What is breast cancer?
Breast cancer is a malignant (cancerous) tumor that starts in the breast. The disease occurs mostly in women, but men can get breast cancer as well. The information here refers only to breast cancer in women.
A woman's breast is made up of :
glands that make breast milk (lobules )
ducts (small tubes that connect lobules to the nipple)
fatty and connective tissue, blood vessels
lymph (pronounced limf) vessels
Most breast cancers begin in the ducts (ductal carcinoma), some begin in the lobules (lobular carcinoma), and the rest in other tissues. Lymph vessels are like veins, except that they carry lymph fluid instead of blood. Lymph is a clear fluid that contains immune system cells and waste products. Lymph vessels lead to small, bean-shaped collections of tissue called lymph nodes. Most lymph vessels of the breast lead to lymph nodes under the arm. These are called axillary nodes.
If breast cancer cells reach the underarm lymph nodes and continue to grow, they cause the nodes to swell. Once cancer cells have reached these nodes, they are more likely to spread to other organs of the body.
What are benign breast lumps?
Most breast lumps are benign. Benign breast tumors are abnormal growths, but they are not cancerous They do not spread outside of the breast and are not life threatening. But some benign breast lumps can increase a woman's risk of getting breast cancer.
Most lumps turn out to be caused by fibrocystic changes. Cysts are fluid-filled sacs. Fibrosis is the formation of scar-like tissue. Such changes can cause breast swelling and pain. The breasts may feel lumpy, and sometimes there is a clear or slightly cloudy nipple discharge.
What are the main types of breast cancer?
The most common types of breast cancer are:
Carcinoma in situ: This term is used for early stage cancer, when it is confined to the place where it started. In breast cancer, it means that the cancer is confined to the ducts or the lobules, depending on where it started. It has not gone into the fatty tissues in the breast nor spread to other organs in the body.
Ductal carcinoma in situ (DCIS): This is the most common type of noninvasive breast cancer. DCIS means that the cancer is confined to the ducts. It has not spread through the walls of the ducts into the fatty tissue of the breast. Nearly all women with cancer at this stage can be cured. The best way to find DCIS early is with a mammogram.
Lobular carcinoma in situ (LCIS): This condition begins in the milk-making glands but does not go through the wall of the lobules. Although not a true cancer, having LCIS increases a woman's risk of getting cancer later. For this reason, it's important that women with LCIS to follow the screening guidelines for breast cancer
Infiltrating (invasive) ductal carcinoma (IDC): This is the most common breast cancer. It starts in a milk passage or duct, breaks through the wall of the duct, and invades the fatty tissue of the breast. From there it can spread to other parts of the body. IDC is the most common type of breast cancer. It accounts for about 80% of invasive breast cancers.
Infiltrating (invasive) lobular carcinoma (ILC): This cancer starts in the milk glands or lobules. It can spread to other parts of the body. About 10% of invasive breast cancers are of this type.
How many women get breast cancer?
Breast cancer is the most common cancer among women, other than skin cancer. It is the second leading cause of cancer death in women, after lung cancer.
About 212,920 women in the United States will be found to have invasive breast cancer in 2006. About 40,970 women will die from the disease this year. Right now there are slightly over 2 million women living in the United States who have been treated for breast cancer.
The chance of a woman having invasive breast cancer some time during her life is about 1 in 8. The chance of dying from breast cancer is about 1 in 33. Breast cancer death rates are going down. This decline is probably the result of finding the cancer earlier and improved treatment.
What causes breast cancer?
We do not yet know exactly what causes breast cancer, but we do know that certain risk factors are linked to the disease. Some risk factors, such as smoking, can be controlled. Others, like a person's age or family history, can't be changed. But having a risk factor, or even several, doesn’t mean that a person will get the disease.
Some women who have one or more risk factors never get breast cancer. And most women who do get breast cancer don’t have any risk factors. While all women are at risk for breast cancer, the factors listed below can increase a woman’s chances of having the disease.
