Whether an abnormality is found during a routine mammogram or a self-exam, the first step is a diagnostic mammogram, where specialized images that allow for greater magnification are captured. A diagnostic mammogram often includes an ultrasound of the area.
“Many people are familiar with sonography during pregnancy,” says Dr. Rivera; “the exact same instrumentation is used to create a picture of the breast.”
A diagnostic mammogram allows radiologists to further characterize the abnormality and determine what would be the best approach for biopsy, if they determine that’s needed.
If so, they take a sample using a hollow needle guided by ultrasound or stereotactic guidance, in which radiologists use the same setup as the mammogram. The sample is then sent to a lab.
Once cancer is detected, multidisciplinary care comes into play. Doctors work together to determine the best course of action, such as drug therapy or surgery, based on the stage of the cancer, how aggressive it seems to be and whether the cells contain hormone receptors that cause tumor growth when stimulated but are also targets for drugs that reduce the tumor’s size. Some patients benefit from chemotherapy first; others may benefit from surgery.
There are two types of surgery: breast conserving surgery, often called a lumpectomy, and mastectomy, or breast removal. A lumpectomy is the most common. Surgeons remove the tumor, a small amount of surrounding tissue and sometimes nearby lymph nodes. Lumpectomies can usually be done as outpatient surgery and rarely require any post-op pain medicine stronger than ibuprofen or acetaminophen.
“Overall, the recovery is measured in days to maybe a week or two,” says Dr. Rivera. By comparison, recovery from a mastectomy range from a few weeks to two months.
For larger or multiple tumors, and in certain other situations, a mastectomy may be the most beneficial. During a mastectomy, the surgeon removes all breast tissue and sometimes the nipple and breast skin. Both lumpectomies and mastectomies change the appearance of the breast, but restoration is often possible with the help of plastic surgery.
Some patients are referred for radiation therapy. “Most patients who get breast conserving surgery will benefit from the addition of radiation therapy to prevent the cancer from coming back,” says Dr. Rivera.
“Most patients who get breast removal don't require radiation, unless there’s something concerning about their cancer, large tumors, involvement of skin or the chest, or the presence of cancer in their lymph nodes. That's a bit of an advantage over lumpectomy.”
Breast cancer patients are monitored frequently following treatment. The highest risk of recurrence is within the first three years, but Dr. Rivera and the rest of the Scripps oncology team actively monitor patients for the first five years, sometimes longer, depending on their stage of disease.
Dr. Rivera stresses that once there's no longer evidence of disease, most patients will remain cancer free for the rest of their lives. However, breast cancer can return in a much more delayed fashion, 10 to 20 years later, so patients are asked to be vigilant for signs or symptoms.
“Survival with breast cancer in this day and age is very good,” he says.