Definition of breast cancer:
that forms in tissues of the breast, usually the ducts (tubes that carry
milk to the nipple) and lobules (glands that make milk). It occurs in
both men and women, although male breast cancer is rare.
Estimated new cases and deaths from breast cancer in the United States in 2008:
New cases: 182,460 (female); 1,990 (male)
Deaths: 40,480 (female); 450 (male)
The Breasts
The
breasts sit on the chest muscles that cover the ribs. Each breast is
made of 15 to 20 lobes. Lobes contain many smaller lobules. Lobules
contain groups of tiny glands that can produce milk. Milk flows from the
lobules through thin tubes called ducts to the nipple. The nipple is in
the center of a dark area of skin called the areola. Fat fills the
spaces between the lobules and ducts.
The breasts also contain
lymph vessels. These vessels lead to small, round organs called lymph
nodes. Groups of lymph nodes are near the breast in the axilla
(underarm), above the collarbone, in the chest behind the breastbone,
and in many other parts of the body. The lymph nodes trap bacteria,
cancer cells, or other harmful substances.
Understanding Cancer
Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.
Normally,
cells grow and divide to form new cells as the body needs them. When
cells grow old, they die, and new cells take their place.
Sometimes,
this orderly process goes wrong. New cells form when the body does not
need them, and old cells do not die when they should. These extra cells
can form a mass of tissue called a growth or tumor.
Tumors can be benign or malignant:
#
Benign tumors are not cancer:
* Benign tumors are rarely life-threatening.
* Generally, benign tumors can be removed. They usually do not grow back.
* Cells from benign tumors do not invade the tissues around them.
* Cells from benign tumors do not spread to other parts of the body.
# Malignant tumors are cancer:
* Malignant tumors are generally more serious than benign tumors. They may be life-threatening.
* Malignant tumors often can be removed. But sometimes they grow back.
* Cells from malignant tumors can invade and damage nearby tissues and organs.
*
Cells from malignant tumors can spread (metastasize) to other parts of
the body. Cancer cells spread by breaking away from the original
(primary) tumor and entering the bloodstream or lymphatic system. The
cells invade other organs and form new tumors that damage these organs.
The spread of cancer is called metastasis.
When breast cancer
cells spread, the cancer cells are often found in lymph nodes near the
breast. Also, breast cancer can spread to almost any other part of the
body. The most common are the bones, liver, lungs, and brain. 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 bones, the
cancer cells in the bones are actually breast cancer cells. The disease
is metastatic breast cancer, not bone cancer. For that reason, it is
treated as breast cancer, not bone cancer. Doctors call the new tumor
"distant" or metastatic disease.
Risk Factors
No
one knows the exact causes of breast cancer. Doctors often cannot
explain why one woman develops breast cancer and another does not. They
do know that bumping, bruising, or touching the breast does not cause
cancer. And breast cancer is not contagious. You cannot "catch" it from
another person.
Research has shown that women with certain risk
factors are more likely than others to develop breast cancer. A risk
factor is something that may increase the chance of developing a
disease.
Studies have found the following risk factors for breast cancer:
*
Age: The chance of getting breast cancer goes up as a woman gets older.
Most cases of breast cancer occur in women over 60. This disease is not
common before menopause.
* Personal history of breast cancer: A
woman who had breast cancer in one breast has an increased risk of
getting cancer in her other breast.
* Family history: A woman's risk
of breast cancer is higher if her mother, sister, or daughter had breast
cancer. The risk is higher if her family member got breast cancer
before age 40. Having other relatives with breast cancer (in either her
mother's or father's family) may also increase a woman's risk.
*
Certain breast changes: Some women have cells in the breast that look
abnormal under a microscope. Having certain types of abnormal cells
(atypical hyperplasia and lobular carcinoma in situ [LCIS]) increases
the risk of breast cancer.
* Gene changes: Changes in certain genes
increase the risk of breast cancer. These genes include BRCA1, BRCA2,
and others. Tests can sometimes show the presence of specific gene
changes in families with many women who have had breast cancer. Health
care providers may suggest ways to try to reduce the risk of breast
cancer, or to improve the detection of this disease in women who have
these changes in their genes. NCI offers publications on gene testing.
* Reproductive and menstrual history:
- The older a woman is when she has her first child, the greater her chance of breast cancer.
-Women who had their first menstrual period before age 12 are at an increased risk of breast cancer.
- Women who went through menopause after age 55 are at an increased risk of breast cancer.
-Women who never had children are at an increased risk of breast cancer.
-Women who take menopausal hormone therapy with estrogen plus
progestin after menopause also appear to have an increased risk of
breast cancer.
-Large, well-designed studies have shown no link between abortion or miscarriage and breast cancer.
* Race: Breast cancer is diagnosed more often in white women than Latina, Asian, or African American women.
*
Radiation therapy to the chest: Women who had radiation therapy to the
chest (including breasts) before age 30 are at an increased risk of
breast cancer. This includes women treated with radiation for Hodgkin's
lymphoma. Studies show that the younger a woman was when she received
radiation treatment, the higher her risk of breast cancer later in life.
*
Breast density: Breast tissue may be dense or fatty. Older women whose
mammograms (breast x-rays) show more dense tissue are at increased risk
of breast cancer.
* Taking DES (diethylstilbestrol): DES was given to
some pregnant women in the United States between about 1940 and 1971.
(It is no longer given to pregnant women.) Women who took DES during
pregnancy may have a slightly increased risk of breast cancer. The
possible effects on their daughters are under study.
