Discuss all medical advice, diagnosis, and treatment with your healthcare provider.

The Basics

Understanding breast cancer and risk factors for developing breast cancer

Anatomy of the breasts
It is important to understand the structure and location of the breasts and the structures connecting the breasts to the rest of the body enabling them to function as glands.

The breasts are gland-containing organs situated on the front of the chest. Each breast consists of 15 to 20 lobes, which are sections of glandular tissue that together make up the breast as a whole. Within the lobes are many smaller sections called 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 tissue and glands of the breast are connected to the rest of the body via lymph and blood vessels (arteries and veins). Lymph vessels are similar to blood vessels. However, they contain lymphatic fluid, a type of body fluid that contains white blood cells, the immune cells that defend the body against infection and disease. These lymph vessels lead to small, round organs called lymph nodes, sometimes called lymph glands. Some groups of lymph nodes are situated near the breast in the axilla (underarm). Other lymph nodes are situated in locations near the breast including above the collarbone and in the chest behind the breastbone. The lymph nodes trap bacteria, cancer cells, or other harmful substances and, therefore, are involved in the body's immune response to disease.

In 2007 the American Cancer Society (ACS) estimates that breast cancer is the most common cancer to be diagnosed in women and the second most common cause of cancer death in women after lung and bronchial cancer. Also according to the ACS one in eight American women are at risk of developing breast cancer in their lifetime. Scientists are studying breast cancer to learn more about its causes, and they are looking for better ways to prevent, find, and treat it.

Cancer is a disease that begins in cells, the building blocks that form the 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 breaks down. 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; however, sometimes they may cause damage to surrounding tissue through pressure and therefore need to be removed.
• Generally, if a benign tumor is removed, it usually does 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 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 blood vessels or lymphatic vessels that connect organs to the rest of the body. 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 the lymph nodes near the breast such as under the armpit or above the collarbone. Also, breast cancer can spread to almost any other part of the body via blood and lymph vessels. The most common places for breast cancer cells to spread to are the bones, liver, lungs, and brain. When breast cancer cells spread, new foci of tumors arise, and these new tumors have the same 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, because the disease started with a tumor originally in the breast that spread to the bones. For this reason, it is treated as breast and not bone cancer. The new tumor in the bone is also called "distant" or metastatic disease.

Risk factors
No one knows the exact cause of breast cancer. Often there is no explanation for why one woman develops breast cancer and another woman does not. 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.

Research studies have found the following risk factors for breast cancer:

• Age: The chance of getting breast cancer increases as a woman ages. 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. Healthcare 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. The National Cancer Institute (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 certain types of hormone therapy after menopause may have an increased risk of developing 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 in 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 (thick) 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 US 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 is being studied.
• 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. Many risk factors can be avoided. Others, such as family history, cannot. Women can help protect themselves by avoiding 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 healthcare professional. He or she may be able to suggest ways to reduce your risk and can plan a schedule for checkups (usually with screening or checkup mammograms).

Researchers are also studying the effect of diet, physical activity, and genetics on breast cancer risk and whether certain substances in the environment can increase the risk of breast cancer.

Diet
Several studies have suggested that eating a high-fat diet may increase the risk of breast cancer; other studies have not found this to be so. Still, because a high-fat diet is associated with an increased risk of other cancers and heart disease, it's a good idea to limit the amount of fat you eat.

Alcohol
Some studies suggest that drinking alcohol on a regular basis may increase your risk for breast cancer. Like the diet evidence, these studies have also been confusing, and further studies are needed.

Genes
Up to 10% of breast cancers are believed to be inherited. In 1994, researchers found a gene called BRCA1, or breast cancer 1. Although we all carry this gene, it may be defective in one in 400 women, and this gene mutation may be responsible for half of all cases of hereditary breast cancer. Women who carry the mutated gene have an 85% chance of developing breast cancer, often before they turn 50.

Researchers have also found a second breast cancer gene, BRCA2, which they believe is responsible for about 5% of inherited breast cancers. And they expect to find several more breast cancer genes in the coming years.

