tissue is a network of lobes, which are made up of tiny, tube-like structures called lobules that contain milk glands. Tiny ducts connect the glands, lobules, and lobes and carry the milk from the lobes to the nipple, located in the middle of the areola (darker area that surrounds the nipple of the breast). Blood and lymph vessels run throughout the breast; blood nourishes the cells, and the lymph system drains bodily waste products. The lymph vessels connect to lymph nodes.
Statistics
Metaplastic carcinoma of the breast is rare, accounting for less than 5% of all breast cancers.
Cancer statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a woman how long she will live with metaplastic carcinoma of the breast. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.
Source: Greenberg, D., Metaplastic Breast Cancer, Australasian Radiology (2004) 48, 243-247
A risk factor is anything that increases a person's chance of developing a disease, including cancer. There are risk factors that can be controlled, such as smoking, and risk factors that cannot be controlled, such as age and family history. Although risk factors can influence disease, for many risk factors it is not known whether they actually cause the disease directly. Some people with several risk factors never develop the disease, while others with no known risk factors do. Knowing your risk factors and communicating with your doctor can help guide you in making wise lifestyle and health-care choices.
It is not known what factors can raise a person's risk of metaplastic carcinoma of the breast; however, most cases have occurred in women over age 50.
Currently, there are no proven means to prevent breast cancer. A woman's best chance of surviving breast cancer is early detection through regular self-breast examinations, clinical breast examinations, and mammograms (x-rays of the breast). If cancer is found at an early stage, treatment is more likely to be successful.
For women with especially strong family histories of breast cancer, a prophylactic (preventive) mastectomy (surgical procedure to remove breast tissue) may be considered. This appears to reduce the risk of developing breast cancer by at least 95%.
Women who are at higher than normal risk for developing breast cancer may consider chemoprevention (the use of drugs to reduce the risk of breast cancer). Results of large clinical trials have shown that selective estrogen receptor modulators (SERMs), such as tamoxifen (Nolvadex), can reduce a woman's risk of developing breast cancer. A SERM is a medication that blocks estrogen receptors in some tissues and not others.
In addition, tamoxifen can reduce the risk of the cancer recurring (coming back) following treatment. Like estrogen, these drugs help increase bone density in postmenopausal women and protect the cardiovascular system. However, unlike estrogen, SERMs do not promote the development of breast cells into cancer cells.
The Study of Tamoxifen and Raloxifene (STAR) trial, launched in May 1999, is a breast cancer risk reduction trial. The STAR trial is designed to compare the effectiveness of two SERMs, tamoxifen and raloxifene (Evista), in reducing the risk of developing breast cancer in postmenopausal women over age 35 with an increased risk of developing breast cancer. The trial was conducted by the National Cancer Institute (NCI) and the National Surgical Adjuvant Breast and Bowel Project (NSABP). A recent analysis of the clinical trial data show that both tamoxifen and raloxifene reduce the risk of invasive breast cancer by about 50% in women at high risk for the disease, and neither drug significantly impairs quality of life. Because these drugs are associated with different side effects, women should discuss the risks and benefits of each drug with their doctors.
Screening guidelines
Currently, many health organizations recommend that women have a clinical breast examination by a doctor at least every three years and examine their breasts monthly once they reach the age of 20. Women should examine their breasts at the same time each month, preferably at the end of each menstrual period. Many organizations also recommend that women, starting at the age of 40, obtain a clinical breast examination and a mammogram each year and continue to examine their breasts each month. Women are encouraged to discuss the frequency of screening with their doctor.
Mammography is the best tool doctors have to screen for breast cancer and can detect tumors that are too small to be felt. Detecting breast cancer at the earliest possible stage gives women more treatment options and reduces the chance that the cancer has spread to other parts of the body. All women should talk with their doctors about mammography and decide on an appropriate screening schedule. Indeed, there are many women alive today because their cancer was detected at an early stage by mammography.
Occasionally, mammograms may miss a cancer. Other methods of breast imaging, such as ultrasound and magnetic resonance imaging (MRI), are not routinely used for screening purposes. However, they may be helpful in evaluating women at a higher risk for breast cancer, women with a BRCA gene mutation, or those with a suspicious finding during a physical examination. If there is a suspicious finding upon physical examination, further evaluation is necessary, even if the mammogram is interpreted as normal.To learn more about what to expect during a mammography, read Mammography—What to Expect.
Women with metaplastic carcinoma of the breast may experience the following symptoms. Sometimes, women with metaplastic carcinoma of the breast do not show any of these symptoms. Or, these symptoms may be similar to symptoms of other medical conditions. If you are concerned about a symptom on this list, please talk with your doctor.
Many breast cancers develop with no symptoms at all. Some tumors may be visible on a mammogram before symptoms develop. It is important for all women to be familiar with the appearance, feel, shape, and texture of their breasts in order to detect changes as soon as they occur.
New lumps (many women normally have lumpy breasts) or a thickening in the breast or under the arm
Nipple tenderness, discharge, or physical changes (such as a turned inward nipple or a persistent sore)
Skin irritation or changes, such as puckers, dimples, scaliness, or new creases
Warm, red, swollen breasts with a rash resembling the skin of an orange (peau d'orange)
Pain in the breast (usually not a symptom of breast cancer, but should be reported to a doctor)
Doctors use many tests to diagnose cancer and determine if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
The type of cancer
Severity of symptoms
Previous test results
In addition to a physical examination, the following tests may be used to diagnose metaplastic carcinoma of the breast:
Imaging
Diagnostic mammography. Diagnostic mammography is similar to screening mammography except that more views (pictures) of the breast are taken.
