Metaplastic breast cancer, also called metaplastic carcinoma of the breast, is a rare type of breast cancer that is very different from the typical ductal or lobular breast cancer. It describes a cancer that begins in one type of cell (such as those from the glands of the breast) and changes into another type of cell. 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 breast cancer start in the epithelial cells, and then change into squamous (nonglandular) cells. Because the cells that give rise to metaplastic breast cancer are not part of the normal breast gland, this cancer does not have estrogen receptors (ERs), progesterone receptors (PRs), or HER2 (a protein found in 25% of breast cancers). See Diagnosis for more information.
Metaplastic breast cancer is considered an invasive cancer, meaning that it has already spread beyond the duct or lobe at the time of diagnosis.
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, carrying 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, the tiny, bean-shaped organs that normally help fight infection.
Cancer may begin as a single, genetically abnormal cell. As this one cell divides, it eventually becomes a tumor (a mass of cells) and develops a blood supply to nourish its continued growth. At some point, cells may break off from the primary mass and move to other parts of the body in a process called metastasis. Metaplastic breast cancer can metastasize to the lymph nodes and other areas of the body, especially the lungs.
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 cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed 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 occur 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 mastectomy (preventive removal of the breasts) 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 breast cancer risk). One such drug is tamoxifen (Nolvadex), which is a selective estrogen receptor modulator (SERM). A SERM is a medication that blocks estrogen receptors in some tissues and not others. Tamoxifen can reduce a woman’s risk of developing breast cancer and the risk of the cancer recurring once a woman has been treated for breast cancer. Like estrogen, tamoxifen helps increase bone density in postmenopausal women and protects the cardiovascular system. Unlike estrogen, SERMs do not promote the development of breast cells into cancer cells; however, they may increase the risk of blood clots and uterine (endometrial) cancer.
For most women, regular mammography and clinical breast examinations (examinations by a doctor or other health-care professional) can help find early signs of breast cancer. In addition, women should become familiar with their own breasts. Checking your own breasts for lumps with breast self-examination may help if performed correctly. Talk with your doctor for more information.
The STAR trial
The Study of Tamoxifen and Raloxifene (STAR) trial, launched in May 1999, is a breast cancer risk reduction clinical trial. A clinical trial is a research study involving people. The STAR trial compared tamoxifen and raloxifene (Evista) in reducing the risk of breast cancer in postmenopausal women over age 35 who have an increased risk of developing breast cancer. The clinical trial was conducted by the National Cancer Institute and the National Surgical Adjuvant Breast and Bowel Project. A recent analysis of the clinical trial data shows that both tamoxifen and raloxifene reduce the risk of invasive breast cancer by about 50% in women at high risk for the disease (this is the relative risk; the absolute risk for any woman taking these medications to lower the risk of breast cancer is 2% to 3%). Raloxifene does not lower the risk of noninvasive breast cancer. 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
The U.S. Preventive Services Task Force (USPSTF) recommends that women 40 to 75 years old undergo mammography every one to two years, and the American Cancer Society (ACS) recommends yearly mammography. Mammography is the best tool doctors have to screen for breast cancer and can detect a tumor that is too small to be felt. All women should talk with their doctors about mammography and decide on an appropriate screening schedule.
Occasionally, mammograms may miss a cancer. Other methods of breast imaging, such as ultrasound and magnetic resonance imaging (MRI), are not regularly used for screening purposes. However, they may be helpful for evaluating women at a higher risk for breast cancer, including women with a mutation in one of the breast cancer genes (BRCA1 and BRCA2), and women who received radiation therapy for Hodgkin lymphoma. These other screening methods may also be used when there is a suspicious finding on physical examination. If there are suspicious findings on physical examination, further evaluation is necessary, even if the mammogram is interpreted as normal.
The USPSTF and ACS differ on their recommendations for clinical breast examination. The USPSTF recommends a clinical breast examination along with mammography, and the ACS recommends a clinical breast examination every one to three years. Breast self-examination has not been shown to lower deaths from breast cancer, but it is important for women to become familiar with their breasts so that they can be aware of any changes. Women are encouraged to discuss the frequency of screening with their doctors.
