Fighting cancer can be complicated. Whether you are just beginning your journey to fight estrogen receptor positive (ER+) breast cancer or are approaching your 5 year anniversary and are wondering what’s next, you have options to consider and discuss with your healthcare team.
To help supplement the conversations with your physician, below, we have included some helpful information and links from trusted sources about each stage in your journey to fight early stage ER+ breast cancer.
Where are you in your journey to fight early stage ER+ breast cancer?
There are several treatment phases that follow your initial diagnosis of early-stage ER+ breast cancer. In each unique phase, you will discuss potential options with your physician for a treatment plan based on your individual disease characteristics.
Initial diagnostic testing of your biopsy, known as a breast tissue sample, will help to characterize your type of breast cancer and other diagnostic tools have the potential to provide additional information for the immediate, medium and long-term phases of your treatment timeline.
The diagnosis phase of cancer can be overwhelming. Information about your cancer and the stage of disease comes in waves while you wait for the next round of test results and appointments with your healthcare team. When you receive updates on your condition, it can be difficult to stay focused and understand what all those medical terms mean for you.
There are resources that can help you understand what your particular diagnosis means for you. One resource from the National Cancer Institute (NCI), called What You Need to Know About: Breast Cancer, provides a comprehensive guide and a full glossary of terms to understand some of the medical terms you may hear upon being diagnosed with early-stage ER+ breast cancer.
To help prepare for conversations about your diagnosis and the next steps with your healthcare team, the U.S. Department of Health and Human Services developed the factsheet, Early-Stage Breast Cancer Treatment: A Patient and Doctor Dialogue.
Your healthcare team will look at your medical history, use imaging tools such as a magnetic resonance imaging (MRI), and take a sample of the tumor (called a biopsy) to determine your particular diagnosis. The American Cancer Society’s web page, How is breast cancer diagnosed?, can help explain these diagnostic tests.
The results from your diagnostic tests will characterize your type of breast cancer and the stage of the disease, and help to guide your healthcare team to a treatment regimen as well as a plan for longer term maintenance to help prevent your cancer from recurring. Breast Cancer Treatment from the NCI is an excellent guide with clear graphics that help explain the process and where it fits on the cancer timeline. Test results include:
- Tumor Staging with TNM (NCI)
- Tumor Grading (NCI)
- Hormone Receptor Status such as estrogen-receptor positive (Breastcancer.org)
- Human epidermal growth factor receptor 2 (HER2) Status (Breastcancer.org)
According to the NCI, current statistics of 5-year relative* survival rates of all breast cancers based on the type and level of initial cancer diagnosis are as follows:
- Stage 0 and 1 — close to 100%
- Stage II — 93%
- Stage III — 72%
- Stage IV (where the cancer has spread to other parts of the body; known as metastasis) — approximately 22%
It is important to note that these relative survival rates do not factor in all of the variables that make each breast cancer diagnosis unique. Other factors, such as age and breast cancer subtypes based on hormone receptor status such as ER+, also play a role in treatment options, survival rates and quality of life.
It is also important to understand that these statistics are a current snapshot in time and future innovations in treating breast cancer will likely continue to increase survival rates for all stages of breast cancer.
* Relative survival is the measurement of survival in cancer patients compared to the general cancer-free population
While your ER status plays a very important role in treating this disease, the initial treatment plan is typically to remove the tumor itself.
Depending on your diagnosis, initial treatment options to treat your particular type of breast may include:
- Surgery – Used to remove the tumor and possibly surrounding tissue and lymph notes that may also be affected by the disease. Depending on your type of breast cancer and discussions with your healthcare team, surgery could be breast-conserving or a complete mastectomy. There are resources that can help you understand how to prepare, what to expect during, and how you will feel after breast cancer surgery.
- Radiation Therapy – Used externally, such as whole-breast, or internally to disrupt tumor growth with high-energy radiation with or without surgery. There are new methods of therapy, including intraoperative radiation therapy (IORT) as a one-time application of radiation therapy during surgery that does not require post-surgical treatments.
- Chemotherapy – Can be used before surgery (neoadjuvant) to reduce the size of a tumor to make it easier to remove, or after surgery (adjuvant) to help reduce the chance of cancer remaining after surgery by targeting residual cancer cells that were not removed by surgery.