* Being
overweight or obese after menopause: The chance of getting breast cancer
after menopause is higher in women who are overweight or obese.
*
Lack of physical activity: Women who are physically inactive throughout
life may have an increased risk of breast cancer. Being active may help
reduce risk by preventing weight gain and obesity.
* Drinking alcohol: Studies suggest that the more alcohol a woman drinks, the greater her risk of breast cancer.
Other
possible risk factors are under study. Researchers are studying the
effect of diet, physical activity, and genetics on breast cancer risk.
They are also studying whether certain substances in the environment can
increase the risk of breast cancer.
Many risk factors can be
avoided. Others, such as family history, cannot be avoided. Women can
help protect themselves by staying away from known risk factors whenever
possible.
But it is also important to keep in mind that most
women who have known risk factors do not get breast cancer. Also, most
women with breast cancer do not have a family history of the disease. In
fact, except for growing older, most women with breast cancer have no
clear risk factors.
If you think you may be at risk, you should
discuss this concern with your doctor. Your doctor may be able to
suggest ways to reduce your risk and can plan a schedule for checkups.
Screening
Screening Mammogram
Clinical Breast Exam
Breast Self-Exam
Screening
for breast cancer before there are symptoms can be important. Screening
can help doctors find and treat cancer early. Treatment is more likely
to work well when cancer is found early.
Your doctor may suggest the following screening tests for breast cancer:
* Screening mammogram
* Clinical breast exam
* Breast self-exam
You should ask your doctor about when to start and how often to check for breast cancer.
Screening Mammogram
To find breast cancer early, NCI recommends that:
*
Women in their 40s and older should have mammograms every 1 to 2 years.
A mammogram is a picture of the breast made with x-rays.
* Women who
are younger than 40 and have risk factors for breast cancer should ask
their health care provider whether to have mammograms and how often to
have them.
Mammograms can often show a breast lump before it can
be felt. They also can show a cluster of tiny specks of calcium. These
specks are called microcalcifications. Lumps or specks can be from
cancer, precancerous cells, or other conditions. Further tests are
needed to find out if abnormal cells are present.
If an abnormal
area shows up on your mammogram, you may need to have more x-rays. You
also may need a biopsy. A biopsy is the only way to tell for sure if
cancer is present. (The "Diagnosis" section has more information on
biopsy.)
Mammograms are the best tool doctors have to find breast cancer early. However, mammograms are not perfect:
* A mammogram may miss some cancers. (The result is called a "false negative.")
* A mammogram may show things that turn out not to be cancer. (The result is called a "false positive.")
* Some fast-growing tumors may grow large or spread to other parts of the body before a mammogram detects them.
Mammograms
(as well as dental x-rays, and other routine x-rays) use very small
doses of radiation. The risk of any harm is very slight, but repeated
x-rays could cause problems. The benefits nearly always outweigh the
risk. You should talk with your health care provider about the need for
each x-ray. You should also ask for shields to protect parts of your
body that are not in the picture.
Clinical Breast Exam
During
a clinical breast exam, your health care provider checks your breasts.
You may be asked to raise your arms over your head, let them hang by
your sides, or press your hands against your hips.
Your health
care provider looks for differences in size or shape between your
breasts. The skin of your breasts is checked for a rash, dimpling, or
other abnormal signs. Your nipples may be squeezed to check for fluid.
Using
the pads of the fingers to feel for lumps, your health care provider
checks your entire breast, underarm, and collarbone area. A lump is
generally the size of a pea before anyone can feel it. The exam is done
on one side, then the other. Your health care provider checks the lymph
nodes near the breast to see if they are enlarged.
A thorough clinical breast exam may take about 10 minutes.
Breast Self-Exam
You
may perform monthly breast self-exams to check for any changes in your
breasts. It is important to remember that changes can occur because of
aging, your menstrual cycle, pregnancy, menopause, or taking birth
control pills or other hormones. It is normal for breasts to feel a
little lumpy and uneven. Also, it is common for your breasts to be
swollen and tender right before or during your menstrual period.
You should contact your health care provider if you notice any unusual changes in your breasts.
Breast
self-exams cannot replace regular screening mammograms and clinical
breast exams. Studies have not shown that breast self-exams alone reduce
the number of deaths from breast cancer.
Symptoms
Common symptoms of breast cancer include:
* A change in how the breast or nipple feels
-A lump or thickening in or near the breast or in the underarm area
-Nipple tenderness
* A change in how the breast or nipple looks
-A change in the size or shape of the breast
-A nipple turned inward into the breast
-The skin of the breast, areola, or nipple may be scaly, red, or
swollen. It may have ridges or pitting so that it looks like the skin of
an orange.
* Nipple discharge (fluid)
Early breast cancer
usually does not cause pain. Still, a woman should see her health care
provider about breast pain or any other symptom that does not go away.
Most often, these symptoms are not due to cancer. Other health problems
may also cause them. Any woman with these symptoms should tell her
doctor so that problems can be diagnosed and treated as early as
possible.
Diagnosis
If
you have a symptom or screening test result that suggests cancer, your
doctor must find out whether it is due to cancer or to some other cause.
Your doctor may ask about your personal and family medical history. You
may have a physical exam. Your doctor also may order a mammogram or
other imaging procedure. These tests make pictures of tissues inside the
breast. After the tests, your doctor may decide no other exams are
needed. Your doctor may suggest that you have a follow-up exam later on.
Or you may need to have a biopsy to look for cancer cells.