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 caused by a medical condition that is not cancer. 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 nipple turned inward 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 (called 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 suspected
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 tests
Diagnostic mammography. Diagnostic mammography is similar to screening mammography except that more views (pictures) of the breast are taken, and it is often used when a woman is experiencing signs, such as nipple discharge or a new lump. Diagnostic mammography may also be used if something suspicious is found on a screening mammogram.
Ultrasound. An 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.
MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium (a special dye) may be injected into a patient’s vein to create a clearer picture. An MRI may be used once a woman has been diagnosed with cancer to check the other breast for cancer, but the benefit of this is controversial. It may also be used for screening. According to the ACS, women at high risk for breast cancer (for example, women with BRCA gene mutations or a strong family history of breast cancer) should receive MRI screening along with a mammogram. MRI may often be better at seeing a small mass within a woman’s breast than a mammogram or ultrasound, especially for women with very dense breast tissue, but has a higher rate of false-positive test results (a test result that indicates cancer when there is no cancer present) and may result in more biopsies. In addition, an MRI does not show calcifications, which could indicate in situ breast cancer. Talk with your doctor for more information.
Surgical tests
Biopsy. 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 evaluating cells, tissues, and organs to diagnose disease).
Image guided biopsy is used when a distinct lump can't be felt. It can be done with a fine needle aspiration biopsy (FNAB, uses a small needle to remove the tissue sample), stereotactic core biopsy (uses x-rays to find the area of tissue to be removed), or a vacuum-assisted biopsy (uses a thicker needle to remove multiple large cores of tissue). During this procedure, a needle is guided to the area of concern with the help of mammography, ultrasound, or MRI. 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.
Core biopsy can obtain tissue or FNAB can obtain cells in masses that can be felt, and these can then be analyzed for the presence of malignant (cancerous) cells.
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 surgery may be needed to get a clear margin (area of tissue around the tumor where there are no cancer cells) and/or remove lymph nodes.
Doctors may also test the tissue from a biopsy to help guide treatment decisions. The tests include:
Tumor features. Examination of the tumor under the microscope determines if it is invasive or in situ; grade (how different the cancer cells look from healthy cells); and whether the cancer has spread to the blood vessels or lymph vessels. The margins of the tumor are also examined.
Estrogen receptor (ER), progesterone receptor (PR), and HER2 tests. Because the cells that become metaplastic breast cancer are not part of the breast gland, metaplastic breast cancer is always ER-negative, PR-negative, and HER2-negative.
Genetic description of the tumor. Tests that look at the biology of the tumor are becoming more common to understand more about breast cancer.
Blood tests
The doctor may also need to do blood tests to learn more about the cancer.
Complete blood count (CBC). CBC is a blood test done to determine the following:
Hemoglobin level (a measure of the number of oxygen-carrying 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)
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, 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 of any of these substances can indicate liver damage, a signal of possible spread to that organ.
Tumor marker tests. A tumor marker (also called a serum marker or biomarker) is a substance found in a person's blood, urine, or body tissue. The presence of a tumor marker, or having higher or lower than normal levels of a tumor marker, may indicate an abnormal process in the body, which could be because of cancer or a noncancerous condition. Tumor markers may be used for diagnosis, treatment planning, and/or treatment monitoring. For more information, read the Tumor Markers for Breast Cancer.
Additional tests
The doctor may order additional tests (depending on the individual’s medical history and results of the physical examination) to evaluate the stage of the cancer. Read the Staging section for more information. These tests are not recommended for all patients.
A chest x-ray may be used to look for cancer that has spread from the breast to the lung.
A bone scan may be used to look for spread to the bones. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.
A computed tomography (CT or CAT) scan may be used to look for distant tumors. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium is injected into a patient’s vein to provide better detail.
A positron emission tomography (PET) scan may be used to determine whether the cancer has spread. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images.