Hormones
Several hormonal factors increase your risk for breast cancer. If you began to menstruate early, if you enter menopause late (after age 55), or if you have a first child after age 30 or don't have children at all, you have a higher risk. And all of these factors are in some way linked to the female hormone estrogen. Breast cancer has also been associated with the use of hormone therapy after menopause. Most healthcare providers believe that the increased risk of breast cancer from taking hormone therapy is small, compared with some of the benefits it can bring like relief of hot flashes and an increased feeling of well-being. However, because of the research evidence that exists for a link between hormone therapy and breast cancer risk, you should talk to your healthcare professional if you are considering taking hormone therapy.

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Breast cancer symptoms, diagnosis, and screening

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 that comes out of the nipple spontaneously)

Early breast cancer usually does not cause pain. Still, a woman should see her healthcare professional about breast pain or any other symptom that persists. Most often, these symptoms are not due to cancer. Other health problems may also cause them. Any woman with these symptoms should tell her healthcare professional so that problems can be diagnosed and treated as early as possible.

Screening
Screening for breast cancer before there are symptoms is vital because it enables breast cancer to be treated before the disease becomes advanced. Screening can help doctors find and treat cancer early, when treatment is more likely to work well.

The most reliable screening test available for breast cancer is mammography. This means that mammograms are more likely to detect early cancers because they can be visualized on an X-ray. Mammograms are more successful at detecting early breast cancer than having your breasts examined by a healthcare provider. Other screening tests include ultrasound, breast examination by a health professional, and self-breast examination (examining your own breasts at home).

There's been considerable controversy in the medical community about whether women in their 40s should get mammograms, or if it's safer to wait until age 50 to start getting annual mammograms. (There's no question that annual mammograms over the age of 50 are essential: Several studies indicate they can reduce breast cancer deaths by nearly a third.)

The American Cancer Society (ACS), based on the findings of a special ACS panel, recently renewed its position that women should get mammograms starting at age 40. In fact, women need them on a yearly basis (not every other year, as the ACS had previously recommended.) The American College of Radiology and the American College of Obstetricians and Gynecologists also suggest that women get mammograms in their 40s, and the National Cancer Advisory Board recommended in late March 1997 that women have a mammogram every year or 2 starting at age 40.

However, another group of experts convened by the National Institutes of Health (NIH) in January of 1997 reached a different conclusion. After reviewing the same studies as the other groups, NIH experts decided that mammograms are an option until age 50.

What's a baffled woman to do? You may choose to modify the recommendations to suit your personal needs. With the help of your healthcare professional, decide when to start getting mammograms based on:

• Your particular family history
• Your risk factors for breast cancer
• Your anxiety level about getting the disease

NOTE: If you have a family history of breast cancer, you should begin getting regular mammograms in your 30s or earlier, based on your healthcare professional's advice. You should ask your healthcare professional about the right age to start regular screening, how often to get the screening, and which screening test is the best for you.

Breast self-exam
Changes in your breasts (such as change in size, nipple and skin changes, and pain and nipple discharge) may be the first indication that you have breast cancer. Some changes will, of course, not indicate breast cancer because changes can occur as a result of the normal process of aging, pregnancy, menstruation, and taking hormones in the form of birth control pills or hormone therapy. It is normal for breasts to feel a little lumpy and uneven sometimes or all the time. Also, it is common for your breasts to be swollen and tender right before or during your menstrual period. You should contact your healthcare 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.

Diagnosis of breast cancer
If you have a symptom or screening test result that suggests cancer, your healthcare provider must find out whether it is due to cancer or to some other cause. He or she 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 to assess whether it is likely that you have a cancerous tumor. Your doctor may suggest that you have a follow-up exam, especially if the tests come back negative and you have persistent symptoms. Or you may need to have a biopsy to check for cancer cells if the tests do show a tumor.

Clinical breast exam
Your healthcare professional may perform a clinical breast examination either during a general checkup as part of screening or in order to assess some breast symptoms that you complain of (which will help in making a diagnosis).