Clinical Breast Exam
Your
health care provider feels each breast for lumps and looks for other
problems. If you have a lump, your doctor will feel its size, shape, and
texture. Your doctor will also check to see if it moves easily. Benign
lumps often feel different from cancerous ones. Lumps that are soft,
smooth, round, and movable are likely to be benign. A hard, oddly shaped
lump that feels firmly attached within the breast is more likely to be
cancer.
Diagnostic Mammogram
Diagnostic
mammograms are x-ray pictures of the breast. They take clearer, more
detailed images of areas that look abnormal on a screening mammogram.
Doctors use them to learn more about unusual breast changes, such as a
lump, pain, thickening, nipple discharge, or change in breast size or
shape. Diagnostic mammograms may focus on a specific area of the breast.
They may involve special techniques and more views than screening
mammograms.
Ultrasound
An
ultrasound device sends out sound waves that people cannot hear. The
waves bounce off tissues. A computer uses the echoes to create a
picture. Your doctor can view these pictures on a monitor. The pictures
may show whether a lump is solid or filled with fluid. A cyst is a
fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer.
After the test, your doctor can store the pictures on video or print
them out. This exam may be used along with a mammogram.
Magnetic Resonance Imaging
Magnetic
resonance imaging (MRI) uses a powerful magnet linked to a computer.
MRI makes detailed pictures of breast tissue. Your doctor can view these
pictures on a monitor or print them on film. MRI may be used along with
a mammogram.
Biopsy
Your
doctor may refer you to a surgeon or breast disease specialist for a
biopsy. Fluid or tissue is removed from your breast to help find out if
there is cancer.
Some suspicious areas can be seen on a mammogram
but cannot be felt during a clinical breast exam. Doctors can use
imaging procedures to help see the area and remove tissue. Such
procedures include ultrasound-guided, needle-localized, or stereotactic
biopsy.
Doctors can remove tissue from the breast in different ways:
*
Fine-needle aspiration: Your doctor uses a thin needle to remove fluid
from a breast lump. If the fluid appears to contain cells, a pathologist
at a lab checks them for cancer with a microscope. If the fluid is
clear, it may not need to be checked by a lab.
* Core biopsy: Your
doctor uses a thick needle to remove breast tissue. A pathologist checks
for cancer cells. This procedure is also called a needle biopsy.
* Surgical biopsy: Your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells.
- An incisional biopsy takes a sample of a lump or abnormal area.
-An excisional biopsy takes the entire lump or area.
If
cancer cells are found, the pathologist can tell what kind of cancer it
is. The most common type of breast cancer is ductal carcinoma. Abnormal
cells are found in the lining of the ducts. Lobular carcinoma is
another type. Abnormal cells are found in the lobules.
Additional Tests
If
you are diagnosed with cancer, your doctor may order special lab tests
on the breast tissue that was removed. These tests help your doctor
learn more about the cancer and plan treatment:
* Hormone
receptor test: This test shows whether the tissue has certain hormone
receptors. Tissue with these receptors needs hormones (estrogen or
progesterone) to grow.
* HER2 test: This test shows whether the
tissue has a protein called human epidermal growth factor receptor-2
(HER2) or the HER2/neu gene. Having too much protein or too many copies
of the gene in the tissue may increase the chance that the breast cancer
will come back after treatment.
Staging
To
plan your treatment, your doctor needs to know the extent (stage) of
the disease. The stage is based on the size of the tumor and whether the
cancer has spread. Staging may involve x-rays and lab tests. These
tests can show whether the cancer has spread and, if so, to what parts
of your body. When breast cancer spreads, cancer cells are often found
in lymph nodes under the arm (axillary lymph nodes). The stage often is
not known until after surgery to remove the tumor in your breast and the
lymph nodes under your arm.
These are the stages of breast cancer:
* Stage 0 is carcinoma in situ.
o Lobular carcinoma in situ (LCIS): Abnormal cells are in the lining
of a lobule. (See picture of lobule on page 3.) LCIS seldom becomes
invasive cancer. However, having LCIS in one breast increases the risk
of cancer for both breasts.
o Ductal carcinoma in situ (DCIS):
Abnormal cells are in the lining of a duct. DCIS is also called
intraductal carcinoma. The abnormal cells have not spread outside the
duct. They have not invaded the nearby breast tissue. DCIS sometimes
becomes invasive cancer if not treated.
This picture shows ductal carcinoma in situ.
This picture shows ductal carcinoma in situ.
*
Stage I is an early stage of invasive breast cancer. The tumor is no
more than 2 centimeters (three-quarters of an inch) across. Cancer cells
have not spread beyond the breast.
This picture shows cancer cells spreading outside the duct. The cancer cells are invading nearby tissue inside the breast.
This picture shows cancer cells spreading outside the duct. The cancer cells are invading nearby tissue inside the breast.
* Stage II is one of the following:
-The tumor is no more than 2 centimeters (three-quarters of an inch)
across. The cancer has spread to the lymph nodes under the arm.
-The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2
inches). The cancer has not spread to the lymph nodes under the arm.
-The tumor is between 2 and 5 centimeters (three-quarters of an inch
to 2 inches). The cancer has spread to the lymph nodes under the arm
-The tumor is larger than 5 centimeters (2 inches). The cancer has not spread to the lymph nodes under the arm.
* Stage III is locally advanced cancer. It is divided into Stage IIIA, IIIB, and IIIC.
-Stage IIIA is one of the following:
+ The tumor is no more than 5 centimeters (2 inches) across. The
cancer has spread to underarm lymph nodes that are attached to each
other or to other structures. Or the cancer may have spread to lymph
nodes behind the breastbone.
