Introduction to Breast Cancer

Breast cancer is the most common type of cancer among women in the United States (other than skin cancer). Each year, more than 180,000 women in this country learn they have breast cancer. The National Cancer Institute (NCI) has written this booklet to help patients with breast cancer and their families and friends better understand this disease. We hope others will read it as well to learn more about breast cancer.

This booklet discusses screening and early detection, symptoms, diagnosis, treatment, and rehabilitation. It also has information to help patients cope with breast cancer.

Male Breast Cancer

Breast cancer affects more than 1,000 men in this country each year. Although this booklet was written mainly for women, much of the information on symptoms, diagnosis, treatment, and living with the disease applies to men as well.

Cancer research has led to real progress against breast cancer--better survival and improved quality of life. And knowledge about breast cancer is increasing.

What Is Cancer?

Cancer is a group of many different diseases that have some important things in common. They all arise in cells, the body's basic unit of life. To understand different types of cancer, it is helpful to know about normal cells and what happens when they become cancerous.

The body is made up of many types of cells. Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy. Sometimes cells keep dividing when new cells are not needed. These cells may form a mass of extra tissue called a growth or tumor. Tumors can be benign or malignant.

• Benign tumors are not cancer. They can usually be removed, and in most cases, they don't come back. Most important, the cells in benign tumors do not invade other tissues and do not spread to other parts of the body. Benign breast tumors are not a threat to life.
• Malignant tumors are cancer. Cells in these tumors can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how breast cancer spreads and forms secondary tumors in other parts of the body. The spread of cancer is called metastasis.

The Breasts

Each breast has 15 to 20 overlapping sections called lobes. Within each lobe are many smaller lobules, which end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola. Fat fills the spaces around the lobules and ducts. There are no muscles in the breast, but muscles lie under each breast and cover the ribs.

Each breast also contains blood vessels and vessels that carry colorless fluid called lymph. The lymph vessels lead to small bean-shaped organs called lymph nodes. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest. Lymph nodes are also found in many other parts of the body.

Types of Breast Cancer

The most common type of breast cancer begins in the lining of the ducts and is called ductal carcinoma. Another type, called lobular carcinoma, arises in the lobules.

When breast cancer spreads outside the breast, cancer cells are often found in the lymph nodes under the arm (axillary lymph nodes). If the cancer has reached these nodes, it may mean that cancer cells have spread to other parts of the body--other lymph nodes and other organs, such as the bones, liver, or lungs--via the lymphatic system or the bloodstream.

Cancer that spreads is the same disease and has the same name as the original (primary) cancer. When breast cancer spreads, it is called metastatic breast cancer, even though the secondary tumor is in another organ. Doctors sometimes call this "distant" disease.

Risk Factors for Breast Cancer

The risk of breast cancer increases gradually as a woman gets older. This disease is uncommon in women under the age of 35. All women age 40 and older are at risk for breast cancer. However, most breast cancers occur in women over the age of 50, and the risk is especially high for women over age 60.

Research has shown that the following conditions place a woman at increased risk for breast cancer:

• Personal history of breast cancer. Women who have had breast cancer face an increased risk of getting breast cancer again.
• Genetic alterations. Changes in certain genes (BRCA1, BRCA2, and others) make women more susceptible to breast cancer. In families in which many women have had the disease, gene testing can show whether a woman has specific genetic changes known to increase the susceptibility to breast cancer. Doctors may suggest ways to try to delay or prevent breast cancer, or improve the detection of breast cancer in women who have the genetic alterations.
• Family history. A woman's risk for developing breast cancer increases if her mother, sister, daughter, or two or more other close relatives, such as cousins, have a history of breast cancer, especially at a young age.
• Certain breast changes. Having a diagnosis of atypical hyperplasia or lobular carcinoma in situ (LCIS) or having had two or more breast biopsies for other benign conditions may increase a woman's risk for developing cancer.