Ultrasound. Ultrasound uses high-frequency sound waves to create an image of the breast tissue. An ultrasound may distinguish between a solid mass, which may be cancer, and a fluid-filled cyst, which is usually not cancer.
X-ray. An x-ray is a picture of the inside of the body. A chest x-ray can help doctors determine if the cancer has spread to the lungs.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein before the scan to provide better detail.
MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body.
Positron emission tomography (PET) scan. In a PET scan, radioactive sugar molecules are injected into the body. Cancer cells absorb sugar more quickly than normal cells, so they light up on the PET scan. PET scans are often used to complement information gathered from a CT scan, MRI, and physical examination.
Bone scan. A bone scan can show if cancer has spread to the skeletal system. In this procedure, the doctor injects a small amount of a radioactive tracer into the patient’s vein. It collects in areas of the bone, and is detected by a special camera. Healthy bone appears gray to the camera, while areas of injury, such as those caused by cancer, appear dark.
Biopsymethods
A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluates cells, tissues, and organs to diagnose disease).
Image guided percutaneous core biopsy is used when a distinct lump can't be felt. During this procedure, a hollow needle is guided to the area of concern with the help of mammography or ultrasound. If a cancer is only found by MRI, then the needle biopsy may be guided by that technique. A small metal clip may be put into the breast to mark the site of biopsy, in case the sample tissue proves cancerous and additional surgery is required. An advantage of this technique is that a patient may only need one operation for treatment or staging.
Stereotactic core biopsy is a type of image guided biopsy that uses x-rays to find the area of tissue to be removed.
Vacuum-assisted biopsy uses a thicker, hollow needle to remove multiple, larger cores of tissue with a single insertion of the vacuum-assisted probe. This technique also uses image guidance.
Surgical biopsy removes the largest amount of tissue. This biopsy may be incisional (removal of part of the lump) or excisional (removal of the entire lump).
If cancer is diagnosed, a second operation is often needed to obtain a clear margin (area around the tumor where there are no cancer cells) and/or remove lymph nodes.
Doctors may also test the tissue obtained during a biopsy to help guide treatment decisions. The tests include:
Tumor features: Examination of the tumor under the microscope determines whether it is invasive or in situ (in place); ductal or lobular; and well, moderate, or poorly differentiated (a visual measure of how much a cell looks like a healthy cell or a cancer cell). It can also detect the presence of vascular or lymphatic invasion. The margins of the tumor are also examined.
Estrogen receptor (ER) and progesterone receptor (PR) tests. These tests help determine both the prognosis (chance of recovery) and whether the cells respond to hormonal therapy. Generally, ER and/or PR positive (+) tumors will respond to hormone therapy. The ER/PR status helps guide treatment decisions.
HER-2/neu tests: This is a protein that is overexpressed (too much of it) in about 25% of breast cancers. The HER-2 status helps determine whether a drug called trastuzumab (Herceptin) might be useful for treating breast cancer. Read more in the ASCO Patient Guide: HER-2 Testing in Breast Cancer.
Blood tests
The doctor may also require blood tests to help determine whether the cancer has spread outside of the breast.
Complete blood count (CBC). CBC is a blood test done to determine the hemoglobin level (the amount of oxygen in red blood cells), hematocrit level (the percentage of red blood cells in whole blood), the number of white blood cells (cells that help to fight infection), the number of platelets (cells that help blood to clot as necessary), and a differential (the percentage of several types of white blood cells).
Alkaline phosphatase levels. High levels of this enzyme could indicate the disease has spread to the liver, bone cells, or bile ducts.
Total bilirubin count, serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamate pyruvate transaminase (SGPT) levels. These tests evaluate liver function. High levels can indicate liver damage, a signal of possible spread to that organ.
Staging is a way of describing a cancer, such as where it is located, where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis. There are different stage descriptions for different types of cancer.
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How large is the primary tumor and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size of the tumor. Some stages are divided into smaller groups that help describe a patient's condition in more detail.
TX: The primary tumor cannot be evaluated.
T0: There is no evidence of cancer in the breast.
Tis: Refers to carcinoma (cancer) in situ. In this case, the cancer is confined within the natural boundaries of the breast tissue and has not spread into the surrounding tissue of the breast. There are three types of breast carcinoma in situ:
Tis (DCIS): Ductal carcinoma in situ (DCIS) is a precursor of early breast cancer, and means that only a few cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began. It can later develop into an invasive type of breast cancer.
Tis (LCIS): Lobular carcinoma in situ (LCIS) describes abnormal cells found in the lobules, or glands, of the breast. LCIS is not cancer, but women who have LCIS are at increased risk for developing invasive breast cancer (cancer that spreads into surrounding tissues).
Tis (Paget's): Paget's disease of the nipple is a rare form of early breast cancer. This designation is used if there is Paget's disease, but no tumor present, and is known as DCIS of the nipple.
T1: A tumor in the breast is 2 centimeters (cm) or smaller in size at its widest dimension.
T1 mic: Microinvasion, or micrometastases, means a few cancer cells have spread to surrounding tissue, but none are larger than 0.1 cm.
T1a: The tumor is larger than 0.1 cm, but smaller than 0.5 cm.
