Tool Kit

Navigation Tool Kit

This Navigation Toolkit is designed to support healthcare professionals supporting patients in the breast health environment of care. This toolkit provides a structured approach to breast health, complexities of care, current therapies and treatments for conditions of the breast, and includes resources to aid navigators in this field.

Or for instant access click on any of the Table of Content items below

Table of Contents

Acknowledgments & Contributors
Prevention, Lifestyle & Health Promotion
High Risk
Screening Exams
Breast Cancer High Risk Management & Risk Reduction
Diagnostic Work-Up
Diagnosis
Pathology
Breast Cancer Staging
Referrals After Diagnosis
Breast Cancer Treatment
Survivorship
Glossary of Terms

Intent of Use

This Navigation Toolkit is designed to support healthcare professionals supporting patients in the breast health environment of care. This toolkit provides a structured approach to breast health, complexities of care, current therapies and treatments for conditions of the breast, and includes resources to aid navigators in this field.

Acknowledgements and Contributors

  • Kimberly Bolin, BS, RT (R)(M), ARRT, ARDMS – NCBC Executive Director
  • Aerial Gilbert, NCBC Certifications Manager
  • Nicole Centers, MBA, BSN, RN, OCN, CBCN, BHCN
  • Monique Tiffany, MSN, RN, CGRA, BHCN
  • Christine Brown, MS, BSN, RN, RD, OCN, BHCN
  • Kristy Denny. RT(R)(M)(BS), ARRT, BHCN, CGRA
  • Jenifer Dumire, BSN, RN, CVRN-BC, BHCN, CGRA
  • Lisa Spencer, M.Ed., BSRT(T), CMF, BHCN
  • Charlotte Vasile, ARRT, RT(R)(M), BHCN
  • Kimberlee Moses, RN, BSN, OCN
  • Susie Ulloa, BSN, OCN
  • Tami Hudson, RN, BSN, BHCN, CGRA, CGN
  • Adrianne Alexander, RN, BSN
  • Missi DeBoer, BSN, RN, OCN, CN-BN

About the Breast Health Clinical Navigator Certification (BHCNTM)

The NCBC BHCN™ Certification is the most comprehensive navigation program in the industry in regard to multidisciplinary care. The purpose of the BHCN™ exam is to identify applicants that have met the standards of achievement and the navigator's role; enhance patient safety, quality of care and delivery of services through recognition and resolution of barriers to care; and recognize professionals who advance beyond basic knowledge in the specialty field of breast patient navigation.

Prevention, Lifestyle & Health Promotion

Lifestyle-Related Modifiable Risk Factors

  • Alcohol
    • Drinking alcohol is linked to an increased risk of breast cancer. Any amount of alcohol consumption increases breast cancer risk. The risk increases with the amount of alcohol consumed. It is best not to drink alcohol. Women who choose to drink alcohol should have no more than 1 drink equivalent per day.
  • Weight
    • Achieve and maintain a healthy weight throughout life.
    • The link between weight and breast cancer is complex. Research suggests being overweight or obese after menopause increases breast cancer risk.
  • Diet/Nutrition
    • Follow a whole food plant-based dietary pattern at all ages that includes a variety of colorful vegetables and fruits, whole grains, wild fatty fish, low fat dairy, poultry, legumes, nuts, and seeds.
    • Limit consumption of red and processed meats, sugar-sweetened beverages, artificial sweeteners, highly processed foods, and refined grain products.
  • Physical Activity
    • Be physically active and limit sedentary behaviors.
    • Evidence suggests that regular physical activity reduces breast cancer risk, especially in women past menopause. The exact mechanism of how physical activity may lower breast cancer risk isn't clear, but it may be due to its effects on body weight, inflammation, and hormone levels.
    • Adults should get 150–300 min of moderate intensity or 75–150 min of vigorous intensity activity each week (or a combination of these).
  • Tobacco
    • Avoid smoking as both active and passive smoking are associated with an elevated risk for breast cancer.
    • The influence of aerosolized nicotine products on breast health is currently unknown however since these products contain carcinogens, they should be avoided.
  • Not Having Children
    • The effect of pregnancy on breast cancer risk is complex.
    • Women who have not had children or had their first child after age 30 have a slightly higher breast cancer risk. Those who have hand multiple pregnancies or who have become pregnant as a young age reduces breast cancer risk.

