Keeping on Top of Your Condition
brest cancer, breast canser
The Breasts
Each breast has 15 to 20 sections called lobes.
Within each lobe are many smaller lobules.
Lobules end in dozens of tiny bulbs that can produce milk. The lobes,
lobules, and bulbs are all linked by thin tubes called ducts.
These ducts lead to the nipple in the center of a dark area of skin called
the areola.
Fat surrounds the lobules and ducts. There are no muscles in the breast,
but muscles lie under each breast and cover the ribs.
Each breast also contains blood vessels and lymph vessels. The lymph
vessels carry colorless fluid called lymph,
and lead to small bean-shaped organs called lymph
nodes. Clusters of lymph nodes are found near the breast in the axilla
(under the arm), above the collarbone, and in the chest. Lymph nodes are
also found in many other parts of the body.
This
diagram shows the breast.
|
Understanding the Cancer Process
Cancer is a group of many related diseases that begin in cells, the
body's basic unit of life. To understand cancer, it is helpful to know
what happens when normal cells become cancerous.
The body is made up of many types of cells. Normally, cells grow and
divide to produce more cells only when the body needs them. This orderly
process helps keep the body healthy. Sometimes, however, cells keep
dividing when new cells are not needed. These extra cells form a mass of
tissue,
called a growth or tumor.
Tumors can be benign
or malignant.
-
Benign tumors are not cancer. They can usually be removed, and
in most cases, they do not come back. Cells from benign tumors do not
spread to other parts of the body. Most important, benign breast tumors
are not a threat to life.
-
Malignant tumors are cancer. Cells in these tumors are
abnormal. They divide without control or order, and they can invade and
damage nearby tissues and organs. Also, cancer cells can break away from
a malignant tumor and enter the bloodstream or the lymphatic
system. That is how cancer spreads from the original (primary)
cancer site to form new tumors in other organs. The spread of cancer is
called metastasis.
When cancer arises in breast tissue and spreads (metastasizes) outside
the breast, cancer cells are often found in the lymph nodes under the arm
(axillary
lymph nodes). If the cancer has reached these nodes, it means that cancer
cells may have spread to other parts of the body -- other lymph nodes and
other organs, such as the bones, liver, or lungs. When cancer spreads from
its original location to another part of the body, the new tumor has the
same kind of abnormal cells and the same name as the primary tumor. For
example, if breast cancer spreads to the brain, the cancer cells in the
brain are actually breast cancer cells. The disease is called metastatic
breast cancer. (It is not brain cancer.) Doctors sometimes call this
"distant" disease.
Breast Cancer: Who's at Risk?
The exact causes of breast cancer are not known. However, studies show
that the risk of breast cancer increases as a woman gets older. This
disease is very uncommon in women under the age of 35. Most breast cancers
occur in women over the age of 50, and the risk is especially high for
women over age 60. Also, breast cancer occurs more often in white women
than African American or Asian women.
Research has shown that the following conditions increase a woman's
chances of getting breast cancer:
-
Personal history of breast cancer. Women who have had breast
cancer face an increased risk of getting breast cancer in their other
breast.
-
Family history. A woman's risk for developing breast cancer
increases if her mother, sister, or daughter had breast cancer,
especially at a young age.
-
Certain breast changes. Having a diagnosis of atypical
hyperplasia or lobular
carcinoma in situ (LCIS) may increase a woman's risk for
developing cancer.
-
Genetic alterations. Changes in certain genes
(BRCA1, BRCA2, and others) increase the risk of breast cancer. In
families in which many women have had the disease, gene testing can
sometimes show the presence of specific genetic changes that increase
the risk of breast cancer. Doctors may suggest ways to try to delay or
prevent breast cancer, or to improve the detection of this disease in
women who have these changes in their genes.
Other factors associated with an increased risk for breast cancer
include:
-
Estrogen. Evidence suggests that the longer a woman is exposed
to estrogen
(estrogen made by the body, taken as a drug, or delivered by a patch),
the more likely she is to develop breast cancer. For example, the risk
is somewhat increased among women who began menstruation
at an early age (before age 12), experienced menopause
late (after age 55), never had children, or took hormone
replacement therapy for long periods of time. Each of these
factors increases the amount of time a woman's body is exposed to
estrogen.
DES (diethylstilbestrol) is a synthetic form of estrogen that was
used between the early 1940s and 1971. Women who took DES during
pregnancy to prevent certain complications are at a slightly higher risk
for breast cancer. This does not appear to be the case for their
daughters who were exposed to DES before birth. However, more studies
are needed as these daughters enter the age range when breast cancer is
more common.
-
Late childbearing. Women who have their first child late
(after about age 30) have a greater chance of developing breast cancer
than women who have a child at a younger age.
-
Breast density. Breasts that have a high proportion of lobular
and ductal tissue appear dense on mammograms.
Breast cancers nearly always develop in lobular or ductal tissue (not
fatty tissue). That's why cancer is more likely to occur in breasts that
have a lot of lobular and ductal tissue (that is, dense tissue) than in
breasts with a lot of fatty tissue. In addition, when breasts are dense,
it is more difficult for doctors to see abnormal areas on a
mammogram.
-
Radiation therapy. Women whose breasts were exposed to
radiation during radiation therapy before age 30, especially those who
were treated with radiation for Hodgkin's disease, are at an increased
risk for developing breast cancer. Studies show that the younger a woman
was when she received her treatment, the higher her risk for developing
breast cancer later in life.
-
Alcohol. Some studies suggest a slightly higher risk of breast
cancer among women who drink alcohol.