T1b: The tumor is larger than 0.5 cm, but smaller than 1 cm.
T1c: The tumor is larger than 1 cm, but smaller than or equal to 2 cm.
T2: The tumor is larger than 2 cm, but smaller than or equal to 5 cm.
T3: The tumor is larger than 5 cm.
T4: The tumor has spread to the chest wall or to the skin, or is diagnosed as inflammatory breast cancer.
T4a: The tumor has spread into the chest wall.
T4b: There is edema (swelling), pitting (as in peau d'orange), or ulceration (a sore, painful area where the breast skin/tissue is breaking down) of the breast skin or surrounding skin nodules of the same breast.
T4c: There are signs of both T4a and T4b.
T4d: Refers to inflammatory carcinoma. This is an aggressive type of breast cancer that causes the breast to look red and swollen and feel warm.
Node. The "N" in the TNM staging abbreviation means node. Lymph nodes are tiny, bean-shaped organs located throughout the body that normally help fight infection and cancer as part of the body's immune system. There are lymph nodes very near to the breast that are under the arm, above the collarbone, and under the breastbone. There are also distant lymph nodes (lymph nodes found in other parts of the body).
NX: The lymph nodes cannot be assessed.
N0: No cancer was found in the lymph nodes.
N1: The cancer has spread to one to three of the axillary lymph nodes (under the arm).
N2: The cancer has spread to four to nine lymph nodes under the arm and the nodes are stuck to each other or other structures. Or, the cancer has spread only to the internal mammary lymph nodes (lymph nodes to the right or left of the sternum [breast bone] on the inside of the chest).
N2a: The cancer has spread to four to nine lymph nodes under the arm, and these nodes are stuck to each other or other structures.
N2b: The cancer has spread only to the lymph nodes in the breast, not the lymph nodes under the arm.
N3: The cancer has spread to 10 or more nodes under the breastbone.
N3a: The cancer has spread to 10 or more infraclavicular lymph nodes (under the collarbone).
N3b: The cancer has spread to lymph nodes behind the breast and under the arms.
N3c: The cancer has spread to the supraclavicular lymph nodes (above the collarbone).
If there is cancer in the lymph nodes, it helps doctors to know how many lymph nodes are involved. When the pathologist looks at the tissue samples from the biopsy, he or she will determine whether there the number of lymph nodes that contain cancer.
Metastasis. The "M" in the TNM system describes if the cancer has metastasized to other parts of the body.
MX: Distant spread cannot be assessed.
M0: The disease has not metastasized.
M1: There is metastasis to another part of the body.
Cancer stage grouping
Doctors assign the stage of the cancer by combining the T, N, and M classifications.
Stage 0: DCIS is cancer that has not spread past the ducts or lobules of the breast (the natural boundaries). It is also called noninvasive cancer.
Stage I: The tumor is small and has not spread to the lymph nodes (T1, N0, M0).
Stage IIa: Any one of these conditions:
The tumor is smaller than 2 cm, and has spread to the axillary lymph nodes under the arm (T1, T1 mic, N1, M0).
The tumor is between 2 cm and 5 cm, but has not spread to the axillary lymph nodes (T2, N0, M0).
There is no evidence of a tumor in the breast, but there is cancer in the axillary lymph nodes (T0, N1, M0).
Stage IIb: Any one of these conditions:
The tumor is between 2 cm and 5 cm, and has spread to the axillary lymph nodes (T2, N1, M0).
The tumor is larger than 5 cm, but has not spread to the axillary lymph nodes (T3, N0, M0).
Stage IIIa: Any of these conditions:
The tumor is smaller than 5 cm, and has spread to the axillary lymph nodes that are attached to each other or to other structures (T0, T1, T1 mic, T2, N2, M0).
The tumor is larger than 5 cm, and has spread to the axillary lymph nodes, which may or may not be attached to each other or to other structures (T3, N1 or N2, M0).
Stage IIIb: The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the lymph nodes under the arm, but has not spread to other parts of the body (T4, N0, N1, N2, M0).
Stage IIIc: A tumor of any size that has not spread to distant parts of the body, but has spread to the lymph nodes above the collarbone, under the collarbone, or both the nodes inside the breast and under the arm (any T, N3, M0).
Stage IV: The tumor can be any size and has spread to distant sites in the body, usually the bones, lungs, liver, or brain (any T, any N, M1).
Recurrent breast cancer
Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (called a local recurrence), in the chest wall, or in another part of the body (called a distant metastasis), including distant organs (such as the lungs or liver), bones, or other lymph nodes.
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
The treatment of metaplastic carcinoma of the breast depends on the size and location of the tumor, whether the cancer has spread, and the woman’s overall health. In many cases, a team of doctors will work with the woman to determine the best treatment plan.
Because metaplastic carcinoma of the breast is so rare, the best course of treatment has not yet been determined. Therefore, metaplastic carcinoma of the breast is treated in the same way as more common breast cancers. It has been suggested in multiple studies, however, that a woman’s prognosis is connected to the size of her tumor, rather than lymph node involvement. Specifically, a woman with a tumor smaller than 4 cm has a better prognosis than a woman with a tumor larger than 4 cm.
Even though the doctor will tailor the treatment for breast cancer to the woman’s disease and personal situation, there are some general steps in the logic of treating breast cancer. Primarily, the initial therapy for early-stage disease is aimed at eliminating any visible tumor. Therefore, doctors will recommend surgery to remove the tumor with or without radiation therapy. Most of the time radiation therapy to the remaining breast tissue will be recommended, although there are certain situations where it is not recommended (for example, in patients older than age 70).