Your healthcare professional feels each breast for lumps and looks for other problems. If you have a lump, he/she will feel its size, shape, and texture and check whether 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
Mammograms that are performed in women who have no usual symptoms are called screening mammograms. A screening mammogram is like a checkup. However, if a woman has unusual breast symptoms or physical signs, she will most likely be referred to a doctor for diagnostic mammogram. This is a mammogram that is performed to specifically look for abnormalities in the area of the breast where the symptoms are present. Diagnostic mammograms are X-ray pictures of the breast, like screening mammograms. However, they take clearer, more detailed images of areas that look abnormal and can detect 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 and 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 pictures that can be viewed on a monitor. The pictures may show whether a lump is filled with fluid or is solid. A cyst is a fluid-filled sac that is not cancerous. But a solid mass may be cancer. This exam may be used along with a mammogram to gather information about your symptoms and whether they are likely to be caused by cancer.

Magnetic resonance imaging (MRI)
Magnetic resonance imaging (MRI) uses a powerful magnet linked to a computer to create 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
If results from screening tests suggest cancer, your doctor may refer you to a surgeon or breast disease specialist for a biopsy of your breast tissue. Fluid or tissue is removed from your breast usually via a fine needle to help determine whether there is cancer. Before the biopsy needle is inserted, you will be given an injection to numb the skin and breast tissue so you do not feel sharp pain. Biopsies of breast tissue are usually performed under the guidance of an ultrasound machine. In other words, an ultrasound machine visualizes the breast lump that needs a biopsy. The picture is projected onto a screen, ensuring that the tissue sample is taken from the exact area of the lump as revealed by the ultrasound.

Tissue for diagnosis of breast cancer can be removed from the breast in different ways:

• Fine-needle aspiration: A thin needle is used to remove fluid or cells from a breast lump. If the fluid appears to contain cells, a pathologist at a lab checks them with a microscope for cancer. Clear fluid may not need to be checked by a lab.
• Core biopsy: A thick needle is used to remove breast tissue. A pathologist checks the tissue for cancer cells. More tissue can be removed by a core biopsy than in a fine-needle biopsy. A core biopsy may be more useful in certain cases in order to make an accurate diagnosis.
• Surgical biopsy: A surgeon removes a sample of tissue by excising or cutting it out (not using a needle). 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, a pathologist can determine what kind of cancer it is. The most common type of breast cancer is ductal carcinoma, in which abnormal cells are found in the lining of the ducts. Lobular carcinoma in which abnormal cells are found in the lobules is another type.

Additional tests If you are diagnosed with cancer, your healthcare professional may order special lab tests on the breast tissue that was removed. These tests may help provide more details about the cancer and therefore will help guide your doctor in recommending treatment. Here are some tests that are commonly performed on breast tissue cells:

• Hormone receptor test: This test shows whether the tissue has certain hormone receptors. Receptors are parts of a cell that receive signals from certain substances attached to them so that the cells can be influenced by the substance via the receptor. 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 reappear after treatment.

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Stages of breast cancer

To plan treatment, your healthcare professional needs to know the extent (stage) of the disease; in other words whether the disease is early or advanced. The stage is based on the size of the tumor and whether the cancer has spread. Determining the extent of the tumor is called staging, a procedure that may involve performing imaging tests like X-rays and/or CT scans 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). Often the stage 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 called carcinoma in situ.
  • Lobular carcinoma in situ (LCIS): Abnormal cells are found in the lining of a lobule. (See explanation picture of lobule) LCIS seldom becomes invasive cancer. However, having LCIS in one breast increases the risk of cancer for both breasts.
  • Ductal carcinoma in situ (DCIS): Abnormal cells are found in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread outside the duct and have not invaded the nearby breast tissue. DCIS sometimes becomes invasive cancer if not treated.
• Stage I is an early stage of invasive or advanced breast cancer. The tumor is no more than 2 centimeters (three-quarters of an inch) across. Cancer cells have not spread beyond the breast.
• Stage II is one of the following:
  • The tumor in the breast 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 may have 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 may be a large tumor, but the cancer has not spread beyond the breast and nearby lymph nodes. It is locally advanced cancer.
• Stage IIIA is one of the following:
  • The tumor in the breast is smaller than 5 centimeters (2 inches). The cancer has spread to underarm lymph nodes that are attached to one another or to other structures.
  • The tumor is more than 5 centimeters across. The cancer has spread to the underarm lymph nodes.
• Stage IIIB is one of the following:
  • The tumor has grown into the chest wall or the skin of the breast.
  • The cancer has spread to lymph nodes behind the breastbone.
  • Inflammatory breast cancer is a rare type of Stage IIIB breast cancer. The breast looks red and swollen because cancer cells block the lymph vessels in the skin of the breast.
• 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 under or above 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 it may recur in any other part of the body, such as the bone, liver, or lungs.