+ The tumor is more than 5
centimeters across. The cancer has spread to underarm lymph nodes that
are either alone or attached to each other or to other structures. Or
the cancer may have spread to lymph nodes behind the breastbone.
-Stage IIIB is a tumor of any size that has grown into the chest wall
or the skin of the breast. It may be associated with swelling of the
breast or with nodules (lumps) in the breast skin.
+ The cancer may have spread to lymph nodes under the arm.
+ The cancer may have spread to underarm lymph nodes that are
attached to each other or other structures. Or the cancer may have
spread to lymph nodes behind the breastbone.
+ Inflammatory
breast cancer is a rare type of breast cancer. The breast looks red and
swollen because cancer cells block the lymph vessels in the skin of the
breast. When a doctor diagnoses inflammatory breast cancer, it is at
least Stage IIIB, but it could be more advanced.
-Stage IIIC is a tumor of any size. It has spread in one of the following ways:
+ The cancer has spread to the lymph nodes behind the breastbone and under the arm.
+ The cancer has spread to the lymph nodes above or below the collarbone.
* Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body.
*
Recurrent cancer is cancer that has come back (recurred) after a period
of time when it could not be detected. It may recur locally in the
breast or chest wall. Or it may recur in any other part of the body,
such as the bone, liver, or lungs.
Treatment
Getting a Second Opinion
Treatment Methods
Surgery
Radiation Therapy
Chemotherapy
Hormone Therapy
Biological Therapy
Treatment Choices by Stage
Many
women with breast cancer want to take an active part in making
decisions about their medical care. It is natural to want to learn all
you can about your disease and treatment choices. Knowing more about
breast cancer helps many women cope.
Shock and stress after the
diagnosis can make it hard to think of everything you want to ask your
doctor. It often helps to make a list of questions before an
appointment. To help remember what the doctor says, you may take notes
or ask whether you may use a tape recorder. You may also want to have a
family member or friend with you when you talk to the doctor - to take
part in the discussion, to take notes, or just to listen. You do not
need to ask all your questions at once. You will have other chances to
ask your doctor or nurse to explain things that are not clear and to ask
for more details.
Your doctor may refer you to a specialist, or
you may ask for a referral. Specialists who treat breast cancer include
surgeons, medical oncologists, and radiation oncologists. You also may
be referred to a plastic surgeon.
Getting a Second Opinion
Before
starting treatment, you might want a second opinion about your
diagnosis and treatment plan. Many insurance companies cover a second
opinion if you or your doctor requests it. It may take some time and
effort to gather medical records and arrange to see another doctor. You
may have to gather your mammogram films, biopsy slides, pathology
report, and proposed treatment plan. Usually it is not a problem to take
several weeks to get a second opinion. In most cases, the delay in
starting treatment will not make treatment less effective. To make sure,
you should discuss this delay with your doctor. Some women with breast
cancer need treatment right away.
There are a number of ways to find a doctor for a second opinion:
* Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.
*
NCI's Cancer Information Service, at 1-800-4-CANCER, can tell you about
nearby treatment centers. Information Specialists also can provide
online assistance through LiveHelp at http://www.cancer.gov/cis.
* A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.
*
The American Board of Medical Specialties (ABMS) has a list of doctors
who have had training and passed exams in their specialty. You can find
this list in the Official ABMS Directory of Board Certified Medical
Specialists. This Directory is in most public libraries. Also, ABMS
offers this information at http://www.abms.org.
Treatment Methods
Women
with breast cancer have many treatment options. These include surgery,
radiation therapy, chemotherapy, hormone therapy, and biological
therapy. These options are described below. Many women receive more than
one type of treatment.
The choice of treatment depends mainly on the stage of the disease. Treatment options by stage are described below.
Your
doctor can describe your treatment choices and the expected results.
You may want to know how treatment may change your normal activities.
You may want to know how you will look during and after treatment. You
and your doctor can work together to develop a treatment plan that
reflects your medical needs and personal values.
Cancer treatment is either local therapy or systemic therapy:
*
Local therapy: Surgery and radiation therapy are local treatments. They
remove or destroy cancer in the breast. When breast cancer has spread
to other parts of the body, local therapy may be used to control the
disease in those specific areas.
* Systemic therapy: Chemotherapy,
hormone therapy, and biological therapy are systemic treatments. They
enter the bloodstream and destroy or control cancer throughout the body.
Some women with breast cancer have systemic therapy to shrink the tumor
before surgery or radiation. Others have systemic therapy after surgery
and/or radiation to prevent the cancer from coming back. Systemic
treatments also are used for cancer that has spread.
Because
cancer treatments often damage healthy cells and tissues, side effects
are common. Side effects depend mainly on the type and extent of the
treatment. Side effects may not be the same for each woman, and they may
change from one treatment session to the next.
Surgery
Surgery
is the most common treatment for breast cancer. There are several types
of surgery. Your doctor can explain each type, discuss and compare the
benefits and risks, and describe how each will change the way you look:
*
Breast-sparing surgery: An operation to remove the cancer but not the
breast is breast-sparing surgery. It is also called breast-conserving
surgery, lumpectomy, segmental mastectomy, and partial mastectomy.
Sometimes an excisional biopsy serves as a lumpectomy because the
surgeon removes the whole lump.
The surgeon often removes the
underarm lymph nodes as well. A separate incision is made. This
procedure is called an axillary lymph node dissection. It shows whether
cancer cells have entered the lymphatic system.
After
breast-sparing surgery, most women receive radiation therapy to the
breast. This treatment destroys cancer cells that may remain in the
breast.