Most women who develop breast cancer have none of the risk
factors listed above, other than the risk that comes with growing
older. Scientists are conducting research into the causes of breast cancer
to learn more about risk factors and ways of preventing this disease.
Detecting Breast Cancer
Women should talk with their doctor about factors that can increase
their chance of getting breast cancer. Women of any age who are at higher
risk for developing this disease should ask their doctor when to start and
how often to be checked for breast cancer. Breast cancer screening has
been shown to decrease the risk of dying from breast cancer.
Women can take an active part in the early detection of breast cancer
by having regularly scheduled screening
mammograms and clinical breast exams (breast exams performed by health
professionals). Some women also perform breast self-exams.
A screening mammogram is the best tool available for finding breast
cancer early, before breast cancer symptoms appear. A mammogram is a special
kind of x-ray. Screening mammograms are used to look for breast changes in women
who have no signs of breast cancer.
Mammograms can often detect a breast lump before it can be felt. Also,
a mammogram can show small deposits of calcium in the breast. Although
most calcium deposits are benign, a cluster of very tiny specks of calcium
(called microcalcifications)
may be an early sign of cancer.
If an area of the breast looks suspicious on the screening mammogram,
additional (diagnostic) mammograms may be needed. Depending on the
results, the doctor may advise the woman to have a biopsy.
Although mammograms are the best way to find breast abnormalities
early, they do have some limitations. A mammogram may miss some cancers
that are present (false negative) or may find things that turn out not to
be cancer (false positive). And detecting a tumor early does not guarantee
that a woman's life will be saved. Some fast-growing breast cancers may
already have spread to other parts of the body before being detected.
Nevertheless, studies show that mammograms reduce the risk of dying
from breast cancer. Most doctors recommend that women in their forties and
older have mammograms regularly, every 1 to 2 years.
Some women perform monthly breast self-exams to check for any changes
in their breasts. When doing a breast self-exam, it's important to
remember that each woman's breasts are different, and that changes can
occur because of aging, the menstrual
cycle, pregnancy, menopause, or taking birth control pills
or other hormones.
It is normal for the breasts to feel a little lumpy and uneven. Also, it
is common for a woman's breasts to be swollen and tender right before or
during her menstrual period. Women in their forties and older should be
aware that a monthly breast self-exam is not a substitute for regularly
scheduled screening mammograms and clinical breast exams by a health
professional.
Breast Cancer Symptoms
Early breast cancer usually does not cause pain. In fact, when
breast cancer first develops, there may be no symptoms of breast cancer at
all. But as the cancer grows, it can cause changes that women should watch for:
-
A lump or thickening in or near the breast or in the underarm
area;
-
A change in the size or shape of the breast;
-
Nipple
discharge or tenderness, or the nipple pulled back (inverted)
into the breast;
-
Ridges or pitting of the breast (the skin looks like the skin of an
orange); or
-
A change in the way the skin of the breast, areola, or nipple looks
or feels (for example, warm, swollen, red, or scaly).
A woman should see her doctor about any symptoms like these. Most
often, they are not cancer, but it's important to check with the doctor so
that any problems can be diagnosed and treated as early as
possible.
Diagnosing Breast Cancer
To help find the cause of any sign or symptom, a doctor does a careful
physical exam and asks about personal and family medical history. In
addition, the doctor may do one or more breast exams:
-
Clinical breast exam. The doctor can tell a lot about a lump
by carefully feeling it and the tissue around it. Benign lumps often
feel different from cancerous ones. The doctor can examine the size and
texture of the lump and determine whether the lump moves easily.
-
Mammography.
X-rays of the breast can give the doctor important information about a
breast lump.
-
Ultrasonography.
Using high-frequency sound waves, ultrasonography can often show whether
a lump is a fluid-filled cyst
(not cancer) or a solid mass (which may or may not be cancer). This exam
may be used along with mammography.
Based on these exams, the doctor may decide that no further tests are
needed and no treatment is necessary. In such cases, the doctor may need
to check the woman regularly to watch for any changes.
Biopsy
Often, fluid or tissue must be removed from the breast so the doctor
can make a diagnosis. A woman's doctor may refer her for further
evaluation to a surgeon or other health care professional who has
experience with breast diseases. These doctors may perform:
-
Fine-needle
aspiration. A thin needle is used to remove fluid and/or
cells from a breast lump. If the fluid is clear, it may not need to be
checked by a lab.
-
Needle biopsy.
Using special techniques, tissue can be removed with a needle from an
area that looks suspicious on a mammogram but cannot be felt. Tissue
removed in a needle biopsy goes to a lab to be checked by a pathologist
for cancer cells.
-
Surgical biopsy. In an incisional biopsy, the surgeon cuts out
a sample of a lump or suspicious area. In an excisional biopsy, the
surgeon removes all of a lump or suspicious area and an area of healthy
tissue around the edges. A pathologist then examines the tissue under a
microscope to check for cancer cells.
|
When a woman needs a biopsy, these are some questions she may
want to ask her doctor:
-
What type of biopsy will I have? Why?
-
How long will it take? Will I be awake? Will it hurt?
-
How soon will I know the results?
-
If I do have cancer, who will talk with me about breast cancer treatments?
When? |
When Cancer Is Found
The most common type of breast cancer is ductal carcinoma.
It begins in the lining of the ducts. Another type, called lobular
carcinoma, arises in the lobules. When cancer is found, the pathologist
can tell what kind of cancer it is (whether it began in a duct or a
lobule) and whether it is
(has invaded nearby tissues in the breast).