The next step in the management of early-stage cancer is to reduce the risk of the disease recurring and to eliminate any cancer cells that may remain. If a tumor is of a certain size or lymph nodes are involved, the doctor may recommend additional therapy, such as radiation therapy, chemotherapy, or hormonal therapy. If the cancer recurs, the woman may choose additional surgery, depending on where the cancer is found, or a variety of treatments designed to fight distant metastases.
When planning the treatment of a woman's breast cancer, the doctor will consider many factors, including:
The stage and grade (how the cancer cells compare with normal cells as viewed under a microscope) of the tumor
The tumor's hormonal status (ER, PR) (See Diagnosis)
The woman's age and general health
The woman's menopausal status
The presence of known mutations to breast cancer genes
Factors that may signify an aggressive tumor, such as HER-2/neu amplifications (See Diagnosis)
Surgery
Generally, the smaller the tumor, the more surgical options a woman has. The types of surgery include the following:
A lumpectomy removes the tumor and a small "clean," or disease-free, margin of tissue around the tumor. For an invasive cancer, follow-up radiation therapy is routinely given to the disease site.
A partial mastectomy removes the tumor, an area of normal tissue, and part of the lining over the chest muscle where the tumor was. This surgery is similar to a lumpectomy. It is also called a segmental mastectomy and requires follow-up radiation therapy.
A total mastectomy removes the entire breast, but not the underarm lymph nodes. This surgery is also called a simple mastectomy.
A modified radical mastectomy removes the breast, some of the underarm lymph nodes, and the lining over the chest muscles.
Axillary lymph node dissection involves the surgeon removing lymph nodes from under the arm and having them examined by a pathologist for cancer cells. Because each person has different number of underarm lymph nodes, the actual number of lymph nodes removed varies from 4 to 60.
Sentinel lymph node biopsy is a procedure in which the surgeon finds and removes the sentinel (first) lymph node (generally one to three nodes) that receives drainage from the breast. The pathologist then examines it for cancer cells. To identify the sentinel lymph node, the surgeon injects a dye and/or a radioactive tracer into the area around the person's primary breast tumor. The dye or tracer will travel to the lymph nodes, arriving at the sentinel node first. The surgeon can find the node when it turns color (if the dye is used) or emits radiation (if the tracer is used). Sentinel lymph node biopsy has a lower risk of lymphedema (swelling of the arm) than axillary lymph node dissection, which removes most of the lymph nodes from under the arm. If the sentinel node is cancer-free, research has shown that there is a good possibility that the subsequent nodes will also be free of cancer and no further surgery of the lymph nodes is performed. If the sentinel lymph node shows cancer is present, then the surgeon will perform an axillary lymph node dissection. For more information, read the ASCO Patient Guide: Sentinel Lymph Node Biopsy in Early Stage Breast Cancer.
Most patients with invasive cancer will first undergo either sentinel lymph node biopsy or an axillary dissection. For those whose sentinel nodes indicate cancer, an axillary dissection is still considered necessary. Surgical treatment options include the following:
Lumpectomy and radiation therapy
Partial mastectomy and radiation therapy
Total mastectomy
Modified radical mastectomy
For invasive breast cancer, the combination of lumpectomy or partial mastectomy, underarm lymph node removal, and radiation therapy has been proven in clinical trials to be as effective as a modified radical mastectomy in treating small tumors.
Women are encouraged to talk with their doctors about which surgical option is right for them. More aggressive surgery (such as a mastectomy) is not always better and may result in additional complications.
Women who undergo a mastectomy may wish to consider breast reconstruction, which is surgery to rebuild the breast. Reconstruction may be done with tissue from another part of the body, or with synthetic implants. A woman may choose to have this done at the time of the mastectomy or at some point in the future.
Adjuvant therapy is treatment that is given in addition to surgery to decrease the risk of the breast cancer returning. Adjuvant therapies include radiation therapy, chemotherapy, and hormonal therapies. They are intended to eliminate any breast cancer cells lingering in the body. Adjuvant therapy decreases the risk of recurrence but does not necessarily eliminate it. It is still being determined if adjuvant therapy is the best course of treatment for metaplastic carcinoma of the breast.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Radiation therapy is given regularly for a number of weeks following a lumpectomy or partial mastectomy in order to eliminate remaining cancer cells near the tumor site or elsewhere within the breast. Radiation therapy is also recommended for some women after a mastectomy depending upon the size of their tumor, number of cancerous lymph nodes under the arm, and width of the margin of resection obtained by the surgeon. Radiation therapy may be given before surgery to shrink a large tumor and make it easier to remove, although this approach is rare.
Radiation therapy is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation treatment is given using pellet implants, it is called brachytherapy or internal radiation therapy.
Radiation therapy can cause side effects, including fatigue, swelling, and skin changes. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related pneumonia, is rare.
In the past, with older equipment and techniques of radiation therapy, women treated for left-sided breast cancers had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare most of the heart from radiation damage. While exposure to radiation is thought to be a risk factor of cancer after many years, less than one in 500 survivors will develop a different kind of cancer, other than a breast cancer, within the area that was treated. Clinical studies comparing lumpectomy and radiation therapy with mastectomy have not shown a difference in the number of patients developing or dying of other cancers within a 20-year time span.
Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy travels through the bloodstream to cancer cells throughout the body and destroy cancer cells that have migrated from the original site of the tumor. It may be given orally or intravenously (IV). Chemotherapy is usually given in cycles. Generally, chemotherapy does not require a hospital stay, and women are usually treated in an outpatient setting.
An oncologist may administer chemotherapy before surgery (neoadjuvant therapy) to shrink a large tumor, or after surgery (adjuvant therapy). The goal is to remove the entire tumor during surgery.
Different medications are useful for different cancers, and research has shown that combinations of certain drugs are more effective than individual drugs. Some common regimens for breast cancer include combinations of two or three of the following:
Cyclophosphamide (Cytoxan or Neosar)
Methotrexate (Amethopterin)
Fluorouracil (5-FU, Efudex)
Doxorubicin (Adriamycin, Rubex)
Epirubicin (Ellence)
Paclitaxel (Taxol)
Docetaxel (Taxotere)
Women in clinical trials may be offered new drugs or new combinations of existing drugs. Common combinations of drugs include the following:
CMF (cyclophosphamide, methotrexate, and 5-FU)
CAF (cyclophosphamide, doxorubicin, and 5-FU)
CEF (cyclophosphamide, epirubicin, and 5-FU)
EC (epirubicin and cyclophosphamide)
AC (doxorubicin and cyclophosphamide)
TAC (docetaxel, doxorubicin, and cyclophosphamide)
AC followed by T (doxorubicin and cyclophosphamide, followed by paclitaxel)
TC (docetaxel and cyclophosphamide)
Because it is unknown if metaplastic carcinoma of the breast behaves like the typical infiltrating ductal or lobular cancer (which make up approximately 95% of breast cancers), some doctors will administer slightly different chemotherapy, such as cisplatin (Platinol)-based chemotherapy, usually with 5-FU.
Chemotherapy affects both healthy and cancerous cells in the body. Normal cells that grow quickly, such as those lining the gastrointestinal tract or hair follicles, may be damaged or killed along with cancer cells. Side effects can include fatigue, nausea, vomiting, a lowered white blood cell count, and a corresponding increased risk of infection, mouth sores, hair loss, and premature menopause. Most of these side effects go away once treatment is stopped and are not long term, with the exception of premature menopause. However, long-term side effects may occur including heart damage, nerve damage, or secondary cancers.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to multiple drug databases.
Hormonal therapy
Hormonal therapy is useful to manage tumors that test positive for either estrogen or progesterone receptors. These tumors use hormones to fuel their growth. Blocking the hormones limits the growth of these types of tumors.
If it is determined that the tumor uses estrogen or progesterone to grow (hormone receptor positive [see Diagnosis]), then hormonal treatment may be used alone or together with chemotherapy. Examples of hormonal therapy used as adjuvant therapies are tamoxifen, anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin).
Tamoxifen is the drug that researchers have studied the longest for use as a hormonal therapy. It blocks estrogen from binding to tumor cells. It has been shown effective in reducing the risk of recurrence in the treated breast; the risk of developing cancer in the other breast; and the risk of developing cancer in women with no history of the disease, but who are at higher than average risk for developing breast cancer. Current research shows that there is no benefit in taking tamoxifen longer than five years for node-negative breast cancer.
The side effects of tamoxifen include hot flashes, a small increased risk of uterine (endometrial) cancer and uterine sarcoma, and an increase in the risk of blood clots. Tamoxifen can be effective in both premenopausal and postmenopausal women.
In postmenopausal women who have an increased risk of developing breast cancer, raloxifene has shown to be another hormonal therapy that is as effective as tamoxifen in preventing invasive breast cancer, but not as effective in preventing noninvasive cancers, such as DCIS. The side effects of raloxifene include a small risk of blood clots, leg and joint pain, hot flashes, pain during sexual intercourse, and vaginal dryness. Raloxifene has not been evaluated in premenopausal women, and it is not considered a substitute for tamoxifen for adjuvant therapy for women with hormone receptor-positive breast cancer. Raloxifene is not recommended for treatment of invasive breast cancer.
Aromatase inhibitors decrease the production of estrogen and are effective in postmenopausal women. They work by blocking the aromatase enzyme, which is necessary for production of estrogen. They are emerging as the preferred treatment for women with hormone-sensitive cancers. Several of these drugs include anastrozole, letrozole, and exemestane. For more information, please read the ASCO Technology Assessment for Patients: Aromatase Inhibitors for Early Breast Cancer.
Targeted therapy
Several promising new breast cancer drugs work by stopping the action of abnormal proteins that cause cells to grow and divide out of control.
Monoclonal antibodies target proteins that are present in unusually large amounts in breast cancer cells.
Trastuzumab is already approved for the treatment of advanced breast cancer for tumors that overexpress HER-2/neu. Recent data presented at the 2005 American Society of Clinical Oncology Annual Meeting demonstrated an approximate 50% decrease in relapse and an improvement in survival in women with early breast cancer with a HER-2/neu-positive breast cancer who received trastuzumab either with or after adjuvant chemotherapy. At this time, one year of trastuzumab is recommended. Patients receiving trastuzumab have a 3% to 4 % risk of heart problems, and this risk is increased if a patient has additional risk factors for heart disease. These heart problems do not always go away, but they are usually treatable with medication. Ongoing research is assessing how much trastuzumab is enough (nine weeks vs. up to 2 years).