Staging is a way of describing a cancer, such as where it is located, if or 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 other parts 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 and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.
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 precancer, but it can later develop into an invasive type of breast cancer. A designation of DCIS 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.
Tis (LCIS): Lobular carcinoma in situ (LCIS) describes abnormal cells found in the lobules or glands of the breast. LCIS is not cancer, but it increases the risk of developing invasive breast cancer.
Tis (Paget’s): Paget’s disease of the nipple is a rare form of early breast cancer. This designation is used only if there is Paget’s disease but no tumor present. If there is a tumor, it is classified according to the size of the tumor.
T1: A tumor in the breast is 2 centimeters (cm) or smaller in size at its widest dimension.
T1mic: Microinvasion, or micrometastases, means a few cancer cells have spread to surrounding tissue, but none 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 not larger than 2 cm.
T2: The tumor is larger than 2 cm but not larger than 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), thickening of the skin (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 where the breast is red, swollen, and warm.
Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes located under the arm, above and below the collarbone, and under the breastbone are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.
NX: The lymph nodes cannot be evaluated.
N0: No cancer was found in the lymph nodes.
N1: The cancer has spread to one to three axillary lymph nodes.
N2: The cancer has spread to four to nine lymph nodes under the arm or to the internal mammary lymph nodes (lymph nodes to the right or left of the sternum [breastbone] on the inside of the chest) without axillary node involvement.
N2a: The cancer has spread to four to nine lymph nodes under the arm (at least one tumor deposit is larger than 2 mm).
N2b: The cancer has spread only to the internal mammary lymph nodes.
N3: The cancer has spread to 10 or more lymph nodes under the arm or to the infraclavicular lymph nodes (located under the collarbone) or to the internal mammary nodes with axillary node involvement.
N3a: The cancer has spread to 10 or more lymph nodes under the arm or to the infraclavicular lymph nodes.
N3b: The cancer has spread to internal mammary nodes and axillary nodes.
N3c: The cancer has spread to the supraclavicular lymph nodes.
If there is cancer in the lymph nodes, it also helps doctors to plan treatment to know how many lymph nodes are involved. The pathologist can determine the number of lymph nodes affected by cancer.
Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.
MX: Distant spread cannot be evaluated.
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: Disease that has not spread past the natural boundaries of the breast. 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 or equal to 2 cm and has spread to the axillary lymph nodes under the arm (T1 or T1mic, N1, M0).
The tumor is larger than 2 cm but not larger than 5 cm and 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 larger than 2 cm but not larger than 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 (T1, N2, M0 or T2, N2, M0).
The tumor is larger than 5 cm and has spread to the axillary lymph nodes (T3, N1, M0 or T3, 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, M0; T4, N1, M0; or T4, 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 in the N3 group (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 or liver, or chest wall (any T, any N, M1).
Recurrent:Recurrent cancer is cancer that comes back after treatment.
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.
This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, read the clinical trials section.
Because metaplastic carcinoma of the breast is rare, the best course of treatment has not yet been determined. Therefore, metaplastic carcinoma of the breast is treated in the same way as a more common breast cancer is treated. It has been suggested in multiple studies, however, that a woman’s prognosis is related to the size of her tumor, rather than the number of lymph nodes that contain cancer. Specifically, a woman with a tumor smaller than 4 cm has a better prognosis than a woman with a tumor larger than 4 cm.
Overview of breast cancer treatment
The biology and behavior of a breast cancer affects the treatment. Some tumors are small but grow fast, while others are large and grow slower. When planning the treatment for breast cancer, the doctor will consider many factors, including:
The stage and grade of the tumor
The patient’s age and general health
The patient’s menopausal status
The presence of known mutations to breast cancer genes
Even though the doctor will specifically tailor the treatment for breast cancer for each patient, there are some general steps for treating breast cancer. If the cancer can be removed by surgery, that is usually the first treatment. After surgery, a woman may have additional treatment, called adjuvant therapy, which removes any remaining cancer cells. Adjuvant therapies include radiation therapy, chemotherapy, and targeted therapy. Although adjuvant therapy lowers the risk of recurrence, it 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.