Special lab tests of the tissue help the doctor learn more about the
cancer. For example, hormone
receptor tests (estrogen
and progesterone
receptor tests) can help determine whether hormones help the cancer to
grow. If test results show that hormones do affect the cancer's growth (a
positive test result), the cancer is likely to respond to hormonal
therapy. This therapy deprives the cancer cells of estrogen.
Other tests are sometimes done to help the doctor predict whether the
cancer is likely to progress. For example, the doctor may order x-rays and
lab tests. Sometimes a sample of breast tissue is checked for a gene (the
human epidermal growth factor receptor-2 or HER-2 gene) that is associated
with a higher risk that the breast cancer will come back. The doctor may
also order special exams of the bones, liver, or lungs because breast
cancer may spread to these areas.
|
If the diagnosis is breast cancer, a woman may want to ask these
questions:
-
What kind of breast cancer do I have?
-
What did the hormone receptor test show? What other lab tests
were done on the tumor tissue, and what did they show?
-
How will you determine whether the disease has spread?
-
How will this information help in deciding what type of
breast cancer treatments or further tests will be best for
me? |
Planning Breast Cancer Treatments
Many women with breast cancer want to take an active part in decisions
about their medical care. They want to learn all they can about their
disease and their choices of breast cancer treatments. However, the shock and stress
that people often feel after a diagnosis of cancer can make it hard for them to
think of everything they want to ask the doctor. Often it is helpful to
prepare a list of questions in advance. To help remember what the doctor
says, patients may take notes or ask whether they may use a tape recorder.
Some people also want to have a family member or friend with them when
they talk to the doctor -- to take part in the discussion, to take notes,
or just to listen.
The patient's doctor may refer her to doctors who specialize in
breast cancer treatments, or she may ask for a referral. Breast cancer treatments
generally begin within a few weeks after the diagnosis. There will be time for
the woman to talk with the doctor about her treatment choices, to get a second
opinion, and to prepare herself and her loved ones.
Second Opinion
Before starting breast cancer treatments, the patient might want a second opinion
about the diagnosis and the treatment plan. Some insurance companies
require a second opinion; others may cover a second opinion if the woman
requests it. It may take a little while to arrange to see another doctor.
In most cases, a brief delay (up to 3 or 4 weeks) between biopsy and
treatment does not make breast cancer treatments any less effective. There are
a number of ways to find a doctor for a second opinion:
-
The patient's doctor may refer her to one or more specialists.
Specialists who treat women with breast cancer include surgeons, medical
oncologists, plastic
surgeons, and radiation
oncologists. At cancer centers or special centers for breast
diseases, these doctors often work together as a team.
-
The Cancer Information Service, at 1-800-4-CANCER, can tell callers
about treatment facilities, including cancer centers and other
NCI-supported programs, in their area.
-
Patients can get the names of specialists from their local medical
society, a nearby hospital, or a medical school.
-
The Official ABMS Directory of Board Certified Medical
Specialists lists doctors' names along with their speciality and
their educational background. This resource, produced by the American
Board of Medical Specialties (ABMS), is available in most public
libraries.
Breast Cancer Treatment Methods
Breast cancer may be treated with local therapy
or systemic
therapy. Some patients have both kinds of breast cancer treatment.
Local therapy is used to remove or destroy breast cancer in a specific
area. Surgery
and radiation
therapy are local treatments. They are used to treat the disease
in the breast. When breast cancer has spread to other parts of the body,
local therapy may be used to control cancer in those specific areas, such
as in the lung or bone.
Systemic treatments are used to destroy or control cancer throughout
the body. Chemotherapy,
hormonal
therapy, and biological
therapy are systemic treatments. Some patients have systemic
therapy to shrink the tumor before local therapy. Others have systemic
therapy to prevent the cancer from coming back, or to treat cancer that
has spread.
Surgery is the most common of treatments for breast cancer, and
there are several types of surgery. The doctor can explain each type,
discuss and compare their benefits and risks, and describe how each will
affect the patient's appearance.
-
An operation to remove the cancer but not the breast is called
breast-sparing surgery or breast-conserving
surgery. Lumpectomy
and segmental
mastectomy (also called partial mastectomy) are types of
breast-sparing surgery. After breast-sparing surgery, most women receive
radiation therapy to destroy cancer cells that remain in the area.
-
An operation to remove the breast (or as much of the breast as
possible) is a mastectomy.
Breast
reconstruction is often an option at the same time as the
mastectomy, or later on.
-
In most cases, the surgeon also removes lymph nodes under the arm to
help determine whether cancer cells have entered the lymphatic system.
This is called an axillary
lymph node dissection.
In lumpectomy, the surgeon removes the breast cancer and some normal
tissue around it. (Sometimes an excisional biopsy serves as a lumpectomy.)
Often, some of the lymph nodes under the arm are removed.
In segmental mastectomy, the surgeon removes the cancer and a larger
area of normal breast tissue around it. Occasionally, some of the lining
over the chest muscles below the tumor is removed as well. Some lymph
nodes under the arm may also be removed.
In total mastectomy (simple), the surgeon removes the whole breast. Some
lymph nodes under the arm may also be removed.
In modified
radical mastectomy, the surgeon removes the whole breast, most of
the lymph nodes under the arm, and, often, the lining over the chest
muscles. The smaller of the two chest muscles also may be taken out to
help in removing the lymph nodes.
