Cancer Affects Everyone

It’s no secret that cancer affects everyone.

And it’s  also no secret that breast cancer is one of the most common cancers in women. The National Cancer Institute has reported more than 200,000 women will be diagnosed with breast cancer in 2010 and more than 39,800 of them will die this year.

While breast cancer awareness has become widely known around the world, little is known about two types of this disease: Paget’s Disease of the Nipple and triple-negative. Dr. Daleela Dodge, a general surgeon at the Lancaster Surgical Group and Lancaster General Health Campus, has treated female patients with both types of breast cancer and said though they are uncommon, it is important for women to be informed.

Paget’s Disease of the Nipple is a type of cancer that forms in or around the nipple, and it is not related to Paget’s Disease of the Bone. The disease accounts for less than 5 percent of all breast cancers. Though scientists don’t know the causes of Paget’s Disease, theories suggest that it starts in the skin or in the breast area and then spreads to the nipple.

Symptoms of the early-stage disease include redness or crusting of the nipple skin. Women with the more advanced stage may have tingling, itching, increased sensitivity, or pain in the nipple. Paget’s Disease is more common in women who are at least 50 years old.

Patients can feel the mass in the breast during a physical exam and a mammography. Proper diagnosis is performed by a biopsy, in which a doctor removes a small sample of tissue. However, a woman may experience signs and symptoms an average of six to eight months before the diagnosis is made.

Paget’s Disease initially stays in the nipple before spreading to the areola or other areas of the breast. Because the disease is confined, it does not spread to the lymph nodes.

“All breast cancer is treated best with integrated multispecialty care,” Dodge said. “Treatment of Paget’s disease, for example, generally includes a surgical lumpectomy with sentinel lymph node biopsy, a course of radiation and, in many patients, a five-year course of anti-estrogen therapy.”

Triple-negative breast cancer, which affects 10 to 20 percent of women, occurs if the tumor is receptor negative for estrogen, progesterone, and HER-2, also called human epidural growth factor receptor. According to the Triple Negative Breast Cancer Foundation, a receptor is basically a protein that lives inside or on the surface of a cell and binds to something in the body to cause the cells to react. Detection is not an issue in triple-negative breast cancers.

“What distinguishes these cancers is that they are so aggressive that even when detected at an early stage, for example, when they are still under 1 or 2 centimeters, they are more likely to recur and thus may need chemotherapy treatment even when detected at a very small size,” Dodge said.

Most triple-negative cancer cells are basal-like, meaning the cells line the breast ducts or the tubes in the breast through which the milk travels. The TNBC Foundation suggests that about 70 percent of triple-negative breast cancers are basal-like. Everyone is born with a BRCA1 and BRCA2 genes. These genes help prevent the development of certain types of cancers. However, when people are born with a mutation or an abnormality in the BRCA1 gene, there’s a high risk of developing basal-like breast cancer.

“There’s an 85 percent chance of developing breast cancer, and there’s a 40 percent chance of getting ovarian cancer,” Dodge explained. “About 20 to 25 percent of the patients I treat have the triple-negative disease.”

While triple-negative is typically responsive to chemotherapy, there are some medicines that may or may not also be helpful to cancer patients. For instance, Dodge refers to Herceptin, otherwise known as Trastuzumab, as the “miracle drug” because it can be “well tolerated and can kill cancer cells.”

Another drug called Tamoxifen can target the estrogen receptor. This commonly used hormonal drug can potentially block the effects of estrogen on breast cancer cells as well as control any remaining cancer cells that have been left in the body after surgery.

Dodge said triple-negative tumors have a completely different way of acting around the body.

“They are more likely to go to the brain and liver while hormone receptor positive tumors most often go to the bones first,” she said. “We are treating cancers now based on biology.”

Researchers are trying to understand the biology of triple-negative breast cancer, particularly how this type behaves and what puts people at risk for it. With a high recurrence rate, triple-negative breast cancer can occur in young and premenopausal women between the ages of 30 and 40. Though triple-negative can affect women of all races, it is mostly common in African-American women in their 20s and 30s.

Still, triple-negative can affect those in great physical health. For Lititz resident Drue Feilmeier, the sudden discovery of a lump under her left arm felt like being in a dramatic movie scene. She was diagnosed with triple-negative breast cancer in the September 1999.

“I found out later that the tumor had grown in my lymph nodes so I never even felt the breast lump. I had just been at my OB-GYN earlier in the summer. I had a breast exam and got the results saying, ‘Oh, you’re great,’” she said. “It was a big surprise for [me]. Rarely, I went to the doctor. I was always a healthy person in terms of I rarely got a cold.”

Feilmeier had a biopsy, discovering that she had 13 positive lymph nodes. Surgery was performed in October. Because she was ineligible to receive follow-up treatments due to her age and the fact that she had 13 “aggressive cells,” Feilmeier searched out to find the most aggressive treatment plan for herself. At the time, that was the stem cell transplant. She went to Johns Hopkins University in Maryland for a second opinion.

Dodge explained that 10 years ago, stem cell transplants with high dosages of chemotherapy were an option for patients with high risk, especially triple-negative disease, but “since then, it’s been shown that outcomes with this treatment were no better than with the standard regimens of chemotherapy so it is no longer an option.”

Feilmeier opted not to get a stem cell transplant, and instead, went through eight rounds of chemotherapy and 30 rounds of radiation treatments. This proved to be a great decision because in the spring of 2000, Feilmeier was in remission.

“It felt awesome, and I never want to belittle how awesome it was. But way more significant to me was that instead of feeling despair about my past and dread about my future, I just loved the days,” she recounted. “That was the greatest gift out of that whole year.”

Diagnosed with triple-negative breast cancer in late 2009, Connie Keares, of Mountville, was instructed by her family doctor to meet with Dodge immediately. Keares had felt a lump on her left breast while performing karate techniques.

“When I went in to see Dr. Dodge for the first time, the lump had gotten so big at that point that you could feel it on the outside,” she said. “She went ahead and did a biopsy while I was in her office, and it took three days to get the results back. Dr. Dodge diagnosed it from the biopsy.”

Unlike Feilmeier, Keares underwent neoadjuvant chemotherapy, a type of treatment given before surgery. This procedure allows doctors see how the tumor is responding. Giving neoadjuvant chemotherapy before surgery may shrink a large tumor to a size that allows for breast conservation in a woman with smaller breasts. In December 2009, Keares had surgery to put in a mediport.

“The hardest part about the chemotherapy was accessing the port. My port was faulty, and we didn’t know that until it broke. It took about an hour to set up the chemo. For me, it was very stressful. I felt so sorry for the nurses,” she said. “On Jan. 6, they did the first test. The tube in the port was emptying into my aorta valve at the top, rather than in the middle.”

Surgery had to be done again to replace the mediport before she could fully start the chemotherapy. After 16 weeks, Keares was on the road to recovery, completing eight chemotherapy treatments. Her surgery in May was a success as doctors performed a mastectomy. On July 30, she completed her eight-week radiation treatment schedule.

“The triple-negative has really started to hit me now because I think initially, I just wanted to get through the treatment,” she said.

Feilmeier and Keares hope to inspire other women to get properly checked out on a regular basis, especially scheduling a mammogram.

“I think it’s important for women to know that when you find a lump, it’s important to get it checked out right away,” said Keares. “If you don’t pay attention to it, it can kill you.”