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Ask Your Healthcare Provider

Treatment and talking to your healthcare provider

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 healthcare provider. It often helps to make a list of questions before an appointment. To help remember what your 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 accompany you 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 talk about your concerns and to receive explanations for details that are unclear.

Your may be referred 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.

Treatment methods
There are different ways of treating breast cancer depending on the type of cancer, the stage of cancer, and other factors. Treatment methods include surgery, radiation therapy, chemotherapy, hormone therapy, and biological therapy. These options are described below. Many women receive more than one type of treatment.

Your healthcare provider can describe your treatment choices and the expected results. You may want to know how treatment may affect your normal activities and 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 or a combination:

• Local therapy: Breast surgery and radiation therapy to the breast are local treatments that 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. Taken either as pills or as injections 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 local therapy (surgery or radiation) is done. Others have systemic therapy after surgery and/or radiation to prevent the cancer from recurring. 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. They may not be the same for each woman, and they may change from one treatment session to the next.

Before treatment starts, your healthcare team will explain possible side effects and suggest ways to help you manage them. The National Cancer Institite (NCI) provides helpful booklets about cancer treatments and coping with side effects. These include Radiation Therapy and You, Chemotherapy and You, Biological Therapy, and Eating Hints for Cancer Patients.

At any stage of disease, supportive care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. Information about such care is available on NCI's Web site at http://www.cancer.gov/cancertopics/coping and from information specialists at
1-800-4-CANCER or from Live Help, an online site.

You may want to talk with your healthcare provider about taking part in a clinical trial, a research study of new treatment methods.

Questions you may want to ask your healthcare provider before your treatment begins:

• What did the hormone receptor test show? What did other lab tests show?
• Do any lymph nodes show signs of cancer?
• What is the stage of the disease? Has the cancer spread?
• What is the goal of treatment? What are my treatment choices? Which do you recommend for me, and why?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment? How can side effects be managed?
• What can I do to prepare for treatment?
• Will I need to stay in the hospital? If so, for how long?
• What is the treatment likely to cost? Will my insurance cover the cost?
• How will treatment affect my normal activities?
• Would a clinical trial be appropriate for me?

Surgery
Surgery is the most common treatment for breast cancer. There are several types of surgery. (See pictures below.) Your healthcare provider can explain each type, discuss and compare the benefits and risks, and describe how each type will change the way you look:

• Breast-sparing surgery: An operation to remove the cancer but not the breast is called breast-sparing surgery. It is also known as 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 (by means of a separate incision) the underarm lymph nodes as well. This procedure is called an axillary lymph node dissection and shows whether cancer cells have entered the lymph vessels.

After breast-sparing surgery, most women receive radiation therapy to the breast to destroy 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 sentinel lymph node biopsy involves injecting a radioactive dye into the lymph vessels surrounding the breast and following the route of the dye. Usually the dye will flow from the lymph vessels to the nearest main lymph node called the sentinel node. If the sentinel node is biopsied and contains cancer cells, it is more likely that the cancer has spread. If the sentinel node is free of cancer cells, then a surgeon may determine that a woman's lymph nodes are clear and do not necessarily need to be removed. He/she removes fewer lymph nodes, which causes fewer side effects. (If the surgen finds cancer cells in the axillary lymph nodes, an axillary lymph node dissection usually is done.)

You may choose to have breast reconstruction. This is plastic surgery to rebuild the shape of the breast that 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.

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. After surgery, the plan can be adjusted if you need more relief. Any kind of surgery also carries a risk of infection, bleeding, or other problems. You should alert your doctor immediately if you develop any problems.

