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"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

After a breast cancer diagnosis has been made, your physicians will need to determine the cancer's status, whether it has spread, and, if so, how far. This process is called staging and helps to determine the prognosis and the best treatment. Early-stage breast cancer is generally more treatable and is associated with a better prognosis compared with more advanced stages.

Treatment options for early-stage breast cancer include surgery (lumpectomy or mastectomy); radiation therapy; systemic therapy (chemotherapy, endocrine (hormone) therapy, anti HER2 therapy, and/or immunotherapy). Systemic therapy options depend on the specific characteristics of the tumor and your overall health and medical history.

Breast cancer staging is determined by a combination of factors including tumor size, lymph node involvement, grade, presence or absence of metastasis, and presence or absence of estrogen receptor (ER), progesterone receptor (PR), and HER2-neu status.

Managing early-stage breast cancer is a group effort that includes your medical oncologist, surgeon, radiation oncologist, primary care physician, and other healthcare professionals -- and most importantly, you.

Diagnosis/Staging

Early-stage invasive breast cancer refers to disease that has been detected at an early point in its development and has not spread beyond the breast and nearby lymph nodes. The disease is generally divided into per the American Joint Committee on Cancer (AJCC) staging system.

AJCC staging was originally based on anatomy alone, using primary tumor size (T), nodal involvement (N), and the presence or absence of metastasis (M) (TNM staging). The 2017 8th edition of staging, however, presented a new prognostic staging system for breast cancer which in addition to TNM staging also includes tumor grade and estrogen receptor (ER), progesterone receptor (PR), and HER2/neu status.

Stage 1 is characterized by the presence of small tumors or cancerous cells that have begun to invade nearby breast tissue but have not yet spread to lymph nodes outside the breast or other areas of the body. Stage 1 has two substages:

• Stage 1A: Small primary tumor up to 2 cm in diameter, with no evidence of lymph node involvement or distant metastasis (T1, N0, M0)

• Stage 1B: Small primary tumor (<2 cm) located in breast tissue (T1, N0, M0)

There are other types of benign but high-risk breast conditions: atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ, which increase the risk of in situ and/or invasive carcinoma in either breast.

Surgery

Early-stage breast cancers are often treated with breast-conservation therapy with surgical lumpectomy to remove primarily just the tumor.

Lumpectomy is typically followed by radiation therapy to eliminate any microscopic residual disease. Radiation is sometimes omitted in elderly patients with low-risk disease. The sentinel lymph node (defined as the first lymph node where cancer cells are more likely to spread from the breast), is often removed during the same procedure as the lumpectomy to identify lymph node involvement. Additional lymph nodes may be removed depending on the results of the sentinel lymph node biopsy.

Not all patients are candidates for breast-conservation therapy and in some cases, a may be recommended. In a simple or total mastectomy, the entire breast is removed. This surgery includes the removal of the nipple, areola, fascia (covering) of the pectoralis major muscle (main chest muscle), and skin. In some cases, sentinel lymph nodes may also be removed.

A modified radical mastectomy combines a simple mastectomy with the removal of the lymph nodes under the arm, which is called an axillary lymph node dissection. A radical mastectomy is much more extensive with removal of the chest wall muscles and is rarely done. Other options are skin-sparing mastectomy and nipple-sparing mastectomy.

Your surgeon will discuss the advantages and disadvantages of each procedure with you, as well as breast reconstruction options you may wish to consider. You will meet with a plastic surgeon as well to discuss breast reconstruction.

Radiation Therapy

Radiation therapy after your surgical procedure may be performed to target any remaining cancer cells and reduce the risk of recurrence. For most people, this will take place over 3 to 5-6 weeks, although in some cases, it may be completed in a single week.

Your radiation oncologist will help you understand the details of the treatment plan designed for you and its potential side effects.

Systemic Therapy

Systemic therapy is designed to target and eliminate potential cancer cells throughout the entire body. The goal of this therapy is to reduce the risk of breast cancer recurrence as well as improve your long-term survival by destroying micrometastases that might not be detectable through imaging or other means.

Depending on the tumor's characteristics, systemic therapy is administered before surgery (called neoadjuvant treatment) or after surgery (adjuvant treatment). The main types of systemic therapy used in early-stage breast cancer are chemotherapy, endocrine (hormone) therapy, anti-HER2 therapy, and immunotherapy.

Neoadjuvant therapy offers an opportunity to evaluate tumor response and adjust therapy in the adjuvant setting if necessary.

A chemotherapy regimen is typically given in cycles, with rest periods in between to allow the body to recover.

Hormone therapy, also called endocrine therapy, is recommended if you have hormone-receptor positive breast cancer. Options for endocrine therapy include the selective estrogen receptor modulator tamoxifen, and aromatase inhibitors. Tamoxifen works by attaching to estrogen receptors on cancer cells, blocking estrogen from binding to these receptors, and preventing the estrogen-driven growth of cancer cells.

Hormone therapy is typically prescribed for 5-10 years.

Your oncologist will go over treatment options, duration, and potential side effects in detail.

Targeted Therapies

Different types of drugs target the HER2 protein.

Monoclonal antibodies are manufactured versions of immune system proteins, which are designed to attach to the HER2 protein on cancer cells and stop it from growing. Trastuzumab (Herceptin) and pertuzumab (Perjeta) are two monoclonal antibodies that are used in early-stage disease.

Other targeted therapies that may be possible in early-stage breast cancer are antibody-drug conjugates (ADCs) and kinase inhibitors. ADCs are linked to a chemotherapy drug, and kinase inhibitors block proteins that send signals to cancer cells, such as signals for it to grow.

Immunotherapy aims to stimulate the body's immune system to recognize and attack cancer cells. At this time, outside of a clinical trial, immunotherapy use for early-stage breast cancer is limited to stage II or III triple-negative breast cancer. The currently approved immunotherapy for early-stage breast cancer is pembrolizumab (Keytruda), which is a checkpoint inhibitor.

Treatment Side Effects

• Side effects from surgery can include bleeding and infection at the surgery site; pain, tenderness, or swelling at the surgical site; and limited arm/shoulder movement.

• Side effects from radiation therapy can include swelling, skin changes in the breast, and fatigue.

• Side effects from chemotherapy can include nausea, fatigue, hair loss, and skin conditions.

• Side effects from hormone therapy can include weight changes, hot flashes and night sweats, fatigue, and gastrointestinal symptoms.

• Side effects from targeted therapies can include diarrhea, severe fatigue, and more serious health issues such as heart damage.

The extent and degree of side effects from all treatments will vary by person and by the specific types of treatments used. Always inform members of your healthcare team if you have concerns about any symptoms or complications following any treatment.

Follow-Up and Surveillance

Your medical team will schedule regular follow-up appointments once you have completed active therapy. These visits are a crucial part of managing your health, monitoring your progress, and detecting any potential recurrence as early as possible.

Lifestyle, Self-Care, Support

Engaging in regular physical activity, eating a balanced diet, limiting alcohol use, and getting adequate rest, will play a significant and positive role in managing early-stage breast cancer.

Being diagnosed with breast cancer is an emotional challenge. Support groups of others who are managing their breast cancer are available, both locally and online, and will provide emotional and practical support.

Individual counseling may also be an option you may wish to explore to extend your support network.

Read previous installments in this series:

Part 1: For Your Patients: Breast Cancer Basics

Part 2: For Your Patients: The Crucial Role of the Biopsy in Breast Cancer