* Mastectomy: An operation to remove the breast (or as much
of the breast tissue as possible) is a mastectomy. In most cases, the
surgeon also removes lymph nodes under the arm. Some women have
radiation therapy after surgery.
Studies have found equal
survival rates for breast-sparing surgery (with radiation therapy) and
mastectomy for Stage I and Stage II breast cancer.
Sentinel lymph
node biopsy is a new method of checking for cancer cells in the lymph
nodes. A surgeon removes fewer lymph nodes, which causes fewer side
effects. (If the doctor finds cancer cells in the axillary lymph nodes,
an axillary lymph node dissection usually is done.) Information about
ongoing studies of sentinel lymph node biopsy is in the section on "The
Promise of Cancer Research." These studies will learn the lasting
effects of removing fewer lymph nodes.
In breast-sparing surgery, the
surgeon removes the tumor in the breast and some tissue around it. The
surgeon may also remove lymph nodes under the arm. The surgeon sometimes
removes some of the lining over the chest muscles below the tumor.
In
breast-sparing surgery, the surgeon removes the tumor in the breast and
some tissue around it. The surgeon may also remove lymph nodes under
the arm. The surgeon sometimes removes some of the lining over the chest
muscles below the tumor.
In total (simple) mastectomy, the surgeon removes the whole breast. Some lymph nodes under the arm may also be removed.
In total (simple) mastectomy, 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, and
most or all of the lymph nodes under the arm. Often, the lining over the
chest muscles is removed. A small chest muscle also may be taken out to
make it easier to remove the lymph nodes.
In modified radical
mastectomy, the surgeon removes the whole breast, and most or all of the
lymph nodes under the arm. Often, the lining over the chest muscles is
removed. A small chest muscle also may be taken out to make it easier to
remove the lymph nodes.
You may choose to have breast
reconstruction. This is plastic surgery to rebuild the shape of the
breast. It may be done at the same time as a mastectomy or later. If you
are considering reconstruction, you may wish to talk with a plastic
surgeon before having a mastectomy. More information is in the "Breast
Reconstruction" section.
The time it takes to heal after surgery
is different for each woman. Surgery causes pain and tenderness.
Medicine can help control the pain. Before surgery, you should discuss
the plan for pain relief with your doctor or nurse. After surgery, your
doctor can adjust the plan if you need more relief. Any kind of surgery
also carries a risk of infection, bleeding, or other problems. You
should tell your health care provider right away if you develop any
problems.
You may feel off balance if you've had one or both
breasts removed. You may feel more off balance if you have large
breasts. This imbalance can cause discomfort in your neck and back.
Also, the skin where your breast was removed may feel tight. Your arm
and shoulder muscles may feel stiff and weak. These problems usually go
away. The doctor, nurse, or physical therapist can suggest exercises to
help you regain movement and strength in your arm and shoulder. Exercise
can also reduce stiffness and pain. You may be able to begin gentle
exercises within days of surgery.
Because nerves may be injured
or cut during surgery, you may have numbness and tingling in your chest,
underarm, shoulder, and upper arm. These feelings usually go away
within a few weeks or months. But for some women, numbness does not go
away.
Removing the lymph nodes under the arm slows the flow of
lymph fluid. The fluid may build up in your arm and hand and cause
swelling. This swelling is lymphedema. Lymphedema can develop right
after surgery or months to years later.
You will need to protect your arm and hand on the treated side for the rest of your life:
* Avoid wearing tight clothing or jewelry on your affected arm
* Carry your purse or luggage with the other arm
* Use an electric razor to avoid cuts when shaving under your arm
* Have shots, blood tests, and blood pressure measurements on the other arm
* Wear gloves to protect your hands when gardening and when using strong detergents
* Have careful manicures and avoid cutting your cuticles
* Avoid burns or sunburns to your affected arm and hand
You
should ask your doctor how to handle any cuts, insect bites, sunburn,
or other injuries to your arm or hand. Also, you should contact the
doctor if your arm or hand is injured, swells, or becomes red and warm.
If
lymphedema occurs, the doctor may suggest raising your arm above your
heart whenever you can. The doctor may show you hand and arm exercises.
Some women with lymphedema wear an elastic sleeve to improve lymph
circulation. Medication, manual lymph drainage (massage), or use of a
machine that gently compresses the arm may also help. You may be
referred to a physical therapist or another specialist.
Radiation Therapy
Radiation
therapy (also called radiotherapy) uses high-energy rays to kill cancer
cells. Most women receive radiation therapy after breast-sparing
surgery. Some women receive radiation therapy after a mastectomy.
Treatment depends on the size of the tumor and other factors. The
radiation destroys breast cancer cells that may remain in the area.
Some
women have radiation therapy before surgery to destroy cancer cells and
shrink the tumor. Doctors use this approach when the tumor is large or
may be hard to remove. Some women also have chemotherapy or hormone
therapy before surgery.
Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:
*
External radiation: The radiation comes from a large machine outside
the body. Most women go to a hospital or clinic for treatment.
Treatments are usually 5 days a week for several weeks.
* Internal
radiation (implant radiation): Thin plastic tubes (implants) that hold a
radioactive substance are put directly in the breast. The implants stay
in place for several days. A woman stays in the hospital while she has
implants. Doctors remove the implants before she goes home.
Side effects depend mainly on the dose and type of radiation and the part of your body that is treated.
It
is common for the skin in the treated area to become red, dry, tender,
and itchy. Your breast may feel heavy and tight. These problems will go
away over time. Toward the end of treatment, your skin may become moist
and "weepy." Exposing this area to air as much as possible can help the
skin heal.