Resources:

American Cancer Society

www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/can-i-lower-my-risk.html
www.cancer.org/cancer/types/breast-cancer/risk-and-prevention.html
Breast Cancer Risk Factors and Prevention Methods | American Cancer Society

American Institute for Cancer Research (AICR)

www.aicr.org/cancer-survival/cancer/breast-cancer/

American Society of Clinical Oncology (ASCO)

www.cancer.net/cancer-types/breast-cancer/risk-factors-and-prevention
Centers for Disease Control and Prevention (CDC) www.cdc.gov/cancer/breast/basic_info/prevention.htm

What Are the Risk Factors for Breast Cancer? | CDC
https://www.cdc.gov/breast-cancer/prevention/?CDC_AAref_Val=https://www.cdc.gov/cancer/breast/basic_info/prevention.htm

National Comprehensive Cancer Network (NCCN) - breast cancer risk reduction guideline
https://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf

National Cancer Institute (NCI)

Breast Cancer Prevention - NCIwww.cancer.gov/types/breast/patient/breast-prevention-pdq

Smoking, Weight Management, Diet/Nutrition, Alcohol:
https://www.futuremedicine.com/doi/full/10.2217/bmt-2020-0033

High Risk

The average risk that a woman will develop breast cancer over her lifetime is approximately 12%. Risk is generally categorized as average, intermediate or high. Risk assessment and genetic testing is necessary to differentiate between risk groups and collecting a complete personal and family history is crucial to understanding a patient's risk most appropriately.

Female patients should be assessed for risk beginning at age 25.

Family and personal history questionnaires should include:

  • Personal history
  • Age
  • BMI
  • Hormonal risk factors
  • Breast density
  • Medical history
  • Surgery history
  • Biopsy history
  • Family history
  • Number of cancer diagnoses

Some risk factors can elevate or even significantly increase genetic risk. Patients should be considered for genetic testing when certain personal and family risk factors are identified:

  • Family history of breast cancer especially when diagnosed before age 50, bilateral breast cancer, male breast cancer or triple negative breast cancer (TNBC).
  • Both breast and ovarian cancer on the same side of the family or in a single individual.
  • Family history of cancer in addition to breast, such as prostate, melanoma, pancreatic, stomach, uterine, thyroid, colon, and/or sarcoma.
  • Certain ancestries such as Ashkenazi Jewish (Eastern European) heritage.
  • Known family mutation (KFM) in a gene associated with breast cancer.

Certain breast cancer risk models can help to identify women at increased risk for breast cancer, probability of a breast cancer related gene mutation or to assist with risk reduction strategies such as increased surveillance with breast MRI or certain medications that help lower risk.

Resources:

American College of Radiology (ACR)

https://www.acr.org/-/media/ACR/Files/Breast-Imaging-Resources/Care-Toolkit/Patient-Breast-Cancer-Risk-Assessment-Handout.pdf

American Society of Breast Surgeons (ASBS) https://www.breastsurgeons.org/docs/statements/Position-Statement-on-Screening- Mammography.pdf

National Human Genome Research Institute- Glossary of Genomic and Genetic Terms https://www.genome.gov/sites/default/files/media/files/2022-05/NHGRI-Talking-Glossary.pdf https://www.genome.gov/genetics-glossary

National Comprehensive Cancer Network (NCCN) Pedigree drawing basics (NCCN pg. EVAL-B))

https://www.nccn.org/professionals/physician_gls/pdf/genetics_bop.pdf

Personal cancer history indications for genetic testing & family cancer history indications for genetic testing (NCCN pg. CRIT-2) https://www.nccn.org/professionals/physician_gls/pdf/genetics_bop.pdf

Breast cancer screening https://www.nccn.org/patients/guidelines/content/PDF/breastcancerscreening-patient.pdf

Centers for Disease Control (CDC) https://www.cdc.gov/bring-your-brave/?CDC_AAref_Val=https://www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer/higher_risk_cancer.htm

Sample family history questionnaire: THE PINK SHEET pdf

Screening Exams

Imaging:

  • Screening Mammogram
    • Guidelines for the age to begin a mammogram and the frequency of exams vary by professional society. The most stringent is the ACR recommending that women of average risk start at age 40 and continue with yearly screenings if they are in good health without a cut-off age to stop screening. For women with a Tyrer-Cuzick score >20%, mammography should start at age 30.
    • A screening mammogram is for those who do not have a specific breast concern or symptom, such as a lump. Mammograms use radiation, but a very small dose. A screening mammogram is used as the best way for most women to find cancers early, when they are small, and are very treatable.
  • Screening Ultrasound
    • An ultrasound uses sound waves to make images of the breast. An ultrasound is suggested as a screening tool when a woman has dense breast tissue that might hide breast abnormalities.
  • Screening Breast MRI
    • Breast MRI uses magnetic fields to create an image of the breast. A contrast agent called gadolinium is injected into an IV before the procedure. MRI is the most sensitive form of breast imaging. It is used to assess high-risk patients who have more than a 20 percent chance of developing breast cancer in their lifetimes based on genetics and a strong family history of breast cancer.