Risk factors you cannot change
Gender: simply being a woman is the main risk for breast cancer. While men can also get the disease, it is about 100 times more common in women than in men
Age: The chance of getting breast cancer goes up as a woman gets older. Nearly 8 out of 10 breast cancers are found in women over age 50
Genetic risk factors: About 5% to 10% of breast cancers are linked to changes (mutations) in certain genes. The most common gene changes are those of the BRCA1 and BRCA2 genes. Women with these gene changes have up to an 80% chance of getting breast cancer during their lifetimes. Other gene changes may raise breast cancer risk as well
Family history: Breast cancer risk is higher among women whose close blood relatives have this disease. The relatives can be from either the mother’s or father’s side of the family. Having a mother, sister, or daughter with breast cancer about doubles a woman’s risk
Personal history of breast cancer: A woman with cancer in one breast has a greater chance of getting a new cancer in the other breast or in another part of the same breast. This is different from the first cancer coming back (recurrence)
Race: White women are slightly more likely to get breast cancer than are African-American women. But African American women are more likely to die of this cancer. Many experts now believe that the main reason for this is because they have faster growing tumors. Asian, Hispanic, and American Indian women have a lower risk of getting breast cancer
Earlier abnormal breast biopsy: Certain types of abnormal biopsy results can be linked to a slightly higher risk of breast cancer
Earlier breast radiation: Women who have had radiation treatment to the chest area earlier in life have a greatly increased risk of breast cancer
Menstrual periods: Women who began having periods early (before 12 years of age) or who went through the change of life (menopause) after the age of 55 have a slightly increased risk of breast cancer
Treatment with DES: In the past, some pregnant women were given the drug DES (diethylstilbestrol) because it was thought to lower their chances of losing the baby. Recent studies have shown that these women have a slightly increased risk of getting breast cancer.
Breast Cancer Risk and Lifestyles
Not having children: Women who have had not had children, or who had their first child after age 30, have a slightly higher risk of breast cancer. Being pregnant more than once and at an early age reduces breast cancer risk.
Birth control pills: It is still not clear what part birth control pills might play in breast cancer risk. Studies have found that women now using birth control pills have a slightly greater risk of breast cancer. Women who stopped using the pill more than 10 years ago do not seem to have any increased risk.
Hormone replacement therapy (HRT): It has become clear that long-term use (several years or more) of combined HRT (estrogens together with progesterone) after menopause increases the risk of breast cancer as well as the risk of heart disease, blood clots, and strokes. The breast cancers are also found at a more advanced stage, perhaps because HRT seems to reduce the effectiveness of mammograms. Five years after stopping HRT, the breast cancer risk appears to drop back to normal. Estrogen alone (ERT) does not seem to increase the risk of breast cancer as much, if at all.
Breast-feeding and pregnancy: Some studies have shown that breast-feeding slightly lowers breast cancer risk, especially if the breast-feeding lasts 1½ to 2 years. This could be because breast-feeding lowers a woman’s total number of menstrual periods, as does pregnancy. One study found that having more children and breast-feeding longer could reduce the risk of breast cancer by half
Alcohol: Use of alcohol is clearly linked to a slightly increased risk of getting breast cancer. Women who have 1 drink a day have a very small increased risk. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol. The ACS suggests limiting the amount you drink.
Diet: Being overweight is linked to a higher risk of breast cancer, especially for women after change of life and if the weight gain took place during adulthood. Also, the risk seems to be higher if the extra fat is in the waist area. But the link between weight and breast cancer risk is complex, and studies of fat in the diet as it relates to breast cancer risk have often given conflicting results.
Exercise: Studies show that exercise reduces breast cancer risk. The only question is how much exercise is needed. One study found that as little as 1 hour and 15 minutes to 2 and a half hours per week of brisk walking reduced the risk by 18%. Walking 10 hours a week reduced the risk a little more.
Uncertain Risk Factors
A lot of research is being done to learn how the environment might affect breast cancer risk. At this time, research does not show a clear link between breast cancer risk and environmental pollutants, such as pesticides and PCBs.
While a direct link between smoking and breast cancer has not been found, some studies suggest it might increase breast cancer risk, particularly for women who start smoking as teens. Smoking affects your overall health and increases the risk for many other cancers, as well as heart disease. If you smoke, you should make every attempt to quit.