You may feel off balance if you've had one or both breasts removed, especially 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. Your healthcare provider can suggest exercises to help you regain movement and strength and reduce stiffness and pain in your arm and shoulder. You may be able to begin gentle exercises within days of surgery.

Since nerves may be injured or cut during surgery, you may have numbness and/or a tingling feeling in your chest, underarm, shoulder, and upper arm. These feelings usually go away within a few weeks or months. But for some women, numbness continues.

Removing the lymph nodes under the arm slows the flow of lymph fluid into the lymph vessels. The fluid may build up in your arm and hand and cause swelling. This swelling is known as lymphedema. Lymphedema can develop immediately after surgery or months to years later. Severe lymphedema can lead to other problems like skin infections or blood clots in the arm. Therefore, if you have had a lymph node dissection, you will need to protect your arm and hand on the treated side for the rest of your life to minimize the chance of developing significant lymphedema:

• 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 healthcare provider how to treat any cuts, insect bites, sunburn, or other injuries to your arm or hand. Also, you should contact your doctor if your arm or hand is injured, swells, or becomes red and warm.

If lymphedema occurs, he or she may suggest raising your arm above your heart whenever you can and doing hand and arm exercises. Some women with lymphedema wear an elastic sleeve to improve the flow of lymph fluid. 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. More information about lymphedema is available on NCI's Web site at http://www.cancer.gov and from information specialists at 1-800-4-CANCER or LiveHelp.

Radiation therapy
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells that may remain in the breast. 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.

Some women have radiation therapy before surgery to destroy cancer cells and shrink the tumor. This approach is used when the tumor is large or may be hard to remove. Some women also have chemotherapy or hormone therapy before surgery.

There are two types of radiation therapy to treat breast cancer. Some women receive both types:

• External radiation: The radiation is produced by a large machine outside the body. Most women go to a hospital or clinic for treatments, which 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 into the breast, where they remain for several days. A woman stays in the hospital while she has implants. The implants are removed before she goes home.

Side effects depend mainly on the dose and type of radiation and the part of the body that is treated. Skin in the treated area usually becomes red, dry, tender, and itchy. Your breast may feel heavy and tight. These side effects will go away over time. Toward the end of treatment, your skin may become moist and start to weep fluid. Exposing this area to air as much as possible can help the skin heal.

Bras and tight-fitting clothing may rub your skin and cause soreness. You may want to wear loose-fitting cotton clothes during treatment. Gentle skin care also is important. You should check with your healthcare provider before using any deodorants, lotions, or creams on the treated area. The effects of radiation therapy on the skin tapers off as 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 keeping up some level of activity is also advisable.

Although the side effects of radiation therapy can be distressing, your doctor can usually advise you on ways to manage these side effects.

Questions you may want to ask your healthcare provider before having radiation therapy:

• How will radiation be given?
• When will treatment start? When will it end? How often will I have treatments?
• How will I feel during treatment? Will I be able to drive myself to and from treatment?
• How will we know the treatment is working?
• What can I do to take care of myself before, during, and after treatment?
• Will treatment affect my skin?
• How will my chest look afterward?
• Are there any long-term effects?
• What is the chance that the cancer will return in my breast?
• How often will I need checkups?

Chemotherapy
Chemotherapy uses a combination of anticancer drugs to kill cancer cells. 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, however, need to stay in the hospital during treatment.

Side effects depend mainly on the specific medicine and the dose. Chemotherapy medicines can kill cancer cells and other cells that divide rapidly including:

• Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When chemotherapy affects 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 healthcare provider can suggest ways to control many of these side effects.

Some medicines used for breast cancer can cause tingling or numbness in the hands or feet. This problem usually is resolved after treatment is over. Other side effects may persist. In some women, the medicines used for breast cancer may weaken the heart.

Some anticancer drugs can damage the ovaries, which may stop making hormones. You may have symptoms of menopause including 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 prevents cancer cells from getting or using the natural hormones they need, estrogen and progesterone. Lab tests can show whether a breast tumor has hormone receptors. If you have this kind of tumor, hormone therapy may be an effective treatment.