Bevacizumab (Avastin) is an antiangiogenic monoclonal antibody under evaluation in clinical trials. Anti-angiogenesis agents block angiogenesis (the formation of new blood vessels), which is necessary for tumor growth and metastasis. When combined with paclitaxel chemotherapy, bevacizumab appears to increase the response rate and length of response compared with paclitaxel alone in women whose breast cancer has spread. .
For women with HER-2/neu-positive breast cancer that no longer responds to trastuzumab, a new drug called lapatinib (Tykerb) may slow the growth of breast cancer when combined with capecitabine chemotherapy. Lapatinib is currently available through a clinical trial for women with advanced cancer.
Recurrent breast cancer
Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (a local recurrence); in the chest wall; or in another part of the body, including distant organs (such as the lungs, liver, and bones) called distant metastases. Metaplastic carcinoma of the breast is most likely to metastasize to the lungs.
Breast cancer may also spread to other organs, such as the brain, the opposite breast, adrenal glands, spleen, and ovaries. If the tumor has spread outside of the breast or local lymph nodes, it is generally not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the disease's growth. Some women live years after a recurrence of breast cancer and may undergo many different treatments. With the advent of earlier detection methods and new therapies, breast cancer may be considered a chronic disease for some women.
Generally, a recurrence is detected when people have symptoms. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research has shown that tests do not improve the response to treatments used for advanced disease, nor do they prolong life.
Once metastatic disease is detected, a woman may undergo surgery to remove the metastases, or have chemotherapy, hormone therapy, radiation therapy, or targeted therapy (such as trastuzumab) to control it. Signs and symptoms depend on the site of the recurrence and may include:
A lump under the arm or along the chest wall
Bone pain or fractures, which may signal bone metastases
Headaches or seizures, which may signal brain metastases
Chronic coughing or trouble breathing, which may signal lung metastases
Other symptoms may be related to the location of metastases and may include vision changes, a change in energy levels, feeling unwell, or extreme fatigue.
A biopsy of the recurrent site is often recommended to be certain of the diagnosis and to check for ER, PR, and HER-2/neu status. Often, hormone therapy is used first if possible. Chemotherapy and targeted therapies are also used. Radiation therapy and surgery may be used in certain situations.
The National Comprehensive Cancer Network (NCCN) has a series of treatment guidelines that have been translated into patient-friendly language. In accordance with Cancer.Net’s Linking Policy, please note that this link does not imply ASCO’s endorsement of the content, but rather it is an effort to provide additional information that may be helpful to people living with cancer and their families. The NCCN treatment guide for breast cancer can be found at www.nccn.org.
Doctors and scientists are always looking for better ways to treat patients with metaplastic carcinoma of the breast. A clinical trial is a way to test a new treatment in order to prove that it is safe, effective, and possibly better than a standard treatment.
Patients who participate in clinical trials are among the first to receive new treatments, such as new chemotherapy, before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that this is the only way to make progress in treating metaplastic carcinoma of the breast, such as finding new drugs. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with metaplastic carcinoma of the breast.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands the standard treatments, and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
Cancer and cancer treatment can cause a variety of side effects; some are easily controlled and others require specialized care. Below are some of the side effects that are more common to metaplastic breast cancer and its treatments. For more detailed information on managing these and other side effects of cancer and cancer treatment, visit the Cancer.Net Managing Side Effects section.
Anemia. Anemia is common in people with cancer, especially those receiving chemotherapy. Anemia is an abnormally low level of red blood cells (RBCs). RBCs contain hemoglobin (an iron protein) that carries oxygen to all parts of the body. If the level of RBCs is too low, parts of the body do not get enough oxygen and cannot work properly. Most people with anemia feel tired or weak. The fatigue (tiredness) associated with anemia can seriously affect quality of life and make it more difficult for patients to cope with cancer and treatment side effects.
Fatigue. Fatigue is extreme exhaustion or tiredness, and is the most common problem that people with cancer experience. More than half of patients experience fatigue during chemotherapy or radiation therapy, and up to 70% of patients with advanced cancer experience fatigue. Patients who feel fatigue often say that even a small effort, such as walking across a room, can seem like too much. Fatigue can seriously affect family and other daily activities, can make patients avoid or skip cancer treatments, and may even affect the will to live.
Fluid in the abdomen (ascites). Ascites is the buildup of fluid in the abdomen, in the area around the organs known as the peritoneal cavity. Ten percent of all ascites is caused by cancer and is called malignant ascites. Most cancer-related ascites appears in patients with cancers of the ovary, endometrium (lining of the uterus), breast, colon, gastrointestinal (GI) system, or pancreas. These cancers can cause fluid to build up in the body. People with ascites may experience weight gain, abdominal swelling, a sense of fullness or bloating, a sense of heaviness, indigestion, nausea and/or vomiting, changes to the navel, hemorrhoids (a condition that causes painful swelling near the anus), or ankle swelling.
Fluid in the arms or legs (lymphedema). Lymphedema is the abnormal buildup of fluid in the lymphatic system, the series of channels and nodes (small sacs that hold fluid) that carries lymph through the body and helps fight infection and disease. Lymph is a clear liquid that carries protein and cells that fight infection. When a cancer metastasizes, cells first go to the lymph nodes and then are carried to other parts of the body. Lymphedema can develop immediately after cancer surgery or radiation therapy, or it can develop months or years later. About 10% to 20% of women who have radical mastectomies (removal of the breast, underarm lymph nodes, and lining of the chest muscles) develop lymphedema, causing arm swelling. The most common causes of lymphedema include surgery to remove the lymph nodes, especially for breast cancer, prostate cancer, or melanoma; radiation therapy to the lymph nodes; metastatic cancer (cancer that has spread from its primary location); bacterial or fungal infection; injury to the lymph nodes; and other diseases involving the lymph system.