Internet e-mail rumors have suggested that underarm antiperspirants can cause breast cancer. There is very little evidence to support this idea. Also, there is no evidence to support the idea that underwire bras cause breast cancer.
Several studies show that induced abortions do not increase the risk of breast cancer. Also, there is no evidence to show a direct link between miscarriages and breast cancer.
Silicone breast implants can cause scar tissue to form in the breast. But several studies have found that this does not increase breast cancer risk. If you have breast implants, you might need a special x-ray picture during mammography.
A few recent studies have suggested that women who work at night (nurses on the night shift, for example) have a higher risk of breast cancer. But this has not yet been proven. Also, a recent study suggested women who took antibiotics may have a slightly higher risk of breast cancer. This link is also not clear yet.
How Is Breast Cancer Found?
The earlier breast cancer is found, the better the chances that treatment will work. The goal is to find cancers before they start to cause symptoms. The size of a breast cancer and how far it has spread are the most important factors in predicting the outlook for the patient. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year. Following the guidelines given here improves the chances that breast cancer can be found at an early stage and treated successfully.
American Cancer Society ( ACS) Guidelines for Early Breast Cancer Detection
The ACS recommends the following guidelines for finding breast cancer early in women without symptoms:
Mammogram: Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.
Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, preferably every 3 years. After age 40, women should have a breast exam by a health expert every year. It might be a good idea to have the CBE shortly before the mammogram. You can use the exam to learn what your own breasts feel like.
Breast awareness and breast self-exam (BSE): BSE is an option for women starting in their 20s. If you decide to do BSE, you should have your doctor or nurse check your method to make sure you are doing it right. If you do BSE on a regular basis, you get to know how your breasts normally feel. Then you can more easily notice changes. But it’s OK not to do BSE or not to do it on a fixed schedule.
The most important thing is to see your doctor right away if you notice any of these changes:
a lump or swelling
skin irritation or dimpling
nipple pain or the nipple turning inward
redness or scaliness of the nipple or breast skin
discharge other than breast milk.
But remember that most of the time these breast changes are not cancer.
Women at high risk: Women with a higher risk of breast cancer should talk with their doctor about the best approach for them. This might mean starting mammograms when they are younger, having extra tests, or having more frequent exams.
Mammograms
A mammogram is an x-ray of the breast that is used to detect breast disease.
During a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. The pressure lasts only for a few seconds and usually causes minimial discomfort. Very low levels of radiation are used. The whole procedure takes approxiamately 20 minutes.
If something suspicious is detected, additional testing may be required. Although about 1 in 10 women who get a mammogram will require additional testing, most of these women do not have breast cancer. .
Women with a high risk of breast cancer should talk with their doctor about the best approach for them. They may benefit from starting mammograms when they are younger, having them more often, or having other tests. If you are at higher risk, your doctor might recommend ultrasound or MRI .
Clinical Breast Exam
A clinical breast exam (CBE) is an exam of your breasts by a health expert such as a doctor, nurse practitioner, nurse, or physician assistant. For this exam, you undress from the waist up. The examiner will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, she or he will gently feel your breasts for lumps. The area under both arms will also be examined. This is a good time to learn how to do breast self-exam if you don’t already know how.
Breast Awareness and Breast Self-Exam
Women should be aware of how their breasts normally feel and report any changes to their doctor right away. Finding a change does not mean that you have cancer.
By being aware of how your own breasts feel, you are likely to notice any changes that take place. You can also choose to use a step-by-step approach to checking your breasts on a set schedule. The best time to do breast self-examination (BSE) is when your breasts are not tender or swollen. If you find any changes, see your doctor right away.
It’s OK for women not to do BSE or to do it once in a while. The ACS has detailed information on how to do BSE for women who want to do it.
Symptoms of breast cancer
While the widespread use of screening mammography has increased the number of breast cancers found before they cause any symptoms, some are still missed.
The most common sign of breast cancer is:
a new lump or mass
a lump that is painless, hard, and has uneven edges. but some cancers are tender, soft, and rounded.
It's important to have anything unusual checked by your doctor.