Resources

https://www.acr.org/Practice-Management-Quality-Informatics/Practice-Toolkit/Patient-

Resources/Mammography-Saves-Lives

https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Breast-Cancer-Screening-in-Women-at-Higher-Than-Average-Risk

https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/breast-density-and-your-mammogram-report.html

Breast Cancer High Risk Management & Risk-Reduction

High risk surveillance with MRI in addition to mammography is utilized to screen patients at high risk (>20% lifetime risk).

Certain risk-reducing medications may be used to help reduce the risk of breast cancers. Prophylactic (or preventive) mastectomy is an option to reduce the risk of developing breast cancer in someone who is at the highest risk (hereditary).

Resources:

National Comprehensive Cancer Network (NCCN)

High Risk Screening Recommendations https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf Comparison of Risk Models & Risk Reduction Strategies https://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf Hereditary Testing, Screening & Management https://www.nccn.org/professionals/physician_gls/pdf/genetics_bop.pdf

Diagnostic Work-Up

Imaging:

  • Breast Diagnostic Mammogram
    • Mammograms are used to look at a woman's breast if she has breast symptoms or if something unusual is seen on a screening mammogram. They may include extra views (images) of the breast hat aren't part of screening mammograms. Sometimes diagnostic mammograms are used to screen women who were treated for breast cancer in the past. (Source – American Cancer Society)
  • Breast Ultrasound
    • Breast ultrasound uses sound waves and their echoes to make computer pictures of the inside of the breast. It can show certain breast changes, like fluid-filled cysts, that can be harder to see on mammograms. (Source – American Cancer Society)

Breast Biopsy Types:

  • Ultrasound Guided Biopsy
    • For this procedure, a doctor uses breast ultrasound to view the area that needs to be biopsied. An ultrasound is done first to view the area. Ultrasound is thenused to guide the needle into the correct area. A biopsy marker (clip) is placed near the area of the biopsy. Most often, a mammogram is done after the biopsy to confirm the clip is in the right place. (Source – American Cancer Society)
  • Stereotactic Biopsy
    • For this procedure, a doctor uses mammogram pictures taken from different angles to pinpoint the biopsy site. A computer analyzes the breast x-rays and shows where the needle tip needs to go in the abnormal area. This type of biopsy is often used to check suspicious microcalcifications (tiny calcium deposits) or small masses or other abnormal areas that can't be seen clearly on an ultrasound. The breast will be positioned in the mammography machine and compressed, and an image will be taken to make sure the area in question can still be seen. The biopsy device is placed into the breast, and more images are taken to confirm that the device is in the correct spot to take samples. Several biopsy samples are then taken. Afterwards, the device is removed from the breast, and a biopsy marker (clip) is placed in the area. Another mammogram is then done to confirm the marker is in the right place. (Source – American Cancer Society)
  • MRI Guided Biopsy
    • For this procedure, a doctor uses breast MRI to locate and biopsy the suspicious area. This is most often done when something is seen on a breast MRI that is unlikely to be seen on mammogram or ultrasound. The table will slide into the MRI scanner and images will be taken. Then you'll be given contrast through an IV line (which can help make the abnormal area easier to see), and more images will be taken. The biopsy device is inserted into the breast and more MRI images will then be taken to confirm to that the device is in the correct spot to take samples. Several biopsy samples are then taken, and the device is removed from the breast. A biopsy marker (clip) is then placed in the area of the biopsy. Most often, a mammogram is done after the biopsy to confirm the clip is in the right place.
  • Excisional (Surgical) Biopsy
    • An excisional biopsy removes the entire tumor or abnormal area. An edge (margin) of normal breast tissue around the tumor may be removed as well, depending on the reason for the biopsy.

Resource:

American Cancer Society (ACS)

https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection.html

National Comprehensive Cancer Network (NCCN) https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf

Diagnosis

  • Benign Breast diseases
    • ADH: Atypical ductal hyperplasia is when there are more cells than usual in the lining of the breast duct; the cells grow in an abnormal pattern and have some (but not all) of the features of DCIS. This is a benign breast condition linked to a moderate increase in breast cancer risk.
    • ALH: Atypical lobular hyperplasia is an abnormal growth of cells within lobules of the breast that is linked with an increased risk of breast cancer.
    • Fibroadenoma: Common, benign breast tumors containing both glandular tissue and stromal (connective) tissue. They are most common in women in their 20s and 30s, but they can be found in women of any age. They tend to shrink after a woman goes through menopause.
    • Papilloma: Intraductal papillomas are benign tumors that grow within the milk ducts of the breast. They are made up of gland tissue along with fibrous tissue and blood vessels (called fibrovascular tissue).
    • Radial Scar: Also called complex sclerosing lesions. They're most often found incidentally when a breast biopsy is done. Sometimes radial scars show up as a distortion of the normal breast tissue on a mammogram. They are not really scars, but they look like scars when seen with a microscope. They don't usually cause symptoms
  • DCIS: Ductal carcinoma in situ, also called intraductal carcinoma or stage 0 breast cancer. DCIS is a non-invasive or pre-invasive breast cancer. This means the cells that line the ducts have changed to cancer cells, but they have not spread through the walls of the ducts into the nearby breast tissue.
  • LCIS: Lobular carcinoma in situ is a type of breast change often seen when a breast biopsy is done. In LCIS, cells that look like cancer cells are growing in the lining of the lobules of the breast, but they don't invade through the wall of the lobules. LCIS is not considered cancer, and it typically does not become invasive breast cancer if it isn't treated. However, having LCIS does increase the risk of later developing an invasive breast cancer in either breast.
  • IDC: Invasive ductal carcinoma is the most common type of breast cancer. About 8 in 10 invasive breast cancers are IDC. It starts in the cells that line a milk duct in the breast and it breaks through the wall of the duct, growing into the nearby breast tissues. It may be able to metastasize through the lymph system and bloodstream.
  • ILC: Invasive lobular carcinoma represents about 1 in 10 breast cancers. It starts in the lobules. Like IDC, it can metastasize to other parts of the body. Invasive lobular carcinoma may be harder to detect on physical exam and imaging, like mammograms, than invasive ductal carcinoma. And compared to other kinds of invasive carcinoma, it is more likely to affect both breasts. About 1 in 5 women with ILC might have cancer in both breasts at the time they are diagnosed.
  • IBC: Inflammatory breast cancer is rare; it accounts for only 1% to 5% of all breast cancers. Although it is a type of invasive ductal carcinoma, its symptoms, outlook, and treatment are different. IBC causes symptoms of breast inflammation like swelling and redness, which is caused by cancer cells blocking lymph vessels in the skin causing the breast to look "inflamed."
  • Paget's Disease: It is a rare type of breast cancer involving the skin of the nipple and the areola. Paget disease usually affects only one breast and in 80-90% of cases, it's usually found along with either IDC or ILC.

Resources:

American College of Obstetrics and Gynecology

https://www.acog.org/womens-health/faqs/benign-breast-problems-and-conditions Breast Cancer .ORG

https://www.breastcancer.org/about-you/newly-diagnosed American Cancer Society (ACS)

https://www.cancer.org/cancer/types/breast-cancer/understanding-a-breast-cancer- diagnosis.html

https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early- detection.html

https://www.cancer.org/cancer/types/breast-cancer/non-cancerous-breast-conditions.html

Pathology

Initial Biomarkers

  • Estrogen (ER) + or –
  • Progesterone (PR) + or –
  • HER2 + or – (determined by IHC, ISH- Chromogenic/Fluorescence)
    • 0 (negative)
    • 1+ (sometimes referred to as HER2-low)
    • 2+ (equivocal, sometimes referred to as HER2-low)
    • 3+ (positive)
  • Ki67 %- IHC assay to assess breast cancer with potentially higher risk for recurrence.

These are generally subjective measurements determined by a pathologist. Scored as high or low and often use to determine relevant treatment. Hormone receptor (ER/PR) positive is an indication for endocrine therapy and HER2-positive is an indication for HER2 targeted therapies like Herceptin. The HER2 biomarker is only assessed in invasive breast cancer.

When breast cancer cells spread beyond the breast and nearby lymph nodes it is considered to be metastatic. Most commonly breast cancer will metastasize to the lungs, liver or bones. In the case of advanced and metastatic breast cancer additional biomarker testing, also considered molecular or tumor testing, may be utilized.

Grading

Cancer cells are given a grade when they are removed from the breast and checked in the lab. The grade is based on how much the cancer cells look like normal cells. The grade is used to help predict your outcome (prognosis) and to help figure out what treatments might work best. Invasive breast cancer grading can differ slightly from DCIS.

  • A low-grade number (grade 1) usually means the cancer is slower-growing and less likely to spread.
  • A high-grade number (grade 3) means a faster-growing cancer that's more likely to spread.
  • An intermediate grade number (grade 2) means the cancer is growing faster than a grade 1 cancer but slower than a grade 3 cancer.
  • Necrosis (areas of dead or dying cancer cells) is also noted in DCIS . If there is necrosis, it means the tumor is growing quickly. The term comedo necrosis may be used if a breast duct is filled with dead and dying cells. Comedo necrosis is often linked to a high grade of DCIS and has a higher chance of developing into invasive breast cancer.

Resources:

American Cancer Society (ACS)

https://www.cancer.org/cancer/types/breast-cancer/understanding-a-breast-cancer- diagnosis/breast-cancer-grades.html

https://www.cancer.org/cancer/types/breast-cancer/treatment/treatment-of-breast-cancer-by- stage/treatment-of-stage-iv-advanced-breast-cancer.html

National Comprehensive Cancer Network (NCCN) https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

Breast Cancer Staging

Many factors are used to determine the stage of breast cancer. Staging work-up can include lymph node biopsy in addition to imaging tests such as breast MRI, CT scan, chest X-ray, bone scan and PET (positive emission tomography) scans.