Other factors associated with an increased risk for breast cancer include:

• Breast density. Women age 45 and older whose mammograms show at least 75 percent dense tissue are at increased risk. Dense breasts contain many glands and ligaments, which makes breast tumors difficult to "see," and the dense tissue itself is associated with an increased chance of developing breast cancer.
• Radiation therapy. Women whose breasts were exposed to radiation during their childhood, especially those who were treated with radiation for Hodgkin's disease, are at an increased risk for developing breast cancer throughout their lives. Studies show that the younger a woman was when she received her treatment, the higher her risk for developing breast cancer later in life.
• Late childbearing. Women who had their first child after the age of 30 have a greater chance of developing breast cancer than women who had their children at a younger age.

Also at a somewhat increased risk for developing breast cancer are women who started menstruating at an early age (before age 12), experienced menopause late (after age 55), never had children, or took hormone replacement therapy or birth control pills for long periods of time. Each of these factors increases the amount of time a woman's body is exposed to estrogen. The longer this exposure, the more likely she is to develop breast cancer.

In most cases, doctors cannot explain why a woman develops breast cancer. Studies show that most women who develop breast cancer have none of the risk factors listed above, other than the risk that comes with growing older. Also, most women with known risk factors do not get breast cancer. Scientists are conducting research into the causes of breast cancer to learn more about risk factors and ways of preventing this disease.

Early Detection

When breast cancer is found and treated early, the chances for survival are better. Women can take an active part in the early detection of breast cancer by having regular screening mammograms and clinical breast exams (breast exams performed by health professionals). Some women also perform breast self-exams.

A screening mammogram is the best tool available for finding breast cancer early, before symptoms appear. A mammogram is a special kind of x-ray. It is different from a chest x-ray or x-rays of other parts of the body. Screening mammograms are used to look for breast changes in women who have no signs of breast cancer.

Mammograms can often detect breast cancer before it can be felt. Also, a mammogram can show small deposits of calcium in the breast. Although most calcium deposits are benign, a cluster of very tiny specks of calcium (called microcalcifications) may be an early sign of cancer.

Although mammograms are the best way to find breast cancer early, they do have some limitations. A mammogram may miss some cancers that are present (false negative) or may find things that turn out not to be cancer (false positive). And detecting a tumor early does not guarantee that a woman's life will be saved. Some fast-growing cancers may already have spread to other parts of the body before being detected.

Still, regularly scheduled screening mammograms, together with clinical breast exams, offer the best chance of finding and treating breast cancer early. Studies show that mammograms reduce the risk of dying from breast cancer. The National Cancer Institute recommends that women in their forties and older have mammograms on a regular basis, every 1 to 2 years.

Women should talk with their doctor about factors that can increase the risk for breast cancer. Women of any age who are at higher risk for this disease should ask their doctor when to begin and how often to have screening mammograms and breast exams.

Some women perform monthly breast self-exams to check for any changes in their breasts. When doing a breast self-exam, it's important to remember that each woman's breasts are different, and that changes can occur because of aging, the menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for the breasts to feel a little lumpy and uneven. Also, it is common for a woman's breasts to be swollen and tender right before or during her menstrual period. Remember that for women in their forties and older, a monthly breast self-exam is not a substitute for regularly scheduled screening mammograms and clinical breast exams by a health professional.

Symptoms

Early breast cancer usually does not cause pain. In fact, when breast cancer first develops, there may be no symptoms at all. But as the cancer grows, it can cause changes that women should watch for:

• A lump or thickening in or near the breast or in the underarm area;
• A change in the size or shape of the breast;
• Nipple discharge or tenderness, or the nipple pulled back (inversion) into the breast;
• Ridges or pitting of the breast (the skin looks like the skin of an orange; or
• A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red, or scaly).

A woman should see her doctor about any symptoms like these. Most often, they are not cancer, but it's important to check with the doctor so that any problems can be diagnosed and treated as early as possible.

Diagnosis

An abnormal area on a mammogram, a lump, or other changes in the breast can be caused by cancer or by other, less serious problems. To find out the cause of any of these signs or symptoms, a woman's doctor does a careful physical exam and asks about her personal and family medical history. In addition to checking general signs of health, the doctor may do one or more of the breast exams described on the following page.