Other signs of breast cancer include the following:
a swelling of part of the breast
skin irritation or dimpling
nipple pain or the nipple turning inward
redness or scaliness of the nipple or breast skin
a nipple discharge other than breast milk
a lump in the underarm area
If Breast Cancer Is Suspected
If there is any reason to think you might have breast cancer, you will need other tests. After asking you some questions and doing a complete physical exam (including a clinical breast exam), your doctor may suggest further tests such as the ones below.
Imaging Tests
Mammography: Although mammograms are mostly used for screening, they can also be used if there is reason to think you might have breast cancer. These are called diagnostic mammograms. This kind of mammogram might show that everything is OK and you can return to having yearly mammograms. Or it might show that a biopsy should be done. Even if the mammogram doesn’t show a tumor, if you or your doctor can feel a lump you may need a biopsy. The exception would be if ultrasound shows that the lump is a cyst.
A mammogram cannot show for sure whether cancer is present or not. If your mammogram points to a possible problem, a sample of breast tissue is removed and looked at under a microscope. This is called a biopsy.
Breast ultrasound: An ultrasound uses sound waves to outline a part of the body. The sound wave echoes are picked up by a computer to create an image (picture) that is displayed on the computer screen.
Ultrasound has become a good method to use along with mammograms. It is widely available and costs less than other tests. Usually, it is used to look at a certain area of concern found by the mammogram. It also hel ps to tell the difference between cysts and solid masses without using a needle to draw out fluid.
A ductogram (also called a galactogram ) is a special kind of x-ray that is sometimes helpful in finding the cause of a nipple discharge. A fine plastic tube is placed into the opening of the duct at the nipple. A substance is injected to outline the shape of the duct on an x-ray picture. It will show if there is a mass inside the duct. If there is a discharge, the fluid can be tested for cancer cells.
MRI (magnetic resonance imaging): An MRI scan uses radio waves and strong magnets instead of x-rays. A computer translates these waves into a very detailed picture. Special types of MRIs can be used to better examine cancers found by mammograms or for women who have a high risk of breast cancer. But we don’t know yet whether finding small cancers this way will really save lives.
There are several other tests that can help tell the doctor more about your own situation. If you will have any of these, feel free to ask your doctor to explain them to you.
Biopsy
A biopsy is done when other tests show that you might have breast cancer. The only way to know for sure is for you to have a biopsy. During this test, cells from the breast are removed so they can be studied in the lab. There are several kinds of biopsies. The doctor will select the one best for you.
Fine needle aspiration biopsy (FNAB): A very thin (fine) needle is used in this test to try to draw fluid out of the lump. Your doctor might use ultrasound to guide the needle into the lump. The area may be numbed or not. Sometimes the process of giving the anesthetic could cause more discomfort than the biopsy itself.
If the fluid drawn out is clear, the lump is most likely a benign cyst. Bloody or cloudy fluid can mean either a cyst or, rarely, cancer. If the lump is solid, small pieces of tissue are removed. These will be looked at under a microscope to see if they are cancer.
If the biopsy does not provide a clear answer, or your doctor is still not sure, a second biopsy or a different type of biopsy may be needed.
Stereotactic core needle biopsy: The needle used for this test is larger than the one for fine needle biopsy. It is used to remove several cylinders of tissue. The biopsy is done with local anesthesia (the area is numbed) on an outpatient basis.
Surgical biopsy: Sometimes surgery is needed to remove all or part of a lump so it can be looked at under a microscope. The entire lump as well as some normal tissue around it may be removed. Most often this is done in the hospital on an outpatient basis. Local anesthesia is used and sedation may also be given to relax you and make you less aware of the process.
Ask your doctor which kind of biopsy you will have and what you can expect during and after the test.
Biopsy lab tests: The tissue removed during a biopsy is looked at in the lab to see whether it is benign or cancerous. If it is not cancer, then no further treatment is needed. If it is cancer, the biopsy can help to tell the type of cancer you have and show whether it is invasive or not.
The biopsy sample is also given a grade from 1 to 3. Cancers that look more like normal breast tissue tend to grow and spread more slowly. In general, a lower grade number means a slower-growing cancer, while a higher number means a faster-growing cancer. So the grade helps predict the outcome (prognosis) for the woman.