Bras and some other types of clothing may rub your
skin and cause soreness. You may want to wear loose-fitting cotton
clothes during this time. Gentle skin care also is important. You should
check with your doctor before using any deodorants, lotions, or creams
on the treated area. These effects of radiation therapy on the skin will
go away. The area gradually heals once treatment is over. However,
there may be a lasting change in the color of your skin.
You are
likely to become very tired during radiation therapy, especially in the
later weeks of treatment. Resting is important, but doctors usually
advise patients to try to stay as active as they can.
Although the side effects of radiation therapy can be distressing, your doctor can usually relieve them.
Chemotherapy
Chemotherapy
uses anticancer drugs to kill cancer cells. Chemotherapy for breast
cancer is usually a combination of drugs. The drugs may be given as a
pill or by injection into a vein (IV). Either way, the drugs enter the
bloodstream and travel throughout the body.
Women with breast
cancer can have chemotherapy in an outpatient part of the hospital, at
the doctor's office, or at home. Some women need to stay in the hospital
during treatment.
Side effects depend mainly on the specific
drugs and the dose. The drugs affect cancer cells and other cells that
divide rapidly:
* Blood cells: These cells fight infection, help
your blood to clot, and carry oxygen to all parts of the body. When
drugs affect your blood cells, you are more likely to get infections,
bruise or bleed easily, and feel very weak and tired. Years after
chemotherapy, some women have developed leukemia (cancer of the blood
cells).
* Cells in hair roots: Chemotherapy can cause hair loss. Your
hair will grow back, but it may be somewhat different in color and
texture.
* Cells that line the digestive tract: Chemotherapy can
cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip
sores.
Your doctor can suggest ways to control many of these side effects.
Some
drugs used for breast cancer can cause tingling or numbness in the
hands or feet. This problem usually goes away after treatment is over.
Other problems may not go away. In some women, the drugs used for breast
cancer may weaken the heart.
Some anticancer drugs can damage
the ovaries. The ovaries may stop making hormones. You may have symptoms
of menopause. The symptoms include hot flashes and vaginal dryness.
Your menstrual periods may no longer be regular or may stop. Some women
become infertile (unable to become pregnant). For women over the age of
35, infertility is likely to be permanent.
On the other hand, you
may remain fertile during chemotherapy and be able to become pregnant.
The effects of chemotherapy on an unborn child are not known. You should
talk to your doctor about birth control before treatment begins.
Hormone Therapy
Some
breast tumors need hormones to grow. Hormone therapy keeps cancer cells
from getting or using the natural hormones they need. These hormones
are estrogen and progesterone. Lab tests can show if a breast tumor has
hormone receptors. If you have this kind of tumor, you may have hormone
therapy.
This treatment uses drugs or surgery:
* Drugs:
Your doctor may suggest a drug that can block the natural hormone. One
drug is tamoxifen, which blocks estrogen. Another type of drug prevents
the body from making the female hormone estradiol. Estradiol is a form
of estrogen. This type of drug is an aromatase inhibitor. If you have
not gone through menopause, your doctor may give you a drug that stops
the ovaries from making estrogen.
* Surgery: If you have not gone
through menopause, you may have surgery to remove your ovaries. The
ovaries are the main source of the body's estrogen. A woman who has gone
through menopause does not need surgery. (The ovaries produce less
estrogen after menopause.)
The side effects of hormone therapy
depend largely on the specific drug or type of treatment. Tamoxifen is
the most common hormone treatment. In general, the side effects of
tamoxifen are similar to some of the symptoms of menopause. The most
common are hot flashes and vaginal discharge. Other side effects are
irregular menstrual periods, headaches, fatigue, nausea, vomiting,
vaginal dryness or itching, irritation of the skin around the vagina,
and skin rash. Not all women who take tamoxifen have side effects.
It
is possible to become pregnant when taking tamoxifen. Tamoxifen may
harm the unborn baby. If you are still menstruating, you should discuss
birth control methods with your doctor.
Serious side effects of
tamoxifen are rare. However, it can cause blood clots in the veins.
Blood clots form most often in the legs and in the lungs. Women have a
slight increase in their risk of stroke.
Tamoxifen can cause
cancer of the uterus. Your doctor should perform regular pelvic exams.
You should tell your doctor about any unusual vaginal bleeding between
exams.
When the ovaries are removed, menopause occurs at once.
The side effects are often more severe than those caused by natural
menopause. Your health care provider can suggest ways to cope with these
side effects.
Biological Therapy
Biological therapy helps the immune system fight cancer. The immune system is the body's natural defense against disease.
Some
women with breast cancer that has spread receive a biological therapy
called Herceptin® (trastuzumab). It is a monoclonal antibody. It is made
in the laboratory and binds to cancer cells.
Herceptin is given
to women whose lab tests show that a breast tumor has too much of a
specific protein known as HER2. By blocking HER2, it can slow or stop
the growth of the cancer cells.
Herceptin is given by vein. It may be given alone or with chemotherapy.
The
first time a woman receives Herceptin, the most common side effects are
fever and chills. Some women also have pain, weakness, nausea,
vomiting, diarrhea, headaches, difficulty breathing, or rashes. Side
effects usually become milder after the first treatment.
Herceptin
also may cause heart damage. This may lead to heart failure. Herceptin
can also affect the lungs. It can cause breathing problems that require a
doctor at once. Before you receive Herceptin, your doctor will check
for your heart and lungs. During treatment, your doctor will watch for
signs of lung problems.