Along with staging, other sophisticated tools can help determine prognosis and help you and your doctor make decisions about adjuvant therapy. The website Adjuvant! Online (www.adjuvantonline.com) is one such tool that your doctor can access to interpret a variety of prognostic factors. This website should only be used with the interpretation of your doctor.
When surgery to remove the cancer is not possible, chemotherapy, radiation therapy, and/or targeted therapy may be used.
The treatment of recurrent cancer and metastatic cancer depends on how the cancer was first treated and the characteristics of the cancer mentioned above. More complete descriptions of each treatment option are listed below.
Surgery
Generally, the smaller the tumor, the more surgical options a woman has. The types of surgery include the following:
A lumpectomy is the removal of the tumor and a small, clear (cancer-free) margin of tissue around the tumor. For DCIS and an invasive cancer, follow-up radiation therapy to the remaining breast tissue is recommended. A lumpectomy may also be called a partial mastectomy or a segmental mastectomy.
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. The actual number of nodes removed may vary.
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 nipple. 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 often has a lower risk of lymphedema (swelling of the arm) than axillary lymph node dissection. 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 Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer.
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 be able to have this done at the same time as a mastectomy or at some point in the future.
Most patients with invasive cancer will undergo either sentinel lymph node biopsy or an axillary lymph node dissection. For those with sentinel nodes that indicate cancer, an axillary lymph node dissection is still considered necessary. Research is underway to determine if this continues to be true.
To summarize, surgical treatment options include the following:
Lumpectomy or partial mastectomy and radiation therapy
Total mastectomy, with or without immediate reconstruction, with or without sentinel node biopsy and possible axillary lymph node dissection
Modified radical mastectomy with or without immediate reconstruction
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. The combination of lumpectomy and radiation therapy has a higher risk of the cancer coming back in the same breast or near the breast, but the long-term survival of women is the same as those who have a mastectomy.
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Adjuvant radiation therapy is given regularly for a number of weeks after a lumpectomy or partial mastectomy to eliminate any remaining cancer cells near the tumor site or elsewhere within the breast. Adjuvant 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 tissue margin around the tumor removed by the surgeon. Adjuvant radiation therapy is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is rare.
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 a left-sided breast cancer 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 for 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 trials comparing lumpectomy and adjuvant 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.
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 implants, it is called internal radiation therapy or brachytherapy. In this treatment, small radioactive pellets are placed in or near the site of the breast tumor within plastic catheters placed temporarily in the breast. A balloon catheter placed near the breast that delivers radiation therapy (called Mammosite) is another type of radiation therapy.
Standard radiation therapy after a lumpectomy or partial mastectomy is external-beam radiation therapy given for five days (Monday through Friday) for six to seven weeks. This usually includes radiation therapy to the whole breast first for four and a half to five weeks, followed by a more focused treatment to the site of the tumor bed in the breast for the remaining treatments. This focused part of the treatment, called a boost, is standard for women with invasive breast cancer because it reduces the risk of a recurrence in the breast. This boost is also usually given for women with in situ breast cancer and is the subject of an ongoing international clinical trial.Standard radiation therapy after a mastectomy is given to the chest wall for five days (Monday through Friday) for five to six weeks. If there is evidence of cancer in the underarm lymph nodes, radiation therapy may also be given to the lymph node areas in the neck or underarm near the breast or chest wall.
There has been growing interest in newer radiation methods to shorten the length of treatment from six to seven weeks to periods of three to four weeks. In one method (called hypo-fractionated radiation therapy), a higher daily dose is given to the whole breast each day so that the overall length of treatment is shortened to three to four weeks. This approach can also be combined with a higher dose given to the tumor bed in the breast either during or after the whole breast radiation treatments. Clinical trials from Canada and the United Kingdom have shown that these shorter schedules can be equally accepted by patients with the same cancer control rates and side effects as longer radiation treatment schedules. These shorter schedules may become more accepted in the United States and are one way to improve the convenience and time required to complete a course of radiation.