The biopsy sample can also be tested to see whether it has receptors for certain hormones such as estrogen and progesterone. If it does, it is often referred to as ER-positive or PR-positive. Such cancers tend to have a better outlook than cancers without these receptors because they are much more likely to respond to hormone treatment. About 2 out of 3 breast cancers have these receptors.
Other lab tests may also be done to help figure out how quickly the cancer is growing and what treatments might work best.
Tests to Find Breast Cancer Spread
Chest x-ray: This test may be done to see whether the cancer has spread to the lungs.
Bone scan: This test can help show whether the cancer has spread to the bones. The patient is given a very low dose of radiation. The bone attracts the radiation which will show up on the scan as a "hot spot." These hot spots could be cancer but other problems such as arthritis can also be the cause. Therefore, x-rays of hot spots may be needed.
CT scan (computed tomography): A CT scan is a special type of x-ray. Many pictures are taken from different angles. These images are combined by a computer to produce a detailed picture of the internal organs. This test can help tell if the cancer has spread to the liver or other organs. It can also be used to guide a biopsy needle into a suspicious area.
MRI (magnetic resonance imaging): An MRI scan uses radio waves and strong magnets instead of x-rays. This test can be helpful in looking at the brain and spinal cord.
PET scan (positron emission tomography): This test uses a form of sugar that contains a radioactive atom. Cancer cells absorb high amounts of this sugar. A special camera can then spot these cells. PET is useful when the doctor thinks the cancer has spread but doesnÂ’t know where. It may also be useful in checking lymph nodes for cancer before they are removed.
There are other tests that might be done to help the doctor decide on the best treatment for you. Feel free to ask the doctor to explain any other tests you are having.
If cancer is found there is time for you to learn about the disease. A biopsy is done first, followed by further testing and then a decision about treatment is made. You have time to talk to your doctor and family before choosing a course of action. There is no need to rush into treatment. You may also want to get a second opinion before you decide on the treatment that is best for you.
Staging
Staging is the process of finding out how widespread the cancer is. The stage of a cancer is the most important factor in choosing among treatment options. The stage, in turn, is based on the results of the physical exam, biopsy, and other tests the doctor may have ordered.
The most common system used to describe the stages of breast cancer is the AJCC/TNM system. This system takes into account the tumor (T), whether the cancer has spread to lymph nodes (N), and whether it has spread to distant organs (M , for metastasis). Numbers after the T, N, and M give details about the cancer.
All of this information is combined in a process called stage grouping. The stage is then expressed as a Roman numeral. After stage 0 (carcinoma in situ), the other stages are I through IV (1-4). Some of the stages are further sub-divided using the letters A, B, and C. In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more advanced cancer.
After looking at your test results, the doctor will tell you the stage of your cancer. Breast cancer staging can be complex. Be sure to ask your doctor to explain your stage in a way you understand. This will help you both decide on the best treatment for you.
Breast Cancer Survival by Stage
The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is found. Of course, many people live much longer than 5 years. Five-year relative survival rates leave out patients dying of other diseases. This means that anyone who died of another cause, such as heart disease, is not counted.
The numbers below are based on the precise stage of the cancer. Check with your doctor to find out the exact stage of your cancer. The numbers are also based on women treated a number of years ago. Because we now find more cancers early and use newer treatments, the survival rates are getting better all the time.
Stage 5-year Relative Survival Rate
0 100%
I 100%
IIA 92%
IIB 81%
IIIA 67%
IIIB 54%
IV 20%
While these numbers provide an overall picture, keep in mind that every woman’s situation is unique and the statistics can’t predict exactly what will happen in your case.
Talk with your cancer care team if you have questions about your own chances of a cure, or how long you might survive your cancer. They know your situation best
How Is Breast Cancer Treated?
Local vs. Systemic Treatment
The purpose of local treatment is to treat a tumor without affecting the rest of the body. Surgery and radiation are examples of local treatment.
Systemic treatment is given into the bloodstream or by mouth to reach cancer cells that may have spread beyond the breast. Chemotherapy, hormone therapy, and immunotherapy are systemic treatments.