There are two different types of prognostic staging: clinical staging and pathological staging. Clinical staging is based on imaging studies, non-surgical biopsy, and physical examination. Pathological staging (also called the surgical stage) is determined after surgery as it combines the results of both the clinical staging with the surgical results.

The TNM system is used for staging breast cancer. This scoring system looks at:

  • T (Tumor): the size of the tumor (in centimeters)
  • N (Nodes): whether the cancer has spread to nearby lymph nodes and how many lymph nodes are affected
  • M (Metastasized): whether the cancer has spread to other organs of the body

Breast cancer stage is usually expressed as a number on a scale of 0 through IV — with stage 0 describing non-invasive (or in situ) cancers that remain within their original location and stage IV (metastatic) describing invasive cancers that have spread to other organs such as the bones, lungs, brain, liver, distant lymph nodes, or chest wall.

Resources:

American Cancer Society (ACS)

www.cancer.org/cancer/types/breast-cancer/understanding-a-breast-cancer-diagnosis/stages- of-breast-cancer.html

American Journal of Roentgenonology https://ajronline.org/doi/10.2214/AJR.20.25223 https://ajronline.org/doi/epdf/10.2214/AJR.20.25223 pdf

Referrals After Diagnosis

Based on the pathology report and other factors, clinical professionals will work together to create a plan of care specific to the patient's diagnosis and needs. The multi-disciplinary team may include several providers. This team is made up of providers from many specialties to help

care for all of the patients needs from surgery, treatment, symptom management, psychosocial needs, etc.

Unfortunately, for patients diagnosed with stage IV disease or metastatic breast cancer have a poorer prognosis. Metastatic breast cancer is not curable through surgical procedures or treatment and these patients may need additional services to help manage symptoms, pain, and overall care. Referral to palliative care or hospice may be necessary.

Resources:

Breast Cancer .ORG

https://www.breastcancer.org/research-news/guidelines-help-oncologists-provide- individualized-palliative-care-for-mbc https://www.breastcancer.org/types/metastatic/end-of-life-issues

Optimal Resources for Cancer Care. ACoS CoC Standards 2020. https://www.facs.org/-/media/files/quality- programs/cancer/coc/optimal_resources_for_cancer_care_2020_standards.ashx

National Accreditation of Breast Cancer Programs (NABCP)– Standards Manual (2018). American College of Surgeons.

https://www.facs.org/media/pofgxojm/napbc_standards_manual_2018.pdf

Breast Cancer Treatment

Surgery

Patients may discuss a variety of surgical options with their healthcare provider. Typical surgical interventions for breast cancer may include the following:

  • Lumpectomy/Breast Conservation Therapy
    • Procedure that removes the breast cancer along with a small amount of the healthy tissue surrounding it.
  • Mastectomy (Unilateral vs. Bilateral)
    • Modified-radical- all of the breast tissue the skin of the breast the nipple and the areola. Includes axillary node dissection of generally less than 10 lymph nodes.
    • Nipple-sparing- all of the breast tissue is removed, but the nipple, areola, and the skin of the breast is left intact.
    • Skin-sparing- removal of all the breast tissue, the nipple, and in some cases the areola, but most of the skin over the breast is left intact.
    • Radical- most extensive type of mastectomy and very rarely performed. Includes removal of all of the breast tissue the skin of the breast the nipple and the areola the chest wall muscles under the breast some of the lymph nodes under the arm.
    • Prophylactic (or preventive) mastectomy is done to reduce the risk of developing breast cancer in someone who is at high risk.

Reconstruction

Reconstruction can be utilized after breast cancer surgery and generally includes two main techniques in addition to nipple/areola reconstruction in some cases. Reconstruction can be complete or partial. Breast reconstruction recreates the breast, it doesn't restore sensation to the breast or nipple. In some cases, a combination of these approaches listed below are utilized.

  • Breast implants with or without use of expanders prior to implantation
    • Can be offered as immediate or delayed and in stages. Expanders help to stretch the skin/tissue after mastectomy in order to prepare the surgical site for the breast implant.
  • Flap/autologous reconstruction
    • Pedicled flap- tissue and attached blood vessels are moved together through the body to the breast area.
    • Free flaps- tissue is cut free from its blood supply. It must be attached to new blood vessels in the breast area, using a technique called microsurgery and may involve tissue from various areas in the body.
  • Nipple/areola reconstruction
    • After the chest heals from reconstruction surgery and the position of the breast mound on the chest wall has had time to stabilize, a surgeon can reconstruct the nipple and areola.