Two approaches to lessen the side effects of radiation therapy, partial breast irradiation (PBI, radiation that is given directly to the tumor area instead of the entire breast) and intensity-modulated radiation therapy (IMRT, a more precise method of delivering radiation to the breast by varying the intensity of radiation) are not generally being recommended for patients with metaplastic breast cancer at this time. More information about these techniques can be found in the Cancer.Net Guide to Breast Cancer and by talking with your doctor.
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the drug and the dose used, but can include fatigue, hair loss, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers, but studies have shown that these side effects do not shorten a woman’s survival time.
Chemotherapy may be given orally (by mouth) or intravenously (injected into a vein) and is usually given in cycles. Chemotherapy generally does not require a hospital stay; it is given in an outpatient setting. Chemotherapy may be neoadjuvant therapy (given before surgery to shrink a large tumor) or adjuvant therapy (given after surgery to reduce the risk that the cancer returns). Chemotherapy may also be given at the time of a breast cancer recurrence. Patients in clinical trials may be offered new drugs or new combinations of existing drugs.
Different drugs are useful for different cancers, and research has shown that combinations of certain drugs are more effective than individual ones. The following drugs or combinations of drugs may be used as adjuvant therapy to treat breast cancer:
Cyclophosphamide (Clafen, Cytoxan, Neosar)
Methotrexate (multiple brand names)
Fluorouracil (5-FU, Adrucil)
Doxorubicin (Adriamycin)
Epirubicin (Ellence)
Paclitaxel (Taxol)
Docetaxel (Taxotere)
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.
Paclitaxel, docetaxel, and carboplatin (Paraplat, Paraplatin) may be given after standard adjuvant chemotherapy.
In addition to the drugs and combinations of drugs listed above, the following may be used to treat recurrent breast cancer and metastatic breast cancer:
AT (doxorubicin and docetaxel; doxorubicin and paclitaxel)
GT (gemcitabine and paclitaxel)
Docetaxel and capecitabine
Ixabepilone (Ixempra)
Bevacizumab (Avastin, see below) may be given with chemotherapy in particular situations.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, 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.
Targeted therapy
Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development. Because metaplastic breast cancer does not have HER2, drugs that target this protein are not used to treat this type of cancer.
Bevacizumab is used to treat metastatic or recurrent breast cancer (see below). This drug blocks angiogenesis (the formation of new blood vessels), which is needed for tumor growth and metastasis. When combined with paclitaxel, bevacizumab appears to shrink the tumor and remain smaller for a longer time in women whose breast cancer has spread compared with paclitaxel alone. This combination was approved by the U.S. Food and Drug Administration in 2008.
Recurrent and metastaticbreast 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). Some patients live years after a recurrence of breast cancer.
Breast cancer may also spread to other organs such as the brain, the opposite breast, adrenal glands, spleen, and ovaries and is called metastatic breast cancer. For example, metaplastic carcinoma of the breast is most likely to spread to the lungs. This type of cancer is treatable, but not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the growth of the tumor.
Generally, a recurrence is detected when a person has symptoms. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research has shown that having such tests does not improve the response to treatments used for advanced disease, nor do they prolong life.
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 metastasis and may include changes in vision, changes in energy levels, feeling ill, 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 HER2 status, because this may have changed from the time of the original diagnosis.
The treatment of metastatic or recurrent breast cancer depends on the previous treatment(s) and the characteristics of the tumor. For women with a recurrence within the breast after initial treatment with lumpectomy and adjuvant radiation therapy, the treatment is mastectomy. For women with a recurrence of the chest wall after an initial mastectomy, resection (surgical removal of the recurrence) followed by radiation therapy to the chest wall and lymph nodes is the treatment, unless radiation therapy has already been given (radiation therapy cannot be given to the same area more than once). Chemotherapy and targeted therapies may also be used to treat metastatic cancer. Radiation therapy and surgery may be used in certain situations for women with a distant metastatic recurrence.