In radical
mastectomy (also called Halsted radical mastectomy), the surgeon
removes the breast, both chest muscles, all of the lymph nodes under the
arm, and some additional fat and skin. For many years, this operation was
considered the standard one for women with breast cancer, but it is almost
never used today. In rare cases, radical mastectomy may be suggested if
the cancer has spread to the chest muscles.
|
Here are some questions a woman may want to ask her doctor before
having surgery:
-
What kinds of surgery can I consider? Is breast-sparing surgery
an option for me? Which operation do you recommend for me? What
are the risks of surgery?
-
Should I store some of my own blood in case I need a
transfusion?
-
Do I need my lymph nodes removed? How many? Why? What special
precautions will I need to take if lymph nodes are removed?
-
How will I feel after the operation?
-
Will I need to learn how to do special things to take care of
myself or my incision
when I get home?
-
Where will the scars be? What will they look like?
-
If I decide to have plastic surgery to rebuild my breast, how
and when can that be done? Can you suggest a plastic surgeon for
me to contact?
-
Will I have to do special exercises?
-
When can I get back to my normal activities?
-
Is there someone I can talk with who has had the same breast
cancer treatments I'll be having? |
Breast reconstruction (surgery to rebuild the shape of a breast) is
often an option after mastectomy. Women considering reconstruction should
discuss this with a plastic surgeon before having a mastectomy.
Radiation therapy (also called radiotherapy) is the use of
high-energy rays to kill cancer cells. The radiation may be directed at
the breast by a machine (external radiation). The radiation can also come
from radioactive material placed in thin plastic tubes that are placed
directly in the breast (implant radiation). Some women have both kinds of
radiation therapy.
For external radiation therapy, the patient goes to the hospital or
clinic, generally 5 days a week for several weeks. For implant radiation,
a patient stays in the hospital. The implants remain in place for several
days. They are removed before the woman goes home.
Sometimes, depending on the size of the tumor and other factors,
radiation therapy is used after surgery, especially after breast-sparing
surgery. The radiation destroys any breast cancer cells that may remain in
the area.
Before surgery, radiation therapy, alone or with chemotherapy or
hormonal therapy, is sometimes used to destroy cancer cells and shrink
tumors. This approach is most often used in cases in which the breast
tumor is large or not easily removed by surgery.
|
Before having radiation therapy, a patient may want to ask her
doctor these questions:
-
Why do I need this treatment?
-
What are the risks and side effects of this treatment?
-
Are there any long-term effects?
-
When will the breast cancer treatments begin? When will they end?
-
How will I feel during therapy?
-
What can I do to take care of myself during therapy?
-
Can I continue my normal activities?
-
How will my breast look afterward?
-
What are the chances that the tumor will come back in my
breast? |
Chemotherapy is the use of drugs to kill cancer cells.
Chemotherapy for breast cancer is usually a combination of drugs. The
drugs may be given in a pill or by injection. Either way, the drugs enter
the bloodstream and travel throughout the body.
Most patients have chemotherapy in an outpatient part of the hospital,
at the doctor's office, or at home. Depending on which drugs are given and
her general health, however, a woman may need to stay in the hospital
during her treatment.
Hormonal therapy keeps cancer cells from getting the hormones
they need to grow. This breast cancer treatment may include the use of drugs that change
the way hormones work, or surgery to remove the ovaries,
which make female hormones. Like chemotherapy, hormonal therapy can affect
cancer cells throughout the body.
Biological therapy is a treatment designed to enhance the body's
natural defenses against cancer. For example, Herceptin® (trastuzumab) is
a monoclonal
antibody that targets breast cancer cells that have too much of a
protein known as human epidermal growth factor receptor-2 (HER-2). By
blocking HER-2, Herceptin slows or stops the growth of these cells.
Herceptin may be given by itself or along with chemotherapy.
|
Patients may want to ask these questions about systemic therapy
(chemotherapy, hormonal therapy, or biological therapy):
-
Why do I need this treatment?
-
If I need hormonal treatment, which would be better for me,
drugs or an operation?
-
What drugs will I be taking? What will they do?
-
Will I have side effects? What can I do about them?
-
How long will I be on this
treatment? |
Breast Cancer Treatment Choices
Women with breast cancer now have many treatment options. Many women
want to learn all they can about the disease and their treatment choices
so that they can take an active part in decisions about their medical
care. They are likely to have many questions and concerns about their
treatment options.
The doctor is the best person to answer questions about breast cancer treatments for a
particular patient: what her treatment choices are and how successful her
treatment is expected to be. Most patients also want to know how they will
look after treatment and whether they will have to change their normal
activities. A woman should not feel that she needs to ask all her
questions or understand all the answers at once. She will have many
chances to ask the doctor to explain things that are not clear and to ask
for more information.
A woman may want to talk with her doctor about taking part in a clinical
trial, a research study of new methods in breast cancer treatments. Clinical trials
are an important option for women with all stages of breast cancer. The
"Research on Staging and Treatment" part of "The
Promise of Cancer Research" section has more information.
A woman's treatment options depend on a number of factors. These
factors include her age and menopausal status; her general health; the
size and location of the tumor and the stage
of the cancer; the results of lab tests; and the size of her breast.
Certain features of the tumor cells (such as whether they depend on
hormones to grow) are also considered. In most cases, the most important
factor is the stage of the disease. The stage is based on the size of the
tumor and whether the cancer has spread. The following are brief
descriptions of the stages of breast cancer and the treatments most often
used for each stage. (Other treatments may sometimes be appropriate.)
-
Stage 0 is sometimes called noninvasive carcinoma or carcinoma
in situ.