- Anti-Estrogen Therapy – Used to block estrogen hormone activity to inhibit tumor growth during initial treatment and as a longer term intervention to reduce the likelihood of cancer recurrence. Some anti-estrogen drugs block the ability of estrogen to bind to the estrogen receptor in tumor cells, whereas other drugs inhibit the production of estrogen in your body.
- Other options may include targeted therapies, immunotherapies, and other interventions that have been recently approved for use or are currently in clinical trials. You can find more information about clinical trials at BreastCancerTrials.org.
The NCI has developed an overview of treatment options in Breast Cancer Treatment.
There are also other diagnostic tests that can help you and your physician decide on some of these treatment options, such as Oncotype DX, which helps determine if you are likely to benefit from adjuvant chemotherapy.
Undergoing Five Years of Anti-Estrogen Therapy
After your initial surgery, you and your healthcare team will decide on options during the next phase of treating your disease.
There are two main types of anti-estrogen therapy (also known as hormonal therapy):
- Selective Estrogen Receptor Modulators (SERMs) – SERMs block the connection point between estrogen and a tumor cell (the receptor). SERMs physically block this connection so tumor cells are not stimulated to grow and divide by estrogen. SERMs can be used in pre, peri, and postmenopausal women. SERMs include tamoxifen (Novaldex), raloxifene (Evista).
- Aromatase Inhibitors (AIs) — AIs reduce the amount of estrogen that can feed a tumor cell by blocking the enzyme aromatase used in the body’s production of estrogen. AIs are used primarily in postmenopausal women. AIs include anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara).
The use of anti-estrogen therapy, such as tamoxifen, for up to five years after your initial treatment for cancer has demonstrated a 40-50% reduction in cancer coming back for postmenopausal women and a 30-50% reduction in premenopausal women. The therapy also reduced the risk of new cancer developing in the other breast by about 50%.
There are resources from Breastcancer.org to help, such as Staying on Track with Treatment and their forum Hormonal Therapy — Before, During and After that can connect you with other cancer survivors.
The anti-estrogen treatment regimens that your physician recommends to treat your ER+ breast cancer may depend on your age, other medical conditions, and tolerance of potential side effects while taking these medications. Owning your diagnosis is being honest with yourself and your healthcare team about what you are experiencing.
Use of Anti-Estrogen Therapy Beyond Five Years
Many physicians now recommend the use of anti-estrogen therapy for up to 10 years. Your doctor may recommend continuing tamoxifen for an additional five years or switching to an AI from years 5-10. 10 Years of Hormones for Breast Cancer, ASCO Says from MedPage Today discusses the new guideline.
Although taking anti-estrogen therapy for an additional five years may benefit some women, it only benefits approximately 3-5% of patients overall.* In addition, in your first 5 years of anti-estrogen therapy, you may have experienced one (or several) of the potential side effects associated with anti-estrogen therapy, including:
- Risk of blood clots, especially in the lungs and legs
- Endometrial and uterine cancers
- Bone loss in premenopausal women
- Mood swings, depression, and loss of libido
- Risk of heart attack, angina, heart failure, and hypercholesterolemia
- Bone loss
- Joint pain
- Mood swings and depression
Biotheranostics created a helpful brochure that further discusses the risks and benefits of anti-estrogen therapy for ER+ breast cancer and options that can help you and your healthcare team decide on your course of therapy.
*More information and references regarding the 3-5% benefit can be found in the As a Breast Cancer Survivor, Bring Greater Certainty to Your Journey brochure from Biotheranostics mentioned above.
If you are nearing the end of your first five years of anti-estrogen therapy for early stage ER+ breast cancer and deciding with your healthcare team your options for the next five years, talk to your doctor about any side effects that you may be experiencing and weigh the risks vs. benefits of continuing therapy.
To help you and your doctor with the decision to extend or end anti-estrogen therapy after 5 years, a test called Breast Cancer Index (BCI) may be helpful. Breast Cancer Index assesses your risk of the cancer returning after five years, as well as your likelihood to benefit from anti-estrogen therapy for an additional five years.
Understanding these two pieces of information can help you and your healthcare team confidently decide the best treatment path for you. For more information regarding Breast Cancer Index, including intended use and limitations, please visit the Answers Beyond 5 website.
We hope this post has helped you to understand the different stages of diagnosing and treating ER+ breast cancer. Understanding your diagnosis, what each disease stage means for you, and your options are all important factors as you participate in treatment decisions with your healthcare team.
Stay tuned for our next topic in the coming weeks: Why Does ER+ Breast Cancer Have a Chance of Coming Back?