The National Comprehensive Cancer Network (NCCN) also 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 its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, infection, fatigue, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.
Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health.
Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net’s section on Managing Side Effects, based on ASCO’s curriculum.
In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer.Net’s section on Caring for the Whole Patient.
For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.
After treatment for metaplastic 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 for the coming months and years. The recommendations for breast cancer follow-up care usually include regular physical examinations and mammograms. Specific information can be found in the Follow-Up Care for Breast Cancer. In addition, ASCO offers forms to help keep track of the breast cancer treatment you received and develop a survivorship care plan once treatment ends. Read more about the ASCO Cancer Treatment Summaries.
Breast cancer can come back 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 have these or other symptoms. The possibility of recurrence is a common concern among cancer survivors; 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 therapy because the treatment 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 therapy or if the side effects are not going away.
Women recovering from breast cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced 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 rebuild your strength and energy level and lowers the risk of recurrence. Your doctor can help you create a safe exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer
Research for metaplastic breast cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.
Drugs that target the epidermal growth factor receptor (EGFR, a protein involved in the abnormal growth of cancer cells) and a receptor for c-kit (a protein that when mutated or changed may be involved in the development of cancer) are being tested in clinical trials.
Drugs that target the angiogenesis process are being tested in clinical trials.
New surgical methods that save tissue or prevent scarring are being tested in clinical trials. A skin-sparing mastectomy may result in less scarring than traditional surgery.
Improved radiation therapy, to lower the risk of side effects
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor(s):
What type of breast cancer do I have?
Can you explain my pathology report (laboratory test results) to me?
What is the size of my tumor?
What is a sentinel lymph node biopsy? What are the benefits and risks? Would you recommend it for me?
What is the risk of lymphedema with a sentinel lymph node biopsy? With axillary lymph node dissection?
How many lymph nodes contain cancer?
What stage is my breast cancer? What does that mean?
What are my options for treatment?
Do I need additional surgery?
Should I consider chemotherapy before surgery?
Where clinical trials are open to me?
What are the possible side effects of this treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
Could this treatment affect my fertility (ability to have children in the future)? If so, are there other treatments available that do not pose as high a risk to my fertility but are equally effective?
What are the expected timelines for my treatment plan?
Now that you have examined me, am I a good candidate for reconstruction?
What types of breast reconstruction options do I have?
What are the advantages and disadvantages of each type?
How will you determine if the cancer comes back?
How often will I receive radiation therapy?
How much time will each treatment take?
Will each treatment be the same? Does the radiation dose or area treated change throughout the period of treatment?
Will you describe what I will experience when I receive radiation therapy?
Whom do I call for questions or problems?
What follow-up tests will I need, and how often will I need them?
What support services are available to me? To my family?
American Society of Breast Disease
P.O. Box 140186
Dallas, TX 75214
Phone: 214-368-6836 www.asbd.org
Breastcancer.org
7 E Lancaster Ave., 3rd Fl.
Ardmore, PA 19003 www.breastcancer.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
Fertile Hope
65 Broadway, Ste. 603
New York, NY 10006
Toll Free: 888-994-HOPE (888-994-4673) www.fertilehope.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
25235 Fox Chase Dr.
Chestertown, MD 21620-4401
Phone: 410-778-1982 www.mothersdaughters.org
National Breast Cancer Coalition
1101 17th St., NW, Ste. 1300
Washington, DC 20036
Toll Free: 800-622-2838
Phone: 202-296-7477 www.natlbcc.org
National Cancer Institute
Public Inquiries Office
6116 Executive Blvd., Room 3036A
Bethesda, MD 20892-2580
Toll Free: 800-4-CANCER
Phone: 301-435-3848
TTY: 800-332-8615 www.cancer.gov
National Comprehensive Cancer Network
275 Commerce Dr., Ste. 300
Fort Washington, PA 19034
Phone: 215-690-0300 www.nccn.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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