Fluid around the lungs (malignant pleural effusion). A pleural effusion is a condition characterized by extra fluid building up in the pleural space, the space between the edge of the lungs and the chest wall. A malignant pleural effusion is caused by cancer that grows in the pleural space. About half of patients with cancer develop a pleural effusion. More than 75% of patients with a malignant pleural effusion have lymphoma or cancers of the breast, lung, or ovary. The symptoms of a pleural effusion include dyspnea (shortness of breath), dry cough, pain, feeling of chest heaviness, inability to exercise, and malaise (feeling unwell).
Hair loss (alopecia). A potential side effect of radiation therapy and chemotherapy is hair loss. Radiation therapy and chemotherapy cause hair loss by damaging the hair follicles responsible for hair growth. Hair loss may occur throughout the body, including the head, face, arms, legs, underarms, and pubic area. The hair may fall out entirely, gradually, or in sections. In some cases, the hair will simply thin—sometimes unnoticeably—and may become duller and dryer. Losing one's hair can be a psychologically and emotionally challenging experience and can affect a patient's self-image and quality of life. However, the hair loss is usually temporary, and the hair often grows back.
Hypercalcemia. Hypercalcemia is an unusually high level of calcium in the blood. Hypercalcemia can be life threatening and is the most common metabolic disorder associated with cancer, occurring in 10% to 20% of patients with cancer. While most of the calcium in the body is stored in the bones, about 1% of the body's calcium circulates in the bloodstream. Calcium is important for many bodily functions, including bone formation, muscle contractions, and nerve and brain function. Patients with hypercalcemia may experience loss of appetite, nausea and/or vomiting; constipation and abdominal pain; increased thirst and frequent urination; fatigue, weakness, and muscle pain; changes in mental status, including confusion, disorientation, and difficulty thinking; and headaches. Severe hypercalcemia can be associated with kidney stones, irregular heartbeat or heart attack, and eventually loss of consciousness and coma.
Infection. An infection occurs when harmful bacteria, viruses, or fungi (such as yeast) invade the body and the immune system is not able to destroy them quickly enough. Patients with cancer are more likely to develop infections because both cancer and cancer treatments (particularly chemotherapy and radiation therapy to the bones or extensive areas of the body) can weaken the immune system. Symptoms of infection include fever (temperature of 100.5°F or higher); chills or sweating; sore throat or sores in the mouth; abdominal pain; pain or burning when urinating or frequent urination; diarrhea or sores around the anus; cough or breathlessness; redness, swelling, or pain, particularly around a cut or wound; and unusual vaginal discharge or itching.
Menopausal symptoms in women. Up to 40% of women experience menopausal symptoms because of breast cancer or its treatments. Menopausal symptoms may depend on the type of therapy and may include hot flashes; night sweats; vaginal dryness, itching, irritation, or discharge; painful sexual intercourse; difficulties with bladder control; depressed feelings; and insomnia.
Mouth sores (mucositis). Mucositis is an inflammation of the inside of the mouth and throat, leading to painful ulcers and mouth sores. It occurs in up to 40% of patients receiving chemotherapy. Mucositis can be caused by chemotherapy directly, the reduced immunity brought on by chemotherapy, or radiation treatment to the head and neck area.
Nausea and vomiting. Vomiting, also called emesis or throwing up, is the act of expelling the contents of the stomach through the mouth. It is a natural way for the body to rid itself of harmful substances. Nausea is the urge to vomit. Nausea and vomiting are common in patients receiving chemotherapy for cancer and in some patients receiving radiation therapy. Many patients with cancer say they fear nausea and vomiting more than any other side effects of treatment. When it is minor and treated quickly, nausea and vomiting can be quite uncomfortable but cause no serious problems. Persistent vomiting can cause dehydration, electrolyte imbalance, weight loss, depression, and avoidance of chemotherapy.
Nervous system disturbances. Nervous system disturbances can be caused by many different factors, including cancer, cancer treatments, medications, or other disorders. Symptoms that result from a disruption or damage to the nerves caused by cancer treatment (such as surgery, radiation treatment, or chemotherapy) can appear soon after treatment or many years later. See Managing Side Effects: Nervous System Disturbances for the most common symptoms.
Sexual dysfunction. Sexual dysfunction is common in all people, affecting up to 43% of women and 31% of men. It may be even more common in patients with cancer, because of treatments, the tumor, or stress. Many people, with or without cancer, find it intimidating to discuss sexual problems with their doctors. Sexual problems are most commonly caused by body changes from cancer surgery, chemotherapy or radiation therapy, hormone changes, fatigue, pain, nausea and/or vomiting, medications that reduce libido (desire for sex), fear of recurrence, stress, depression, and anxiety. Symptoms of sexual dysfunction generally fall into four categories: desire disorders, arousal disorders, orgasmic disorders, and pain disorders.