Lobular
carcinoma in situ (LCIS) refers to abnormal cells in the
lining of a lobule. These abnormal cells seldom become invasive cancer.
However, their presence is a sign that a woman has an increased risk of
developing breast cancer. This risk of cancer is increased for both
breasts. Some women with LCIS may take a drug called tamoxifen, which
can reduce the risk of developing breast cancer. Others may take part in
studies of other promising new preventive treatments. Some women may
choose not to have treatment, but to return to the doctor regularly for
checkups. And, occasionally, women with LCIS may decide to have surgery
to remove both breasts to try to prevent cancer from developing. (In
most cases, removal of underarm lymph nodes is not necessary.)
Ductal
carcinoma in situ (DCIS) refers to abnormal cells in the
lining of a duct. DCIS is also called intraductal carcinoma. The
abnormal cells have not spread beyond the duct to invade the surrounding
breast tissue. However, women with DCIS are at an increased risk of
getting invasive breast cancer. Some women with DCIS have breast-sparing
surgery followed by radiation therapy. Or they may choose to have a
mastectomy, with or without breast reconstruction (plastic surgery) to
rebuild the breast. Underarm lymph nodes are not usually removed. Also,
women with DCIS may want to talk with their doctor about tamoxifen to
reduce the risk of developing invasive breast cancer.
-
Stage I and stage II are early stages of breast cancer
in which the cancer has spread beyond the lobe or duct and invaded
nearby tissue. Stage I means that the tumor is no more than about an
inch across and cancer cells have not spread beyond the breast. Stage II
means one of the following: the tumor in the breast is less than 1 inch
across and the cancer has spread to the lymph nodes under the arm; or
the tumor is between 1 and 2 inches (with or without spread to the lymph
nodes under the arm); or the tumor is larger than 2 inches but has not
spread to the lymph nodes under the arm.
Women with early stage breast cancer may have breast-sparing surgery
followed by radiation therapy to the breast, or they may have a
mastectomy, with or without breast reconstruction to rebuild the breast.
These approaches are equally effective in the early stage treatment of breast
cancer. (Sometimes radiation therapy is also given after
mastectomy.)
The choice of breast-sparing surgery or mastectomy depends mostly on
the size and location of the tumor, the size of the woman's breast,
certain features of the cancer, and how the woman feels about preserving
her breast. With either approach, lymph nodes under the arm usually are
removed.
Many women with stage I and most with stage II breast cancer have
chemotherapy and/or hormonal therapy after primary treatment with
surgery or surgery and radiation therapy. This added breast cancer treatment is called
adjuvant
therapy. If the systemic therapy is given to shrink the tumor
before surgery, this is called neoadjuvant
therapy. Systemic treatment is given to try to destroy any
remaining cancer cells and prevent the cancer from recurring, or coming
back, in the breast or elsewhere.
-
Stage III is also called locally advanced cancer. In this
stage, the tumor in the breast is large (more than 2 inches across) and
the cancer has spread to the underarm lymph nodes; or the cancer is
extensive in the underarm lymph nodes; or the cancer has spread to lymph
nodes near the breastbone or to other tissues near the breast.
Inflammatory
breast cancer is a type of locally advanced breast cancer. In
this type of cancer the breast looks red and swollen (or inflamed)
because cancer cells block the lymph vessels in the skin of the
breast.
Patients with stage III breast cancer usually have both local
treatment to remove or destroy the cancer in the breast and systemic
treatment to stop the disease from spreading. The local breast cancer treatment may be
surgery and/or radiation therapy to the breast and underarm. The
systemic treatment may be chemotherapy, hormonal therapy, or both.
Systemic therapy may be given before local therapy to shrink the tumor
or afterward to prevent the disease from recurring in the breast or
elsewhere.
-
Stage IV is metastatic cancer. The cancer has spread beyond
the breast and underarm lymph nodes to other parts of the body.
Women who have stage IV breast cancer receive chemotherapy and/or
hormonal therapy to destroy cancer cells and control the disease. They
may have surgery or radiation therapy to control the cancer in the
breast. Radiation may also be useful to control tumors in other parts of
the body.
-
Recurrent cancer means the disease has come back in spite of
the initial treatment. Even when a tumor in the breast seems to have
been completely removed or destroyed, the disease sometimes returns
because undetected cancer cells remained somewhere in the body after
treatment.
Most recurrences appear within the first 2 or 3 years after
treatment, but breast cancer can recur many years later.
Cancer that returns only in the area of the surgery is called a local
recurrence. If the disease returns in another part of the body, the
distant recurrence is called metastatic breast cancer. The patient may
have one type of treatment or a combination of treatments for recurrent
cancer.
Side Effects of Breast Cancer Treatments
It is hard to protect healthy cells from the harmful effects of breast
cancer treatments. Because treatment does damage healthy cells and tissues,
it causes side effects. The side effects of cancer treatment depend mainly
on the type and extent of the treatment. Also, the effects may not be the
same for each person, and they may be different from one treatment to the
next. An important part of the treatment plan is the management of side
effects.
A patient's reaction to treatment is closely monitored by physical
exams, blood tests, and other tests. Doctors and nurses will explain the
possible side effects of treatment, and they can suggest ways to deal with
problems that may occur during and after treatment. The NCI provides
helpful, informative booklets about breast cancer treatments and coping with side
effects.
Breast Cancer Surgery
Surgery for breast cancer causes short-term pain and tenderness in the area
of the operation, so women may need to talk with their doctor about pain
management. Any kind of surgery also carries a risk of infection, poor
wound healing, bleeding, or a reaction to the anesthesia used during
surgery. Women who experience any of these problems should tell their
doctor or nurse right away.