Systemic Therapy

Chemotherapy may be given as neoadjuvant or adjuvant treatment. Treatment may be determined based on stage, grade, lymph node involvement, age and overall health, certain biomarkers, molecular/prognostic testing results. There are many types of chemotherapy agents used to treat breast cancer and these can be delivered prior to or after surgery.

  • Neoadjuvant- treatment delivered prior to surgery with the goal of shrinking the tumor. May include chemo, endocrine therapy, or targeted therapies.
  • Adjuvant- Treatment delivered after surgery targeting potential remaining cancer cells with the goal of reducing the chance of breast cancer recurrence.

Antihormone Therapy/Endocrine Therapy

Other therapies may be included prior to or following surgery to treat breast cancer that is hormone receptor positive. This may be offered for several years.

  • Tamoxifen
    • A drug that blocks estrogen from binding to breast cancer cells. It is effective for lowering the risk of recurrence breast cancer. Tamoxifen can be effective in pre- menopausal and post-menopausal patients; however it is generally preferred in the pre-menopausal setting.
  • Aromatase inhibitors (AIs)
    • AI's decrease the amount of estrogen made in tissues other than the ovaries in post- menopausal people by blocking the aromatase enzyme. These are generally preferred in the postmenopausal setting but can be considered for patients where Tamoxifen is contraindicated.
  • Ovarian suppression, gonadotropin or luteinizing releasing hormone (GnRH or LHRH)
    • Agonist drugs are sometimes used to stop the ovaries from making estrogen, causing temporary menopause. These are typically given in combination with other hormonal therapy.

Targeted Therapy

Treatment that targets the cancer's specific genes/biomarkers/proteins, or the tissue environment that contributes to cancer growth and survival. These treatments are very focused and work differently than chemotherapy. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells. Many types of targeted therapies currently approved for breast cancer.

Radiation Therapy

Radiation therapy is treatment that uses high-energy rays to destroy cancer cells. Radiation is traditionally scheduled daily Monday - Friday for 3 to 6 weeks; there is criteria for shortened schedules in some cases. There are short-term and long-term effects that may be associated with the use of radiation to treat breast cancer.

  • Adjuvant radiation therapy – Radiation therapy given after surgery. Given after partial mastectomy (lumpectomy) or given after a mastectomy if the tumor is larger, has positive lymph nodes, margins are not clear, and if the tumor invaded the skin or chest wall.
  • Neoadjuvant radiation therapy – This approach is uncommon. Given prior to surgery to shrink the tumor.
  • External bean radiation therapy (EBRT)- can be given to the whole breast or partial breast (given directly to the tumor), or via brachytherapy (placing radioactive sources into the tumor.)
  • Intra Operative Radiation Therapy (IORT)- Radiation given at time of surgery in operating room, typically given with partial mastectomy and when patient meets criteria.
  • Intensity-modulated Radiation Therapy (IMRT) - intensity of the radiation is varied to better target the tumor, spread radiation more evenly throughout the breast, and lessens the radiation dose. May decrease damage to nearby organs and side effects.
  • Proton therapy – Type of external-beam radiation therapy that uses protons rather than x-rays.

Resources:

American cancer Society (ACS)

https://www.cancer.org/cancer/types/breast-cancer/treatment/radiation-for-breast- cancer.html

American Society of Clinical Oncology (ASCO)- Cancer. Net https://www.cancer.net/cancer-types/breast-cancer/types-treatment#chemotherapy https://www.cancer.net/cancer-types/breast-cancer/types-treatment#hormone-therapy National Comprehensive Cancer Network (NCCN) https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf https://www.cancer.gov/types/breast/reconstruction-fact-sheet

Survivorship

The phrase “cancer survivor” can mean different things to different people. It is often used as a general term describing someone who has had a diagnosis of cancer. According to the NCI, a cancer survivor is defined as any individual from the time of diagnosis, through the balance of his or her life.

Navigators can play a pivotal role in the delivery of quality survivorship care across the breast care continuum. Survivorship navigation includes helping to mitigate barriers, providing education, facilitating care coordination, and optimizing health and quality of life both during and after treatment.

Main Categories of Survivorship:

  • Physical effects (acute, long-term/late) of breast cancer and treatment
  • Psychosocial impacts
  • Practical concerns/issues
  • Surveillance and screening recommendations
  • Health promotion/risk reduction strategies

Physical Effects

  • Bone health (i.e. bone density, fracture, bone modulating agents)
  • Breast/chest wall changes (i.e. cosmesis, skin changes, scarring, reconstruction complications),
  • Cardiopulmonary toxicity
  • Fatigue
  • Lymphedema
  • Neuropathy
  • Range of motion limitations
  • Menopausal symptoms
  • Weight gain
  • Reproductive/fertility issues
  • Effects of breast cancer treatment on sexual health/function and intimacy
    • Altered body image
    • Pain associated with intercourse
    • Genitourinary symptoms of menopause
    • Changes in sexual desire/arousal