When people who seem to have no cancer left after surgery are given more treatment it is referred to as adjuvant therapy. Doctors now think that cancer cells can break away from the main tumor and begin to spread through the bloodstream in the early stages of the disease. It’s very hard to tell if this has happened. But if it has, the cancer cells can start new tumors in other organs or the bones. The goal of adjuvant therapy is to kill these hidden cells.
Some people are given systemic treatment (most likely chemotherapy) before surgery to shrink a tumor. This is called neoadjuvant therapy.
Lumpectomy
Partial Mastectomy
Modified Radical Mastectomy
Radical Mastectomy
Types of Surgery for Breast Cancer
Most women with breast cancer will have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm (axillary dissection), to restore the breast's appearance (reconstructive surgery), or to relieve symptoms of advanced cancer. Here is a summary of some of the most common types of breast cancer surgery:
Lumpectomy: Also called breast conservation therapy, lumpectomy involves removing only the breast lump and some normal tissue around it. Radiation treatment is often given for about 6 weeks after this type of surgery. If chemotherapy is going to be used as well, the radiation may be postponed until the chemo is finished.
Partial (segmental) mastectomy : This surgery involves removing more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy.
Simple or total mastectomy: In this surgery the entire breast is removed but not the lymph nodes under the arm or muscle tissue from beneath the breast.
Modified radical mastectomy: This operation involves removing the entire breast and some of the lymph nodes under the arm.
Radical mastectomy: This is extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast. This surgery is rarely done now because modified radical mastectomy has proven to be just as effective with less disfigurement and fewer side effects.
Choosing Between Lumpectomy and Mastectomy
One advantage of lumpectomy is that it saves the way the breast looks. A downside is the need for several weeks of radiation after surgery. But some women who have a mastectomy will still need radiation. For most women with stage I or II breast cancer, lumpectomy or partial mastectomy (along with radiation) is as good as mastectomy. There is no difference in the survival rates of women treated with these 2 methods. Other factors, though, can affect which type of surgery is best for you. And lumpectomy is not an option for all women with breast cancer. Your doctor can tell you if there are reasons why a lumpectomy is not right for you.
Possible side effects of mastectomy and lumpectomy include infection and blood or fluid collecting at the place where the incision is made. If lymph nodes are removed, there could be other side effects as well such as swelling of the arm (lymphedema).
Other Breast Cancer Surgeries
Axillary dissection: This operation is done to find out if the breast cancer has spread to lymph nodes under the arm. Some nodes are removed and looked at under a microscope. Knowing whether there are cancer cells in the lymph nodes can help guide other treatment decisions.
A possible side effect of removing these lymph nodes is swelling of the arm, called lymphedema. It happens to between 1 and 3 out of 10 women who have had these nodes removed. Women who have swelling, tightness, or pain in the arm after lymph node surgery should be sure to tell their doctor right away. Often there are measures to prevent or reduce the effects of the swelling. The American Cancer Society has more information about lymphedema available through our toll-free number or on our Web site.
Sentinel lymph node biopsy: This is a way to look at the lymph nodes without having to remove all of them first. For this test, a radioactive substance and a dye are injected near the tumor. They are carried by the lymph system to the first (sentinel) node to receive lymph from the tumor. This lymph node is the one most likely to contain cancer cells if the cancer has spread. Once this node is found, it is removed and examined. If the sentinel node contains cancer, more lymph nodes are removed. If it is free of cancer, further lymph node surgery might not be needed. This type of biopsy is complex, so it is best to have it done by someone with a lot of experience in doing it.
Reconstructive or breast implant surgery: These operations are not meant to treat the cancer but are done to restore the way the breast looks after mastectomy. If you are having a mastectomy and are thinking about having reconstruction right away, you should talk to a plastic surgeon before your operation. There are several choices about when the surgery can be done and exactly what type it will be.
What to Expect with Surgery
For many women, the thought of surgery can be frightening. But a better understanding of what to expect before, during, and after the operation may help ease your fears.