Treatment Choices by Stage
Your treatment options depend on the stage of your disease and these factors:
* The size of the tumor in relation to the size of your breast
* The results of lab tests (such as whether the breast cancer cells need hormones to grow)
* Whether you have gone through menopause
* Your general health
Below
are brief descriptions of common treatments for each stage. Other
treatments may be appropriate for some women. Clinical trials can be an
option at all stages of breast cancer. "The Promise of Cancer Research"
section has information about clinical trials.
Stage 0
Stage 0 breast cancer refers to lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS):
*
LCIS: Most women with LCIS do not have treatment. Instead, the doctor
may suggest regular checkups to watch for signs of breast cancer.
Some
women take tamoxifen to reduce the risk of developing breast cancer.
Others may take part in studies of promising new preventive treatments.
Having
LCIS in one breast increases the risk of cancer for both breasts. A
very small number of women with LCIS try to prevent cancer with surgery
to remove both breasts. This is a bilateral prophylactic mastectomy. The
surgeon usually does not remove the underarm lymph nodes.
* DCIS:
Most women with DCIS have breast-sparing surgery followed by radiation
therapy. Some women choose to have a total mastectomy. Underarm lymph
nodes are not usually removed. Women with DCIS may receive tamoxifen to
reduce the risk of developing invasive breast cancer.
Stages I, II, IIIA, and Operable IIIC
Women
with Stage I, II, IIIA, and operable (can treat with surgery) IIIC
breast cancer may have a combination of treatments. Some may have
breast-sparing surgery followed by radiation therapy to the breast. This
choice is common for women with Stage I or II breast cancer. Others
decide to have a mastectomy.
With either approach, women
(especially those with Stage II or IIIA breast cancer) often have lymph
nodes under the arm removed. The doctor may suggest radiation therapy
after mastectomy if cancer cells are found in 1 to 3 lymph nodes under
the arm, or if the tumor in the breast is large. If cancer cells are
found in more than 3 lymph nodes under the arm, the doctor usually will
suggest radiation therapy after mastectomy.
The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors:
* The size, location, and stage of the tumor
* The size of the woman's breast
* Certain features of the cancer
* How the woman feels about saving her breast
* How the woman feels about radiation therapy
* The woman's ability to travel to a radiation treatment center
Some
women have chemotherapy before surgery. This is neoadjuvant therapy
(treatment before the main treatment). Chemotherapy before surgery may
shrink a large tumor so that breast-sparing surgery is possible. Women
with large Stage II or IIIA breast tumors often choose this treatment.
After
surgery, many women receive adjuvant therapy. Adjuvant therapy is
treatment given after the main treatment to increase the chances of a
cure. Radiation treatment can kill cancer cells in and near the breast.
Women also may have systemic treatment such as chemotherapy, hormone
therapy, or both. This treatment can destroy cancer cells that remain
anywhere in the body. It can prevent the cancer from coming back in the
breast or elsewhere.
Stages IIIB and Inoperable IIIC
Women
with Stage IIIB (including inflammatory breast cancer) or inoperable
Stage IIIC breast cancer usually have chemotherapy. (Inoperable cancer
means it cannot be treated with surgery.)
If the chemotherapy shrinks the tumor, the doctor then may suggest further treatment:
*
Mastectomy: The surgeon removes the breast. In most cases, the lymph
nodes under the arm are removed. After surgery, a woman may receive
radiation therapy to the chest and underarm area.
* Breast-sparing
surgery: The surgeon removes the cancer but not the breast. In most
cases, the lymph nodes under the arm are removed. After surgery, a woman
may receive radiation therapy to the breast and underarm area.
*
Radiation therapy instead of surgery: Some women have radiation therapy
but no surgery. The doctor also may recommend more chemotherapy, hormone
therapy, or both. This therapy may help prevent the disease from coming
back in the breast or elsewhere.
Stage IV
In most cases,
women with Stage IV breast cancer have hormone therapy, chemotherapy, or
both. Some also may have biological therapy. Radiation may be used to
control tumors in certain parts of the body. These treatments are not
likely to cure the disease, but they may help a woman live longer.
Many
women have supportive care along with anticancer treatments. Anticancer
treatments are given to slow the progress of the disease. Supportive
care helps manage pain, other symptoms, or side effects (such as
nausea). It does not aim to extend a woman's life. Supportive care can
help a woman feel better physically and emotionally. Some women with
advanced cancer decide to have only supportive care.
Recurrent Breast Cancer
Recurrent
cancer is cancer that has come back after it could not be detected.
Treatment for the recurrent disease depends mainly on the location and
extent of the cancer. Another main factor is the type of treatment the
woman had before.
If breast cancer comes back only in the breast
after breast-sparing surgery, the woman may have a mastectomy. Chances
are good that the disease will not come back again.
If breast
cancer recurs in other parts of the body, treatment may involve
chemotherapy, hormone therapy, or biological therapy. Radiation therapy
may help control cancer that recurs in the chest muscles or in certain
other areas of the body.
Treatment can seldom cure cancer that
recurs outside the breast. Supportive care is often an important part of
the treatment plan. Many patients have supportive care to ease their
symptoms and anticancer treatments to slow the progress of the disease.
Some receive only supportive care to improve their quality of life.
Breast Reconstruction
Some
women who plan to have a mastectomy decide to have breast
reconstruction. Other women prefer to wear a breast form (prosthesis).
Others decide to do nothing. All of these options have pros and cons.
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.
Breast reconstruction may be done at the same time as
the mastectomy, or later on. If you are thinking about breast
reconstruction, you should talk to a plastic surgeon before the
mastectomy, even if you plan to have your reconstruction later on.