Psychological Impacts

  • Fear of recurrence, anxiety, sadness, depression, anger, isolation, coping skills, family/partner dynamics
  • Influence of culture, spirituality, gender/gender identity, sexual preference, age, healthcare disparities on psychosocial response across the breast care continuum

Practical Concerns

  • Insurance and financial issues, returning to work, disability, food, housing, childcare, work/school

Risk of Recurrence

  • Recommended surveillance (depending upon breast cancer type)

Health Promotion and Risk Reduction Strategies

  • Refer to lifestyle-related modifiable risk factor section

Complementary and Integrative Health Approaches

  • Physical activity
  • Nutrition
  • Rehabilitation (PT/OT)
  • Movement therapy (i.e. yoga, tai chi)
  • Mind body modalities (i.e. mindfulness, meditation)
  • Other modalities - acupuncture, massage

References:

American Cancer Society

Survivorship: During and After Treatment | American Cancer Society Living as a Breast Cancer Survivor | American Cancer Society

American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline | American Cancer Society

Cancer Survivorship Care Tools for Health Care Professionals | American Cancer Society American Society of Clinical Oncology (ASCO)

Breast Cancer: Survivorship | Cancer.Net

ASCO Cancer Treatment and Survivorship Care Plans | Cancer.Net Breastcancer.org

Cancer Survivorship: What Is It? (breastcancer.org) Cancer Care

Post Treatment Survivorship, Information, Resources (cancercare.org) Cure Magazine

Survivorship section provides general information focused on survivors' needs. www.curetoday.com

GW School of Medicine and Health Sciences

National Cancer Survivorship Resource Center Tools | School of Medicine and Health Sciences (gwu.edu)

Living Beyond Breast Cancer (LBBC) www.lbbc.org

National Cancer Institute (NCI)

www.nccih.nih.gov/health/cancer-and-complementary-health-approaches-what-you-need-to- know

National Coalition for Cancer Survivorship

www.canceradvocacy.org

National Comprehensive Cancer Network (NCCN) Guidelines Detail (nccn.org)www.canceradvocacy.org/resources/cancer-survival-toolbox

Breast Cancer Survivorship: The Importance of a Healthy Lifestyle | NCCN Continuing Education Society for Integrative Oncology

Home (integrativeonc.org)

Glossary of Terms

Adjuvant - Treatment given after primary treatments, such as surgery. The goal is to lower the chance of cancer coming back. Even if all visible cancer is removed during surgery, there may still be some remaining in the body that can't be seen.

Autologous - Refers to using a patient's own tissues or cells for treatment.

Benign breast disease – non-cancerous changes that occur in normal breast tissue Bilateral – pertaining to two, or both, sides

Biomarkers – These are measurable substances or indicators in the body that provide information about a disease or condition. In pathology, biomarkers can help diagnose diseases, predict outcomes, and guide treatment decisions. In breast cancer, biomarkers include estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor 2 (HER2).

Biopsy - a procedure to remove a piece of tissue or a sample of cells from your body so that it can be tested in a laboratory

BI-RADS – Breast Imaging and Reporting System - A system developed by the American College of Radiology to describe mammography results and findings. The range is from 0 – 6.

Bone Density - A measure of the amount of minerals (mainly calcium and phosphorus) contained in a certain volume of bone. Bone density testing is done to detect osteoporosis or bone loss and predict fracture risk.

Breast cancer - Cancer that forms in tissues of the breast. The most common type is ductal carcinoma, which begins in the lining of the milk ducts. Another type is lobular carcinoma, which begins in the lobules of the breast. Invasive breast cancer is breast cancer that has spread from where it began in the breast ducts or lobules to surrounding normal tissue. Carcinoma in situ is a non-invasive or pre-invasive breast cancer.

Breast density - An indicator of how much glandular or fibrous connective tissue relative to the fatty tissue is in the breast. Breast density is determined through mammography and is described as one of four categories: A (almost entirely fatty), B (scattered fibroglandular density), C (heterogeneously dense), and D (extremely dense).

Breast MRI – used to examine the inside of the breast using a magnetic field. This test will be performed with and without a contrast medium called gadolinium.

Cardiotoxicity - Cancer treatment-related cardiotoxicity refers to the damage to the heart and/or cardiovascular system (including heart muscle and vessels) that can occur during or after cancer treatment.

Chemotherapy - Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, or infusion, or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy, or biologic therapy.

Contrast-enhanced mammography – used a contrast material injected through a vein to improve the pictures of the inside of the breast

Endocrine - Relating to hormones and their effects on the body.