A few days after your biopsy you will know whether or not you have cancer, but the extent of the disease will not be known until after surgery. You will most likely meet with your surgeon a few days before the operation to talk about what will happen. You will be asked to sign a consent form giving the doctor permission to do the surgery. This is a good time to ask any questions you might have.
You may be asked to donate blood ahead of time in case you need it during the surgery. Your doctor will also ask you about medicines you are taking. You might need to stop taking some of them a week or two before surgery.
The type of anesthesia you will have depends largely on the kind of surgery being done and your own situation. How long the surgery will take and how long you will be in the hospital also depends on the type of surgery you are having.
As a rule, women having a mastectomy stay in the hospital for 1 or 2 nights and then go home. Lumpectomy and sentinel lymph node biopsy are usually done on an outpatient basis and do not require an overnight stay in the hospital.
The length of the operation depends on the type of surgery you’re having. For example, a mastectomy with lymph node removal will take from 2 to 3 hours.
After surgery you will have a bandage over the surgery site. You may have one or more tubes (drains) from the breast or underarm area to remove fluid that collects during the healing process. Most drains stay in place for a week or two. Once the flow has gone down to about one ounce a day, the drain will be removed.
Most doctors will want you to start moving the arm soon after surgery so that it won’t get stiff. Women who have a lumpectomy or mastectomy are usually surprised by how little pain they have in the breast area. But they are less happy with the strange feelings (numbness, pinching/pulling) in the underarm area.
Talk with your doctor about what you should do after the surgery to care for yourself. YouÂ’ll probably get written instructions that will tell you about the following:
how to take care of the wound and dressing
how to take care of the drains
how to know if you have an infection
when to call the doctor or nurse
when to begin using the arm and how to do arm exercises to prevent stiffness
when to start wearing a bra again
when and how to wear a breast form
what to eat and what not to eat
what medicines to take (including pain medicines)
what activities you should or should not do
what feelings you might have about how you look
You will see your doctor a week or 2 after surgery. He or she should explain the results of your pathology report and talk to you about whether you will need further treatment.
Chemotherapy
Chemotherapy is the use of anticancer drugs injected into a vein or taken as a pill. These drugs enter the bloodstream and reach throughout the body, making the treatment useful for cancers that have spread to distant organs. While these drugs kill cancer cells, they also damage some normal cells, which can lead to side effects.
If chemotherapy is given after surgery it can reduce the chance of breast cancer coming back. Chemotherapy can also be used as the main treatment for a woman whose cancer has already spread outside the breast and underarm area or that spreads widely after the first treatment.
Chemotherapy may be given before surgery, often to shrink the tumor in order to make it easier to remove. This approach also allows the doctors to watch how the tumor responds to the drugs. If the tumor does not shrink, different drugs can be used.
Chemotherapy is given in cycles, with each period of treatment followed by a break. The total course of treatment usually lasts for 3 to 6 months. Often several drugs are used together rather than a single drug alone.
The side effects of chemotherapy depend on the type of drugs used, the amount given, and the length of treatment. You could experience some of these temporary side effects:
being very tired (fatigue, caused by a shortage of red blood cells)
nausea and vomiting
loss of appetite
hair loss
mouth sores
changes in menstrual cycle (this could be permanent)
a higher risk of infection (from a shortage of white blood cells)
bruising or bleeding after minor cuts (from a shortage of blood platelets)
Most of these side effects go away when treatment is over. For example, your hair will grow back. If you have any problems with side effects, be sure to tell your doctor or nurse because there are often ways to help.
Permanent side effects can include early change of life (menopause) and not being able to become pregnant. Heart damage can occur if the drug Adriamycin is used for a long time or in high doses, but doctors are careful to control the dose of this drug and to watch for signs of problems.
Also, many women who have had chemotherapy notice a slight decrease in concentration and memory . This may last a long time.
Very rarely, years after treatment for breast cancer, certain chemotherapy drugs may cause another cancer called acute myeloid leukemia. But the benefit of treating the breast cancer far outweighs the risk of this rare event.
Lastly, many women do not feel as healthy after having chemotherapy as they did before. There may be pain and a mild loss of physical functioning.
Radiation Therapy
Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor.