Removal of a breast can cause a woman's weight to be out of balance --
especially if she has large breasts. This imbalance can cause discomfort
in her neck and back. Also, the skin in the area where the breast was
removed may be tight, and the muscles of the arm and shoulder may feel
stiff. After a mastectomy, some women have some permanent loss of strength
in these muscles, but for most women, reduced strength and limited
movement are temporary. The doctor, nurse, or physical therapist can
recommend exercises to help a woman regain movement and strength in her
arm and shoulder.
Because nerves may be injured or cut during surgery, a woman may have
numbness and tingling in the chest, underarm, shoulder, and upper arm.
These feelings usually go away within a few weeks or months, but some
women have permanent numbness.
Removing the lymph nodes under the arm slows the flow of lymph. In some
women, this fluid builds up in the arm and hand and causes swelling (lymphedema).
Women need to protect the arm and hand on the treated side from injury or
pressure, even long after surgery. They should ask the doctor how to
handle any cuts, scratches, insect bites, or other injuries to the arm or
hand. Also, they should contact the doctor if an infection develops in
that arm or hand.
Breast Cancer Treatments: Radiation Therapy
During radiation therapy, patients may become extremely tired,
especially after several treatments. This feeling may continue for a while
after treatment is over. Resting is important, but doctors usually advise
their patients to try to stay reasonably active, matching their activities
to their energy level. It is also common for the skin in the treated area
to become red, dry, tender, and itchy. The breast may feel heavy and hard,
but these conditions will clear up with time. Toward the end of treatment,
the skin may become moist and "weepy." Exposing this area to air as much
as possible will help the skin heal. Because bras and some types of
clothing may rub the skin and cause irritation, patients may want to wear
loose-fitting cotton clothes. Gentle skin care is important at this time,
and patients should check with their doctor before using any deodorants,
lotions, or creams on the treated area. These effects of radiation therapy
on the skin are temporary, and the area gradually heals once treatment is
over. However, there may be a permanent change in the color of the
skin.
Breast Cancer Treatments: Chemotherapy
As with radiation, chemotherapy affects normal as well as cancer cells.
The side effects of chemotherapy depend mainly on the specific drugs and
the dose. In general, anticancer drugs affect rapidly dividing cells.
These include blood cells, which fight infection, help the blood to clot,
and carry oxygen to all parts of the body. When blood cells are affected,
patients are more likely to get infections, may bruise or bleed easily,
and may feel unusually weak and very tired. Rapidly dividing cells in hair
roots and cells that line the digestive tract may also be affected. As a
result, side effects may include loss of hair, poor appetite, nausea and
vomiting, diarrhea, or mouth and lip sores. Many of these side effects can
now be controlled, thanks to new or improved drugs. Side effects generally
are short-term and gradually go away. Hair grows back, but it may be
different in color and texture.
Some anticancer drugs can damage the ovaries. If the ovaries fail to
produce hormones, the woman may have symptoms of menopause, such as hot
flashes and vaginal dryness. Her periods may become irregular or may stop,
and she may not be able to become pregnant. Other long-term side effects
are quite rare, but there have been cases in which the heart is weakened,
and second cancers such as leukemia (cancer of the blood cells) have
occurred.
Women who are still menstruating may still be able to get pregnant
during treatment. Because the effects of chemotherapy on an unborn child
are not known, it is important for a woman to talk with her doctor about
birth control before treatment begins. After treatment, some women regain
their ability to become pregnant, but in women over the age of 35, infertility
is likely to be permanent.
Breast Cancer Treatments: Hormonal Therapy
The side effects of hormonal therapy depend largely on the specific
drug or type of treatment. Tamoxifen is the most common hormonal
treatment. This drug blocks the cancer cells' use of estrogen but does not
stop estrogen production. Tamoxifen may cause hot flashes, vaginal
discharge or irritation, nausea, and irregular periods. Women who are
still menstruating and having irregular periods may become pregnant more
easily when taking tamoxifen. They should discuss birth control methods
with their doctor.
Serious side effects of tamoxifen are rare. It can cause blood clots in
the veins, especially in the legs and in the lungs, and in a small number
of women, it can slightly increase the risk of stroke. Also, tamoxifen can
cause cancer of the lining of the uterus. Any unusual vaginal bleeding
should be reported to the doctor. The doctor may do a pelvic exam, as well
as a biopsy of the lining of the uterus, or other tests. (This does not
apply to women who have had a hysterectomy,
surgery to remove the uterus.)
Young women whose ovaries are removed to deprive the cancer cells of
estrogen experience menopause immediately. Their symptoms are likely to be
more severe than symptoms associated with natural menopause.
Breast Cancer Treatments: Biological Therapy
The side effects of biological therapy differ with the types of
substances used, and from patient to patient. Rashes or swelling where the
biological therapy is injected are common. Flu-like symptoms also may
occur.
Herceptin may cause these and other side effects, but these effects
generally become less severe after the first treatment. Less commonly,
Herceptin can also cause damage to the heart that can lead to heart
failure. It can also affect the lungs, causing breathing problems that
require immediate medical attention. For these reasons, women are checked
carefully for heart and lung problems before taking Herceptin. Patients
who do take it are watched carefully during treatment.
Breast Reconstruction
After a mastectomy, some women decide to wear a breast form (prosthesis).