Endocrine therapy: Treatment that blocks or removes hormones in cases when hormones cause cancers to grow, such as breast cancer. To slow or stop the growth of cancer, synthetic hormones or other drugs may be given to block the body's natural hormones. Also called hormonal therapy, hormone therapy, and hormone treatment.

Grading – grading of cancer cells to determine how much the cancer cells look like normal cells

Hereditary - Pertaining to conditions or diseases that are passed down from parents to their offspring through genetic inheritance.

High Risk - Refers to individuals who have an increased likelihood of developing a specific disease or condition.

Lumpectomy/Breast Conservation Therapy - Procedure that removes the breast cancer along with a small amount of the healthy tissue surrounding it.

Lymphedema - Refers to localized tissue swelling caused by an accumulation of protein-rich fluid (lymph) that's usually drained through the body's lymphatic system. When the normal lymphatic drainage is blocked, lymphedema can occur.

Malignant breast disease – cancerous changes in the breast which can be a lump or calcium deposits that occur as a result of abnormal cell growth

Mammogram – an x-ray picture of the inside of the breast. Two-dimensional (2D) mammography – uses x-rays to take pictures of the breast, usually from two different angles. A computer is used to make the 2D pictures of the breast. Digital breast tomosynthesis (DBT or 3D) – used x-rays to take pictures of the breast from many angles.

Mastectomy (Unilateral vs. Bilateral)

  • Modified-radical- all of the breast tissue, the skin of the breast, the nipple, and the areola. Includes axillary node dissection of generally less than 10 lymph nodes.
  • Nipple-sparing- all of the breast tissue is removed, but the nipple, areola, and the skin of the breast is left intact.
  • Skin-sparing- removal of all the breast tissue, the nipple, and in some cases the areola, but most of the skin over the breast is left intact.

Menopause – a point in time that marks the end of the menstrual cycle. It is diagnosed 12 months after the last cycle.

Molecular testing - Analyzing genetic or molecular changes in tissues to guide treatment decisions.

MRI – Magnetic Resonance Imaging is an imaging technique using magnets, radio waves and a computer that produces images of so0ft tissues in the body, like muscles and organs. Unlike other imaging tests, this type of scan does not use radiation. This test will be performed with and without a contrast medium called gadolinium.

Multi-Disciplinary – This means combining or involving more than one discipline or field of study. In health care, a multidisciplinary approach involves physicians of different disciples, nurses, clinical researchers, navigators and imaging technologists.

Neoadjuvant - Treatment administered before the main therapy (e.g., neoadjuvant chemotherapy before surgery).

Oncology - A branch of medicine that specializes in the diagnosis and treatment of cancer. It includes medical oncology (the use of chemotherapy, hormone therapy, and other drugs to treat cancer), radiation oncology (the use of radiation therapy to treat cancer), and surgical oncology (the use of surgery and other procedures to treat cancer).

Pathology – the study of organs, tissues and bodily fluids for the diagnosis of disease.

Peripheral Neuropathy - Refers to damage of the peripheral nervous system that sends signals between the central nervous system (the brain and spinal cord) and all other parts of the body. Symptoms include pain, numbness, tingling, swelling or muscle weakness that can be caused by cancer and cancer treatment.

Prognosis - The likely course and outcome of a disease.

Prognostic testing - Assessing factors that predict disease outcomes. Prophylactic - Preventive measures taken to reduce the risk of disease.

Radiation therapy - The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy or brachytherapy).

Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body.

Reconstruction - Many women who have a mastectomy have the option of having the shape of the removed breast rebuilt. This process is called reconstruction, and it can be complete or partial. Breast reconstruction recreates the breast, it doesn't restore sensation to the breast or nipple. In some cases, a combination of different approaches is utilized.

Risk Factor - Something that increases the chance of developing a disease. Some examples of risk factors for cancer are age, family health history, certain genetic changes, human papillomavirus (HPV), obesity, exposure to carcinogens, alcohol, and tobacco products.

Staging – determines how much cancer is in the body and if it has spread

Stereotactic – This means involving, being, utilizing, or used in a surgical technique for precisely directing the tip of a delicate instrument (such as a needle) in three planes using coordinates provided by medical imaging in order to reach a specific locus in the body.

Surveillance - Regular monitoring of patients for screening or after treatment to detect any recurrence or progression of disease.

Targeted therapy - A type of treatment that uses drugs or other substances to target specific molecules that cancer cells need to survive and spread. Targeted therapies work in different ways to treat cancer: some stop cancer cells from growing by interrupting signals that cause them to grow and divide, stopping signals that help form blood vessels, delivering cell-killing

substances to cancer cells, or starving cancer cells of hormones they need to grow. Other targeted therapies help the immune system kill cancer cells or directly cause cancer cell death. Most targeted therapies are either small-molecule drugs or monoclonal antibodies.

Ultrasound – uses sound waves to make images of the inside of the breast. Unilateral – pertaining to one side