Skin problems. The skin is an organ system that contains many nerves. Because of this, skin problems can be very painful. Because the skin is on the outside of the body and visible to others, many patients find skin problems especially difficult to cope with. Because the skin protects the inside of the body from infection, skin problems can often lead to other serious problems. As with other side effects, prevention or early treatment is best. In other cases, treatment and wound care can often improve pain and quality of life. Skin problems can have many different causes, including chemotherapy leaking out of the intravenous (IV) tube, which can cause pain or burning; peeling or burned skin caused by radiation therapy; pressure ulcers (bed sores) caused by constant pressure on one area of the body; and pruritus (itching) in patients with cancer, most often caused by leukemia, lymphoma, myeloma, or other cancers.
Weight gain. Although it is more common to lose weight during cancer treatment, some patients with cancer gain weight. Slight increases in weight during cancer treatment are generally not problematic. However, significant weight gain may affect a patient's health and the ability to tolerate treatments. Chemotherapy, steroid medications, and hormone therapies can cause weight gain.
After treatment for breast cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery. The recommendations for breast cancer follow-up care usually include regular physical examinations and mammograms. Specific information can be found in the ASCO Patient Guide: Follow-up Care for Breast Cancer.
Breast cancer can recur in the breast or other areas of the body. The symptoms of a cancer recurrence include a new lump in the breast, under the arm, or along the chest wall; bone pain or fractures; headaches or seizures; chronic coughing or trouble breathing; extreme fatigue; and/or feeling ill. Talk with your doctor if you experience these or other symptoms. For some people, the possibility of recurrence becomes overwhelming. Learn more about Coping With Fear of Recurrence.
Some patients experience breathlessness, a dry cough, and/or chest pain two to three months after finishing radiation treatment because the radiation can cause swelling and fibrosis (hardening or thickening) of the lungs. These symptoms are usually temporary. Talk with your doctor if you develop any new symptoms after radiation treatment or if the side effects are not going away.
Women taking tamoxifen should have yearly pelvic exams because this drug can increase the risk of uterine cancer. Tell your doctor or nurse if you notice any abnormal vaginal bleeding or other new symptoms.
Women who are taking an aromatase inhibitor, such as anastrozole, exemestane, or letrozole, may consider having a bone density test, as these drugs may cause some bone loss.
Women recovering from breast cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight and diet and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help you rebuild your strength and energy level. Your doctor can help you create a safe exercise plan based upon your needs, physical abilities, and fitness level. Read the Cancer.Net Feature: Healthy Living After Cancer.
Many people also benefit from survivor support groups or counseling.
Late effects of treatment for breast cancer include secondary leukemia, which currently affects 1% of people treated for breast cancer. There has also been some data suggesting that osteoporosis (loss of bone mass that makes bones break easily) is a side effect of treatment.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
What is the size of my tumor?
Am I a candidate for sentinel lymph node biopsy?
How many lymph nodes contain cancer?
Is my cancer hormone receptor positive?
What is my HER-2/neu status? What does that mean?
What stage is my breast cancer? What does that mean?
What are my options for treatment?
Where can I find out about clinical trials or other new treatments for breast cancer?
What are the potential side effects of this treatment, and am I at risk?
How will this treatment benefit me?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
What are the expected timelines for my treatment plan?
Am I a candidate for breast conservation surgery?
Am I a candidate for breast reconstruction?
How can I ease effects of treatments?
Am I at risk for lymphedema and, if so, how can I reduce my risk?
What will my follow-up care include?
How will you determine if the cancer comes back?
Whom do I call for questions or problems?
Whom can I contact for emotional, supportive needs for myself and/or my family?
American Society of Breast Disease
P.O. Box 140186
Dallas, TX 75214
Phone: 214-368-6836 www.asbd.org
Breast Cancer Network of Strength
212 West Van Buren, Ste 1000
Chicago, IL 60607
Toll Free: 800-221-2141 (English)
Toll Free: 800-986-9505 (Spanish)
Phone: 312-986-8338 www.networkofstrength.org
FORCE: Facing Our Risk of Cancer Empowered
16057 Tampa Palms Blvd. W, PMB 373
Tampa, FL 33647
Toll Free Helpline: 866-824-RISK (7475)
Toll Free: 866-288-7475
Phone: 954-255-8732 www.facingourrisk.org
HER2 Support Group
6973 Mimosa Dr.
Carlsbad, CA 92009
Phone: 760-602-9178 www.her2support.org
Living Beyond Breast Cancer
10 E. Athens Ave., Ste. 204
Ardmore, PA 19003
Toll Free: 888-753-LBBC (888-753-5222)
Phone: 610-645-4567 www.lbbc.org
Mothers Supporting Daughters with Breast Cancer
US Mail MSDBC
21710 Bayshore Rd.
Chestertown, MD 21620-4401
Phone: 410-778-1982 www.mothersdaughters.org
National Breast Cancer Coalition
1707 L Street, NW. Ste. 1060
Washington, DC 20036
Toll Free: 800-622-2838 www.natlbcc.org
National Lymphedema Network
Latham Square
1611 Telegraph Ave., Ste. 1111
Oakland, CA 94612-2138
Toll Free: 800-541-3259 www.lymphnet.org
Nueva Vida, Inc.
2000 P St., NW, Ste. 740
Washington, DC 20036
Phone: 202-223-9100 www.nueva-vida.org
SHARE: Self-help for Women with Breast or Ovarian Cancer
1501 Broadway, Ste. 704A
New York, NY 10036
Toll Free: 866-891-2392
Phone: 212-719-0364 www.sharecancersupport.org
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