Others prefer to have breast reconstruction, either at the same time as
the mastectomy or later on. Each option has its pros and cons, and what is
right for one woman may not be right for another. What is important is
that nearly every woman treated for breast cancer has choices. It is best
to consult with a plastic surgeon before the mastectomy, even if
reconstruction will be considered later on.
Various procedures are used to reconstruct the breast. Some use
implants (either saline or silicone); others use tissue moved from another
part of the woman's body. The safety of silicone breast implants has been
under review by the Food and Drug Administration (FDA) for several years.
Women interested in having silicone implants should talk with their doctor
about the FDA's findings and the availability of silicone implants. Which
type of reconstruction is best depends on a woman's age, body type, and
the type of surgery she had. A woman should ask the plastic surgeon to
explain the risks and benefits of each type of reconstruction.
The Cancer Information Service at 1-800-4-CANCER
can suggest other sources of information about breast reconstruction and
can talk with callers about breast cancer support groups.
Rehabilitation after Breast Cancer
Rehabilitation is a very important part of breast cancer treatments. The
health care team makes every effort to help women return to their normal
activities as soon as possible. Recovery will be different for each woman,
depending on the extent of the disease, the type of treatment, and other
factors.
Exercising the arm and shoulder after surgery can help a woman regain
motion and strength in these areas. It can also reduce pain and stiffness
in her neck and back. Carefully planned exercises should be started as
soon as the doctor says the woman is ready, often within a day or so after
surgery. Exercising begins slowly and gently and can even be done in bed.
Gradually, exercising can be more active, and regular exercise becomes
part of a woman's normal routine. (Women who have a mastectomy and
immediate breast reconstruction need special exercises, which the doctor
or nurse will explain.)
Often, lymphedema after surgery can be prevented or reduced with
certain exercises and by resting with the arm propped up on a pillow. If
lymphedema occurs, the doctor may suggest exercises and other ways to deal
with this problem. For example, some women with lymphedema wear an elastic
sleeve or use an elastic cuff to improve lymph circulation. The doctor
also may suggest other approaches, such as medication, manual lymph
drainage (massage), or use of a machine that gently compresses the arm.
The woman may be referred to a physical therapist or another
specialist.
Followup Care for Breast Cancer Patients
Regular followup exams are important after breast cancer treatments.
Regular checkups ensure that changes in health are noticed. Followup exams
usually include examination of the breasts, chest, neck, and underarm
areas, as well as periodic mammograms. If a woman has a breast implant,
special mammogram techniques can be used. Sometimes the doctor may order
other imaging procedures or lab tests.
A woman who has had cancer in one breast should report any changes in
the treated area or in the other breast to her doctor right away. Because
a woman who has had breast cancer is at risk of getting cancer in the
other breast, mammograms are an important part of followup care.
Also, a woman who has had breast cancer should tell her doctor about symptoms &
other physical problems, such as pain, loss of appetite or weight, changes
in menstrual cycles, unusual vaginal bleeding, or blurred vision. She
should also report headaches, dizziness, shortness of breath, coughing or
hoarseness, backaches, or digestive problems that seem unusual or that
don't go away. These symptoms may be a sign that breast cancer has returned,
but they can also be signs of various other problems. It's important to
share these concerns with a doctor.
Support for Women with Breast Cancer
The diagnosis of breast cancer can change a woman's life and the lives
of those close to her. These changes can be hard to handle. It is common
for the woman and her family and friends to have many different and
sometimes confusing emotions. Having helpful information and support
services can make it easier to cope with these problems.
People living with cancer may worry about caring for their families,
keeping their jobs, or continuing daily activities. Concerns about tests,
breast cancer treatments, hospital stays, and medical bills are also common. Doctors,
nurses, and other members of the health care team can answer questions
about treatment, working, or other activities. Meeting with a social
worker, counselor, or member of the clergy can be helpful to people who
want to talk about their feelings or discuss their concerns. Often, a
social worker can suggest resources for help with rehabilitation,
emotional support, financial aid, transportation, or home care.
Friends and relatives can be very supportive. Also, it helps many
patients to discuss their concerns with others who have cancer. Women with
breast cancer often get together in support groups, where they can share
what they have learned about coping with their disease and the effects of
their breast cancer treatments. It is important to keep in mind, however, that each
person is different. Treatments and ways of dealing with cancer that work
for one person may not be right for another -- even if they both have the
same kind of cancer. It is always a good idea to discuss the advice of
friends and family members with the doctor.
Several organizations offer special programs for patients with breast
cancer. Trained volunteers, who have had breast cancer themselves, may
talk with or visit patients, provide information, and lend emotional
support before and after treatment. They often share their experiences
with breast cancer treatments, rehabilitation, and breast reconstruction.
Sometimes women who have had breast cancer are afraid that changes to
their body will affect not only how they look but how other people feel
about them. They may be concerned that breast cancer and its treatment
will affect their sexual relationships. Many couples find that talking
about these concerns helps them find ways to express their love during and
after treatment. Some seek counseling or a couples' support group.
The Promise of Breast Cancer Research
Doctors all over the country are conducting many types of
clinical trials
(research studies in which people
take part voluntarily). These include studies of ways to prevent, detect,
diagnose, and treat breast cancer; studies of the psychological effects of
the disease; and studies of ways to improve comfort and quality of life.
Research already has led to significant advances in these areas, and
researchers continue to search for more effective approaches.
People who take part in clinical trials have the first chance to
benefit from new approaches. They also make important contributions to
medical science. Although clinical trials may pose some risks, researchers
take very careful steps to protect people who take part.