• Hormone therapy uses medicines or surgery:
• Medicines: Your doctor may suggest a drug to block the hormone. One drug is tamoxifen, which blocks estrogen. Another type of drug called an aromatase inhibitor prevents the body from making the female hormone estradiol, a form of estrogen. 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 main source of the body's estrogen. A woman who has gone through menopause does not need the surgery since the ovaries produce less estrogen after menopause.

The side effects of hormone therapy depend largely on the specific drug or type of treatment. In general, the side effects of tamoxifen, the most typical hormone treatment, are similar to some of the symptoms of menopause. The most common are hot flashes and vaginal discharge (vaginal fluid). 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 though who take tamoxifen have side effects.

Serious side effects of tamoxifen are rare. However, it can cause blood clots to form in the veins, primarily in the legs and in the lungs. Women have a slight increase in their risk of stroke. Tamoxifen can cause cancer of the uterus. You should receive regular pelvic exams and alert your doctor about any unusual vaginal bleeding between exams.

It is possible to become pregnant when taking tamoxifen, and the medicine may harm the unborn baby. If you are still menstruating, you should discuss birth control methods with your doctor. When the ovaries are removed, menopause occurs at once. The side effects are often more severe than those caused by natural menopause. Your healthcare provider can suggest ways to cope with these side effects.

Biological therapy
Biological therapy helps the immune system fight cancer. Biological therapy consists of medicines that enhance the way certain cells and chemicals that make up part of our immune system work. 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).

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, herceptin can slow or stop the growth of the cancer cells.

Herceptin is given by vein, either alone or with chemotherapy. The first time a woman receives Herceptin, she may experience 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, which may lead to heart failure. Herceptin can also affect the lungs and can cause breathing problems. Before you receive Herceptin, your healthcare provider will check your heart and lungs. During treatment, he/she will watch for signs of lung problems.

Questions you may want to ask your healthcare provider before having chemotherapy, hormone therapy, or biological therapy:

• What medicines will I be taking? What will they do?
• If I need hormone therapy for my breast cancer treatment, would you recommend medicines or surgery to remove my ovaries instead?
• When will treatment start? When will it end? How often will I have treatments?
• Where will I go for treatment? Will I be able to drive home afterward?
• What can I do to take care of myself during treatment?
• How will we know the treatment is working?
• Which side effects should I tell you about?
• Will there be long-term effects?

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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 or after the mastectomy. If you are considering breast reconstruction, you should talk to a plastic surgeon before the mastectomy, even if you plan to have the reconstruction later.

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 discuss the FDA findings with your doctor, who can advise 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 removes 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.

Questions you may want to ask your doctor about breast reconstruction:

• What is the latest information about the safety of silicone breast implants?
• Which type of surgery would give me the best results? How will I look afterward?
• When can my reconstruction begin?
• How many surgeries will I need?
• What are the risks at the time of surgery? Later?
• Will I have scars? Where? What will they look like?
• If tissue from another part of my body is used, will there be any permanent changes where the tissue was removed?
• What activities should I avoid? When can I return to my normal activities?
• Will I need follow-up care?
• How much will reconstruction cost? Will my health insurance pay for it?

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Frequently asked questions

My breasts are naturally lumpy. Do I need to worry every time I find a new lump?
All new lumps are cause for concern. The trick is to determine whether the lump is just another benign bump—perhaps related to your menstrual cycle if you're still menstruating—or a more dangerous one. If a lump persists, see your healthcare provider. A cancerous lump can develop at any time.

Does mammography produce dangerous radiation?
No. The amount of radiation you'll receive from mammography equipment is actually very low—it's about the amount you get walking down the street on a sunny day. So don't let fear of exposure to radiation keep you from getting regular mammograms.

Does having large breasts make me more susceptible to breast cancer?
Scientists once thought that large breasts might be more prone to developing malignant (cancerous) tumors, but that idea has never been proven by research. Being overweight, however, does increase your risk, and when you're overweight you tend to have larger breasts. So if your breasts are large because you're more than 20% over your ideal weight, it would be a good idea to shed a few pounds.

Can an injury to the breast cause cancer?
No, a bruise or hit to the breast won't cause cancer. If a cancer develops in a spot that's been injured, it's just a coincidence.