• Palpation. The doctor can tell a lot about a lump (its size, its texture, and whether it moves easily) by palpation, carefully feeling the lump and the tissue around it. Benign lumps often feel different from cancerous ones.
• Mammography. X-rays of the breast can give the doctor important information about a breast lump. If an area on the mammogram looks suspicious or is not clear, additional mammograms may be needed.
• Ultrasonography. Using high-frequency sound waves, ultrasonography can often show whether a lump is solid or filled with fluid. This exam may be used along with mammography.

Based on these exams, the doctor may decide that no further tests are needed and no treatment is necessary. (In such cases, the doctor may need to check the woman regularly to watch for any changes.)

Often, however, fluid or tissue must be removed from the breast to make a diagnosis. A woman's doctor may refer her for further evaluation to a surgeon or other health care professional who has experience with breast diseases. These doctors may perform:

• Fine needle aspiration. A thin needle is used to remove fluid from a breast lump. This procedure may show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). Clear fluid removed from a cyst may not need to be checked by a lab.
• Needle biopsy. Using special techniques, tissue can be removed with a needle from an area that is suspicious on a mammogram but cannot be felt. Tissue removed in a needle biopsy goes to a lab to be checked by a pathologist for cancer cells.
• Surgical biopsy. The surgeon cuts out part or all of a lump or suspicious area. A pathologist examines the tissue under a microscope to check for cancer cells.

When a woman needs a biopsy, these are some questions she may want to ask her doctor:

• What type of biopsy will I have? Why?
• How long will it take? Will I be awake? Will it hurt?
• How soon will I know the results?
• If I do have cancer, who will talk with me about treatment? When?

When Cancer Is Found

When cancer is found, the pathologist can tell what kind of cancer it is (whether it began in a duct or a lobule) and whether it is invasive (has invaded nearby tissues in the breast).

Special lab tests of the tissue help the doctor learn more about the cancer. For example, hormone receptor tests (estrogen and progesterone receptor tests) can help predict whether the cancer is sensitive to hormones. Positive test results mean hormones help the cancer grow, and the cancer is likely to respond to hormonal therapy. More information about hormonal therapy can be found in the Treatment section. Other lab tests are sometimes done to help the doctor predict whether the cancer is likely to grow slowly or quickly. The doctor may order x-rays and blood tests. The doctor may also do special exams of the bones, liver, or lungs because breast cancer may spread to these areas.

If the diagnosis is cancer, the patient may want to ask these questions:

• What kind of breast cancer do I have? Is it invasive?
• What did the hormone receptor test show? What other lab tests were done on the tumor tissue, and what did they show?
• How will this information help in decidng what type of treatment or further tests to recommend?

The patient's doctor may refer her to other doctors who specialize in treating cancer, or she may ask for a referral. Treatment generally begins within a few weeks after the diagnosis. There will be time for the woman to talk with the doctor about her treatment choices, to get a second opinion, and to prepare herself and her loved ones.

Treatment

Through continuing research into new treatment methods, women now have more treatment options and hope for survival than ever before. The treatment options for each woman depend on the size and location of the tumor in her breast, the results of lab tests (including hormone receptor tests), and the stage (or extent) of the disease. To develop a treatment plan to fit each patient's needs, the doctor also considers a woman's age and menopausal status, her general health, and the size of her breasts.

Many women want to learn all they can about their disease and their treatment choices so that they can take an active part in decisions about their medical care. They are likely to have many questions and concerns about their treatment options.

The doctor is the best person to answer questions about treatment for a particular patient: what her treatment choices are, how successful her treatment is expected to be, and how much it is likely to cost. Most patients also want to know how they will look after treatment and whether they will have to change their normal activities. Also, the patient may want to talk with her doctor about taking part in a clinical trial, a research study involving people, of new treatment methods.

Calling the National Cancer Institute's Cancer Information Service at 1-800-4-CANCER is another way to gather up-to-date treatment information, including information about current clinical trials. Cancer information specialists can provide thorough, personalized answers to questions about breast cancer treatment. They can suggest other sources of information and support. They can also talk with callers about questions to ask the doctor.

Many patients find it helpful to make a list of questions before seeing the doctor. To make it easier to remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also find that it helps to have a family member or friend with them when they see the doctor--to take part in the discussion, to take notes, or just to listen.