There
are many ways to reconstruct the breast. Some women choose to have
implants. Implants may be made of saline or silicone. The safety of
silicone breast implants has been under review by the Food and Drug
Administration (FDA) for several years. If you are thinking about having
silicone implants, you may want to talk with your doctor about the FDA
findings. Your doctor can tell you if silicone implants are an option.
You also can read information from the FDA on breast implants at
http://www.fda.gov/cdrh/breastimplants/.
You also may have breast
reconstruction with tissue that the plastic surgeon moves from another
part of your body. Skin, muscle, and fat can come from your lower
abdomen, back, or buttocks. The surgeon uses this tissue to create a
breast shape.
Which type of reconstruction is best depends on
your age, body type, and the type of surgery you had. The plastic
surgeon can explain the risks and benefits of each type of
reconstruction.
Complementary and Alternative Medicine
Some women with breast cancer use complementary and alternative medicine (CAM):
* An approach is generally called complementary medicine when it is used along with standard treatment.
* An approach is called alternative medicine when it is used instead of standard treatment.
You may want to ask the doctor these questions before you decide to use CAM:
* What benefits can I expect from this approach?
* What are its risks?
* Do the expected benefits outweigh the risks?
* What side effects should I watch for?
* Will the approach change the way my cancer treatment works? Could this be harmful?
* Is this approach under study in a clinical trial? If so, who sponsors the trial?
* Will my health insurance pay for this approach?
Acupuncture,
massage therapy, herbal products, vitamins or special diets,
visualization, meditation, and spiritual healing are types of CAM.
Many
women say that CAM helps them feel better. However, some types of CAM
may change the way standard treatment works. These changes could be
harmful. And some types of CAM could be harmful even if used alone.
Some types of CAM are expensive. Health insurance may not cover the cost.
Nutrition and Physical Activity
It
is important for women with breast cancer to take care of themselves.
Taking care of yourself includes eating well and staying as active as
you can.
You need the right amount of calories to maintain a good
weight. You also need enough protein to keep up your strength. Eating
well may help you feel better and have more energy.
Sometimes,
especially during or soon after treatment, you may not feel like eating.
You may be uncomfortable or tired. You may find that foods do not taste
as good as they used to. In addition, the side effects of treatment
(such as poor appetite, nausea, vomiting, or mouth sores) can make it
hard to eat well. Your doctor, dietitian, or other health care provider
can suggest ways to deal with these problems. Also, the NCI booklet
Eating Hints for Cancer Patients has many useful ideas and recipes.
Many
women find they feel better when they stay active. Walking, yoga,
swimming, and other activities can keep you strong and increase your
energy. Exercise may reduce nausea and pain and make treatment easier to
handle. It also can help relieve stress. Whatever physical activity you
choose, be sure to talk to your doctor before you start. Also, if your
activity causes you pain or other problems, be sure to let your doctor
or nurse know about it.
Follow-up Care
Follow-up
care after treatment for breast cancer is important. Recovery is
different for each woman. Your recovery depends on your treatment,
whether the disease has spread, and other factors.
Even when the
cancer seems to have been completely removed or destroyed, the disease
sometimes returns because undetected cancer cells remained somewhere in
the body after treatment. Your doctor will monitor your recovery and
check for recurrence of the cancer.
You should report any changes
in the treated area or in your other breast to the doctor right away.
Tell your doctor about any health problems, such as pain, loss of
appetite or weight, changes in menstrual cycles, unusual vaginal
bleeding, or blurred vision. Also talk to your doctor about headaches,
dizziness, shortness of breath, coughing or hoarseness, backaches, or
digestive problems that seem unusual or that don't go away. Such
problems may arise months or years after treatment. They may suggest
that the cancer has returned, but they can also be symptoms of other
health problems. It is important to share your concerns with your doctor
so problems can be diagnosed and treated as soon as possible.
Follow-up
exams usually include the breasts, chest, neck, and underarm areas.
Since you are at risk of getting cancer again, you should have
mammograms of your preserved breast and your other breast. You probably
will not need a mammogram of a reconstructed breast or if you had a
mastectomy without reconstruction. Your doctor may order other imaging
procedures or lab tests.
Sources of Support
Learning
you have breast cancer can change your life and the lives of those
close to you. These changes can be hard to handle. It is normal for you,
your family, and your friends to have many different and sometimes
confusing feelings.
You may worry about caring for your family,
keeping your job, or continuing daily activities. Concerns about
treatments and managing side effects, 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 if you want to talk about your feelings or concerns. Often, a
social worker can suggest resources for financial aid, transportation,
home care, or emotional support.
Friends and relatives can be
very supportive. Also, you may find it helps to discuss your concerns
with others who have cancer. Women with breast cancer often get together
in support groups to share what they have learned about coping with
their disease and the effects of their treatment. It is important to
keep in mind, however, that each woman is different. Ways that one woman
deals with cancer may not be right for another. You may want to ask
your health care provider about advice you receive from other women with
breast cancer.
Several organizations offer special programs for
women with breast cancer. Women who have had the disease serve as
trained volunteers. They may talk with or visit women with breast
cancer, provide information, and lend emotional support. They often
share their experiences with breast cancer treatment, breast
reconstruction, and recovery.
You may be afraid that changes to
your body will affect not only how you look but also how other people
feel about you. You may worry that breast cancer and its treatment will
affect your sexual relationships. Many couples find it helps to talk
about their concerns. Some find that counseling or a couples' support
group can be helpful.