Should I be tested to see whether I carry the breast cancer gene mutations?
Although commercial tests for detecting the abnormal BRCA1 and BRCA2 genes are available, most experts don't advise women to get these tests, unless a woman specifically has certain other risks like a strong family history of breast cancer. In the first place, there is no definite answer for how you should proceed if tests show that you do carry a mutant gene. Should you have a mastectomy, or should you have both breasts removed? Will that really protect you against the 85% lifetime risk of cancer? The answers are simply not known. What's more, you need extensive counseling before and after the test, and if the results are positive, the outcome may affect your ability to get a job or health insurance. And even if the results are negative, you can still get breast cancer just like anyone else who doesn't carry the mutation.

Your best answer right now is to wait for a truly helpful test or a real cure or prevention for breast cancer. Also, of course, it is essential that you keep up with your breast cancer screening.

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Empower Yourself

How to perform a breast self-examination

Although you might feel uncomfortable and afraid the first few times you examine your breasts, the more you get to know the individual characteristics of your breasts—where there are bands of tissue, where the breast attaches to the chest—the more comfortable the exam will become. You'll also find it easier to detect lumps, hard knots, skin thickening, or nipple discharge.

There is no particular rule for how often or when to examine your breasts. For women who are still menstruating, however, it is more difficult to distinguish lumps and other irregularities from normal breast tissue in the premenstrual period because hormones circulating in the body at that time tend to cause the breasts to be more swollen and tender. Therefore, for menstruating women the best time to examine one's breasts is in the week after a period has finished.

Here's a three-step technique for breast self-exam, courtesy of the Susan G. Komen Breast Cancer Foundation:

1. In the shower: Raise one arm and place one of your hands on the back of your head. Slowly and methodically, move the pads of your fingertips of the other hand over the breast in a circular pattern. Don't forget to feel in the armpit area. Repeat on the other side.
2. Before a mirror: With your arms resting at your sides, look for changes in the shape of your breasts, as well as swelling, dimpling, or indentations in the skin, or changes in the skin or nipples. Then raise your arms over your head and repeat the procedure. Finally, place the palms of your hands on your hips and press down so that your chest muscles flex; again, look for changes in the breasts' skin contour and nipples.
3. Lying down: Lie down and put a pillow under your right shoulder and your right arm behind your head. Using the pads of your fingertips, make the same circular pattern of your right breast as you did in the shower. Don't forget to feel the armpit and the chest area from the collarbone to below the breast. Repeat, using firmer pressure. Squeeze the nipple gently to see if there's any discharge. Repeat the procedure on the left breast.

Report any strange findings or changes to your healthcare professional immediately!

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Glossary of breast cancer terms

Areola: The colored skin that surrounds the nipple.

Axilla: The armpit.

Benign: Noncancerous.

Biological therapy: Medicines or treatments that assist the body's immune system fight against infection and or disease. Also known as immunotherapy.

Biopsy: Removal of a sample of tissue for examination and diagnosis of disease.

Cancer Staging: A system for determining how far and where a cancer has spread in the body. The stage of a cancer is directly related to an individual's prognosis. If the cancer is at an early stage, there is more chance that the person will survive the cancer after treatment.

Chemotherapy: Medicine that fights disease by killing cells (otherwise known as medicines that are cytotoxic or medicines that are toxic to cells).

Clinical trial: Clinical, medical, or scientific research study.

Core biopsy: A tissue sample taken via a small needle piercing several layers of skin and then removing the core of the needle for examination.

CT scan: A medical investigation or test that takes images of the inside of the body via a special type of X-ray machine. The images are placed on a computer monitor or printed so that they may be easily interpreted.

Ductal carcinoma: Cancer of the cells lining the milk ducts in the breast.

Estrogen: The main female hormone produced by the body.

Fine-needle biopsy: A procedure in which cells are removed from the tissue of an organ via a fine needle being inserted into the tissue and sucking up some of the cells.

Gene: A collection of DNA that contains the unique characteristics of an individual, making that person different from another person. Genes are usually inherited from parents.

Gene mutation: An abnormality in the DNA coding of a gene. Gland: A gland is an organ that makes substances such as hormones and usually releases them into the blood or other parts of the body.