Women who are interested in being part of a clinical trial should talk
with their doctor.
Breast Cancer Causes and Prevention
Doctors can seldom explain why one woman gets breast cancer and another
doesn't. It is clear, however, that bumping, bruising, or touching
the breast are not causes breast cancer. And this disease is not
contagious; no one can "catch" breast cancer from another person.
Scientists are trying to learn more about breast cancer causes and
factors that increase the risk of developing this disease.
For example, they are looking at whether
the risk of breast cancer might be affected by environmental factors. So
far, scientists do not have enough information to know whether any factors
in the environment increase the risk of this disease or causes breast cancer.
(The main known risk factors are listed in the "Breast Cancer:
Who's at Risk?" section.)
Some aspects of a woman's lifestyle may affect her chances of
developing breast cancer. For example, recent studies suggest that regular
exercise may decrease the risk in younger women. Also, some evidence
suggests a link between diet and breast cancer; however there isn't a direct
link between any food and breast cancer causes. Ongoing studies are
looking at ways to prevent breast cancer through changes in diet or with
dietary supplements. However, it is not yet known whether specific dietary
changes will actually prevent breast cancer. These are active areas of
research.
Scientists are trying to learn whether having a miscarriage or an
abortion increases the risk of breast cancer. Thus far, studies have
produced conflicting results, and this question is still unresolved.
Research has led to the identification of changes (mutations) in
certain genes that increase the risk of developing breast cancer. Women
with a strong family history of breast cancer may choose to have a blood
test to see if they have inherited a change in the BRCA1 or BRCA2 gene.
Women who are concerned about an inherited risk for breast cancer should
talk to their doctor about breast cancer causes. The doctor may suggest
seeing a health professional
trained in genetics. Genetic counseling can help a woman decide whether
testing would be appropriate for her. Also, counseling before and after
testing helps women understand and deal with the possible results of a
genetic test. Counseling can also help with concerns about employment or
about health, life, and disability insurance. The Cancer Information
Service can supply additional material on genetic testing.
Scientists are looking for drugs that may prevent the development of
breast cancer. In one large study, the drug tamoxifen reduced the number
of new cases of breast cancer among women at an increased risk for the
disease. Doctors are now studying how another drug called raloxifene
compares to tamoxifen. This study is called STAR (Study of Tamoxifen and
Raloxifene).
Detection and Diagnosis of Breast Cancer
At present, mammograms are the most effective tool we have to detect
breast cancer. Researchers are looking for ways to make mammography more
accurate, such as using computers to read mammograms (digital
mammography). They are also exploring other techniques, such as magnetic
resonance imaging (MRI), breast ultrasonography,
and positron
emission tomography (PET), to produce detailed pictures of the
tissues in the breast.
In addition, researchers are studying tumor markers. These are
substances that may be present in abnormal amounts in people with cancer.
Tumor markers may be found in blood or urine, or in fluid from the breast
(nipple aspirate).
Some of these markers may be used to check women who have already been
diagnosed with breast cancer. At this time, however, no tumor marker test
is reliable enough to be used routinely to detect breast cancer.
Breast Cancer Treatments
Through research, doctors try to find new, more effective ways to treat
cancer. Many studies of new approaches for patients with breast cancer are
under way. When laboratory research shows that a new treatment method has
promise, cancer patients receive the new approach in treatment clinical
trials. These studies are designed to answer important questions and to
find out whether the new approach is safe and effective. Often, clinical
trials compare a new treatment with a standard approach.
Researchers are testing new anticancer drugs, doses, and treatment
schedules. They are working with various drugs and drug combinations, as
well as with several types of hormonal therapy. They also are looking at
the effectiveness of using chemotherapy before surgery (called neoadjuvant
chemotherapy) and at new ways of combining treatments, such as adding
hormonal therapy or radiation therapy to chemotherapy.
New biological approaches also are under study. For example, several
cancer vaccines have been designed to stimulate the immune system to mount
a response against breast cancer cells. Combinations of biological
treatments with other agents are also undergoing clinical study.
Researchers are exploring ways to reduce the side effects of treatment
(such as lymphedema from surgery), improve the quality of patients' lives,
and reduce pain. One procedure under study is called sentinel
lymph node biopsy. Researchers are trying to learn whether this
procedure may reduce the number of lymph nodes that must be removed during
breast cancer surgery. Before surgery, the doctor injects a radioactive
substance near the tumor. The substance flows through the lymphatic system
to the first lymph node or nodes where cancer cells are likely to have
spread (the "sentinel" node or nodes). The doctor uses a scanner to locate
the radioactive substance in the sentinel nodes. Sometimes the doctor also
injects a blue dye near the tumor. The dye travels through the lymphatic
system to collect in the sentinel nodes. The surgeon makes a small
incision and removes only the nodes with radioactive substance or blue
dye. A pathologist checks the sentinel lymph nodes for cancer cells. If no
cancer cells are detected, it may not be necessary to remove additional
nodes. If sentinel lymph node biopsy proves to be as effective as the
standard axillary lymph node dissection, the new procedure could prevent
lymphedema.
Chemotherapy can reduce the ability of bone
marrow to make blood cells. That is why researchers are studying
ways to help the blood cells recover so that high doses of chemotherapy
can be given. These studies use biological therapies (known as colony-stimulating
factors), autologous
bone marrow transplants, or peripheral
stem cell transplants.
Keeping on Top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
A new service available to patients provides a convenient means of staying informed, and ensures that the information is both reliable and accurate. If you wish to find out more about HealthNewsflash's innovative service, take the tour.
