Many breast cancer patients begin their treatment or surgery to remove the tumor and adjacent lymph nodes. If these treatments were not successful, then Chemotherapy and HER2 inhibitors are used. In-Addition to the above procedures, external beam radiation therapy, or intensity-modulated radiation therapy can be used. Some breast cancers overexpress receptors for the hormones estrogen and progesterone. These receptors can tell the cancer signal to grow and divide. We are now using various endocrine therapies designed to slow cancer growth. Antiestrogen drugs are treating both premenopausal and postmenopausal women.

CDK 4 and CDK 6 inhibitors to stop cancer cells from reproducing are now the standards of care. We also treat bony metastasis to help keep the osteoclast under control and to strengthen the bones and reduce the risk of fractures. In the United States, unfortunately, breast cancer remains the most frequent cancer in women and the second most frequent cause of cancer death.

Breast cancer is a heterogeneous disease with many different biologic features. Each feature has a different clinical response to therapy. It is essential to measure various molecular and genomic factors because all patients are different. In addition to defining biologic tumor subsets, currently, gene expression profiling is performed to stratify tumors as having a reasonable risk or bad risk. Several of these are now available commercially. We can now measure genomic "biomarkers," which are pathways that lead to tumor aggressiveness and growth, which can be blocked by both pharmaceutical and natural products.

Chemosensitivity can predict which chemotherapy is most effective. In the landmark study, the MD Anderson Cancer Center was the first to report that a multi Gene analysis of fine-needle aspiration specimens predicts response to different chemotherapies. National organizations such as the Society of clinical oncology, the College of American pathologists, and the National comprehensive cancer network have ongoing efforts to interpret data through these multi Gene biomarkers. Testing for natural substances will show which natural elements can kill your cancer and impede metastasis. Evaluating for chemotherapy resistance is also essential. Also, an evaluation of each patient's immune system is of critical importance.

Most breast cancer's are intimately linked with exposure to estrogen and alterations in the estrogen receptor signaling pathway. There are regulatory proteins in the premotor region of the estrogen response of genes. These regulatory proteins direct the transcription of numerous growth-promoting genes, including progesterone. The level of estrogen expression is a highly effective predictor for response to antiestrogens recommended for all estrogen expressing tumors. We now know there is a cross-talk relationship in that estrogen can illuminate insulin-like growth factors as well as other growth factors. The use of an aromatase inhibitor is now the standard of care. The problem is that it becomes resistant to this, and in this case, the mTOR and other inhibitors are useful.

These receptor pathways, mainly Tyrosinase kinase receptors, play an essential role in the initiation of cancer. The HER2 is a member of the human epidermal growth factor receptors. The amplification of this gene or protein overexpression is found to 20% of invasive breast cancers and is associated with accelerated cell growth and proliferation and poor outcomes. There are a multitude of other pathways that can now be measured and blocked.

Angiogenesis or the formation of new blood vessels around the cancer is a tightly regulated process that has shown to be an essential part of tumor growth and spread. The vascular endothelial growth factor regulates endothelial cell growth and new blood vessel formation. These VEGF cause new blood vessels that feed cancer to grow.

We now know multiple molecular subtypes and clinical presentations exist that are ranging from aggressive to indolent. Recent molecular analysis has shown a light on the heterogenicity by mapping patterns that correspond to clinical phenotypes. We are now able to look at breast cancer susceptibility genes, gene expression, somatic mutations, and epigenetic modifications.

We are now able to measure "liquid biopsies" circulating cancer tumor cells, which are tumor DNA fragments circulating in the blood. These liquid biopsies involve the analysis of circulating tumor cells and help predict metastasis or determine whether cancer cells will return after treatment.

By evaluating the genetic mutations of each cancer, I am now able to personalize all the treatments for the patient. We now know that cancer is a disease of the genome caused by the acquisition of a cell of mutations in specific essential cancer genes. These mutations change pathways involved in regulating cell growth and how the cancer cell interacts with the environment. The Nature publication of February 5, 2020, reported that in the integrative analysis of 2658 whole cancer genomes, there are matching healthy tissues across 38 tumor types.

This analysis is called the Pan-cancer analysis of the entire genomes Consortium. This new molecular testing can promptly evaluate genetic cancer markers that are up-regulated. We can now block these pathways to halt the progression of cancer.

Metronomic chemotherapy is utilized based on the low testing dose. Low-dose chemotherapy does not produce chemoresistance and does not adversely affect the patient's immune system. There are no toxic side effects compared to the conventional method of the maximum tolerated dose chemotherapy due to the use of natural substances, which are synergistic and directly kill cancer cells. New studies show that they decrease chemotherapy resistance and will improve the patient's immune status. All targeted therapies are to block the "biomarkers, "which are driving cancer to grow.

The use of checkpoint inhibitors along with chemotherapy and radiation are now becoming the standard of care.

The new era of immunotherapy with checkpoint inhibitors, especially for triple-negative breast cancer, is now being used. In 2019 the FDA approved the immune checkpoint inhibitor Tecentriq in combination with Abraxane for patients with inoperable locally advanced or metastatic triple-negative breast cancer. The new treatment, called "Keytruda," is approved to treat metastatic cancer or inoperable cancer that has an elevated tumor mutational burden or microsatellite instability. These checkpoint inhibitors are dependent on the patient's underlying immune system, which is of critical importance, and optimization of the patient's immune function actively pursued.

Personalized vaccines for your stage IV breast cancer are currently treatable. They are created in the laboratory from your cancer cells in your blood. They are injected back into your bloodstream to attack cancer and can be performed several times a year. Optimization of the patient's underlying immune function is of critical importance as with the checkpoint inhibitors and is combined with these checkpoint inhibitors.