Heart failure: A condition in which the heart is diseased and is not pumping properly, so there may be inadequate amounts of oxygen reaching the vital organs of the body.

HER2 test: HER2 (human epidermal growth factor receptor 2) is a protein found on the surface of cells. This protein helps with controlling cell growth. However, if this protein is abnormal for any reason the cell growth becomes disturbed, which can affect cancer cell growth, making it more rapid, for example. The HER2 test if breast cancer cells have this abnormal HER2 protein. If so, breast cancer cells may not respond as well to standard treatments.

Hormone receptor: A protein molecule usually on the surface of a cell. A particular hormone is attracted to the receptor and when it binds it causes many changes in the cell.

Hormone therapy: Hormones that women can take in order to boost their levels of hormones like estrogen, which are lower during menopause.

Invasive breast cancer: Cancer that has spread outside the milk ducts or glands and into the internal tissue of the breast.

Lumpectomy: Removal of a discrete lump from an organ like the breast via a surgical procedure or operation.

Lymph nodes: Small glands that are connected to lymph vessels and function to filter lymph fluid of foreign bacteria and particles. They are an important part of the body's defense against disease.

Lymphedema: Retention of lymph fluid because of complete or partial blockage of its drainage in the lymph vessels. It can cause visible swelling of the arms, legs, or whatever the site of the blockage may be.

Lymph vessel: Thin-walled tube-like structure that carries lymph fluid from the tissues in the body to the lymph nodes.

Malignant: Cancerous.

Mammogram: An X-ray of the breasts.

Mastectomy: Removal of one or both breasts by surgery.

Menopause: Otherwise known as the change of life, it is the end of menstrual periods in women and a normal part of the aging process.

Metastatic cancer : Cancer that has spread from the primary site where it started to other parts of the body via the blood and lymph vessels.

MRI (Magnetic Resonance Imaging): A method of imaging the internal structures of the body through a magnetic field. It is capable of projecting 2- or 3-dimensional images.

Nipple: A protuberance of skin in the center of the breast that contains small tubes connecting the glands of the breast to the outside.

Nipple discharge: A fluid that emerges from the nipple. This fluid is either clear, cloudy, or bloodstained. If the discharge is bloodstained, it is more likely to represent an underlying breast cancer.

Obese: A condition of being significantly overweight.

Oncologist: A specialist physician who treats cancer.

Ovaries: Organs in the female that produce and store eggs for reproduction.

Radiation therapy: Therapy or treatment that makes use of radiation in order to kill cancer cells.

Screening: Performing medical tests in order to attempt to detect diseases early before they become advanced.

Self-breast examination: A breast exam a woman performs on her own breasts at home.

Side effects: Symptoms, illness, or problems that occur when treatment or medicines have undesired effects that are in addition to or instead of the actual desired effect.

Ultrasound: A form of medical imaging in which high-frequency sound waves that the body is exposed to enable many internal organs of the body to be visualized on a screen. Ultrasound helps in the diagnosis of many diseases.

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Breast cancer resources and tools

Private Organizations

American Cancer Society
1599 Clifton Road, NE
Atlanta, GA 30329-4243
Phone: 1-800-ACS-2345
http://www.cancer.org

National Alliance of Breast Cancer Organizations
9 East 37th Street, 10th Floor
New York, NY 10016
Phone: 212-719-0154
TDD: 888-80-NABCO (62226)
http://www.nabco.org

Mayo Clinic
13400 East Shea Blvd.
Scottsdale, AZ 85259
Phone: 480-301-8000 (general information)
Phone: 1-800-446-2279 (central appointment office)
http://www.mayoclinic.com/

The Susan G. Komen Breast Cancer Foundation
5005 LBJ Freeway
Suite 370
Dallas, TX 7524
Phone: 800-IM AWARE (800-462-9273)
http://www.komen.org

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References

Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:347.

Berry DA, Cirrincione C, Henderson IC, et al. Estrogen receptor status and outcomes of modern chemotherapy for patients with node-positive breast cancer. JAMA. 2006;295:1658.

Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;365:1687.

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