Most often, external radiation is used for treating breast cancer. It is much like getting a regular x-ray but for a longer period of time. Radiation therapy may be used to destroy cancer cells remaining in the breast, chest wall, or underarm area after surgery or- less often-to reduce the size of a tumor before surgery.
Treatment is usually given 5 days a week in an outpatient center over a period of about 6 weeks, beginning about a month after surgery. Each treatment lasts a few minutes. The treatment itself is painless. If it is used along with chemotherapy, radiation is usually given after chemotherapy is finished.
One method being used is called Mammosite. It consists of a balloon attached to a thin tube. The balloon is placed into the lumpectomy space and filled with salt water. Radioactivity is added through the tube. The radioactive material is added and removed twice a day for 5 days. Then the balloon is removed.
The main side effects of radiation therapy are swelling and heaviness in the breast, sunburn-like changes in the treated area, and fatigue. These changes to the breast tissue and skin usually go away in 6 to 12 months. In some women, the breast becomes smaller and firmer after radiation therapy. Radiation therapy is not given during pregnancy because it can harm the fetus.
Another way to give radiation is to place radioactive seeds (pellets) into the breast tissue next to the cancer. It may be given to add an extra “boost” of radiation to the tumor. It is also being studied as the only source of radiation. So far the results have been good, but more study is needed with this method before it can be used as standard treatment.
Hormone Therapy
The female hormone estrogen promotes the growth of breast cancer cells in some women. For these women, several methods to block the effect of estrogen or to lower its levels are used to treat breast cancer.
A drug such as tamoxifen , which blocks the effects of estrogen, can be given to counter the effects of estrogen. Tamoxifen is taken in pill form, usually for 5 years after surgery, to reduce the risk the cancer will come back. Recent studies have clearly shown that this drug helps women of all ages with early breast cancer if their cancer has estrogen receptors. It is also used to reduce the risk of breast cancer in women who are at high risk.
Some studies have shown an increase of early stage cancer of the lining of the uterus among women taking tamoxifen. But this cancer is usually found at a very early stage and is almost always cured by surgery. Tell your doctor right away if you have any unusual vaginal bleeding. Blood clots are another possible side effect of tamoxifen. Others can include hot flashes and mood swings. Still, for most women with breast cancer, the benefits of tamoxifen far outweigh the risks.
Aromatase inhibitors are a type of drug that stops the body from making estrogen. They only work for women who are past menopause and whose cancers are hormone positive. These drugs may be used after, or even instead of, tamoxifen to reduce the risk of the breast cancer coming back. They don’t cause uterine cancer and very rarely cause blood clots. They can, however, cause bone thinning and fractures because they remove estrogens from the body.
There are several other drugs that affect female hormones which are being used for breast cancer. Your doctor can give you more details about any recommended treatments.
Other Treatments
Trastuzumab (Herceptin) is a drug that attaches to a growth-promoting protein (HER2/neu) that is found in small amounts on the surface of normal breast cells and most breast cancers. Some breast cancers have too much of this protein, which can cause the cancer to grow and spread faster. Herceptin can stop this protein from causing breast cancer cell growth. It may also help the immune system to better attack the cancer.
Recent studies have shown that adding trastuzumab to chemotherapy lowers the rate of cancer coming back and the death rate over chemotherapy alone after surgery for certain women. This approach may become standard adjuvant treatment in these cases.
The side effects of this drug are fairly mild. They may include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. But some women have heart damage during treatment. If you are having this treatment, you should tell your doctor right away if you have any shortness of breath or trouble with physical activities.
Two drugs (bisphosphonates) that help strengthen bones are in use. They are given into a vein to help prevent bone damage if the cancer has spread to the bone.
In the past, it was thought that very high doses of chemotherapy followed by a method called stem cell transplant might offer some women with a high risk of the cancer coming back or with advanced cancer the best chance for a cure. But doctors have found that the women who received high dose therapy did not live any longer than women who had standard dose chemotherapy. And high dose chemotherapy with stem cell support can cause serious side effects. Research in this area is still going on. For now, experts in the field suggest that women receive this treatment only as part of a clinical trial.