Here are some questions a woman may want to ask the doctor before treatment begins:

• What are my treatment choices?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• Are new treatments under study? Would a clinical trial be appropriate for me?

There is a lot to learn about breast cancer and its treatment. Patients should not feel that they need to ask all their questions or understand all the answers at once. They will have many other chances to ask the doctor to explain things that are not clear and to ask for more information.

Planning Treatment

Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. It may take a week or two to arrange to see another doctor. Studies show that a brief delay (up to several weeks) between biopsy and treatment does not make breast cancer treatment less effective. There are a number of ways to find a doctor for a second opinion:

• The patient's doctor may refer her to one or more specialists. Specialists who treat breast cancer include surgeons, medical oncologists, plastic surgeons, and radiation oncologists. Sometimes these doctors work together at cancer centers or special centers for breast diseases.
• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other NCI-supported programs, in their area.
• Patients can get the names of specialists from their local medical society, a nearby hospital, or a medical school.
• The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their background. This resource, produced by the American Board of Medical Specialties, is available in most public libraries.

Methods of Treatment

Methods of treatment for breast cancer are local or systemic. Local treatments are used to remove, destroy, or control the cancer cells in a specific area. Surgery and radiation therapy are local treatments. Systemic treatments are used to destroy or control cancer cells throughout the body. Chemotherapy and hormonal therapy are systemic treatments. A patient may have just one form of treatment or a combination. Different forms of treatment may be given at the same time or one after another.

Surgery is the most common treatment for breast cancer. Several types of surgery may be used. The doctor can explain each of them in detail, discuss and compare the benefits and risks of each type, and describe how each will affect the patient's appearance. An operation to remove the breast (or as much of the breast as possible) is a mastectomy. Breast reconstruction is often an option at the same time as the mastectomy, or later on. An operation to remove the cancer but not the breast is called breast-sparing surgery or breast-conserving surgery. Lumpectomy and segmental mastectomy (also called partial mastectomy) are types of breast-sparing surgery. They usually are followed by radiation therapy to destroy any cancer cells that may remain in the area. In most cases, the surgeon also removes lymph nodes under the arm to help determine whether cancer cells have entered the lymphatic system.

In lumpectomy, the surgeon removes the breast cancer and some normal tissue around it. Often, some of the lymph nodes under the arm are removed. In segmental mastectomy, the surgeon removes the cancer and a larger area of normal breast tissue around it. Occasionally, some of the lining over the chest muscles below the tumor is removed as well. Some of the lymph nodes under the arm may also be removed. In total (simple) mastectomy, the surgeon removes the whole breast. Some of the lymph nodes under the arm may also be removed. In modified radical mastectomy, the surgeon removes the whole breast, most of the lymph nodes under the arm, and often the lining over the chest muscles. The smaller of the two chest muscles is also taken out to help in removing the lymph nodes. In radical mastectomy (also called Halsted radical mastectomy), the surgeon removes the breast, the chest muscles, all of the lymph nodes under the arm, and some additional fat and skin. For many years, this operation was considered the standard one for women with breast cancer, but it is very rarely used today and only in cases of advanced cancer in which the cancer has spread to the chest muscles.

Breast reconstruction (surgery to rebuild a breast's shape) is often an option after mastectomy. Women considering reconstruction should discuss this with a plastic surgeon before having a mastectomy.

Here are some questions a woman may want to ask her doctor before having surgery:

• What kinds of surgery can I consider? Which operation do you recommend for me?
• Is breast-sparing surgery followed by radiation therapy an option for me?
• Do I need my lymph nodes removed? How many? Why?
• How will I feel after the operation?
• Where will the scars be? What will they look like?
• If I decide to have plastic surgery to rebuild my breast, how and when can that be done? Can you suggest a plastic surgeon for me to contact?
• Will I have to do special exercises?
• When can I get back to my normal activities?

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells and stop them from growing. The rays may come from radioactive material outside the body and be directed at the breast by a machine (external radiation). The radiation can also come from radioactive material placed directly in the breast in thin plastic tubes (implant radiation). Some women receive both kinds of radiation therapy.

For external radiation therapy, patients go to the hospital or clinic each day. When this therapy follows breast-sparing surgery, the treatments are given 5 days a week for 5 to 6 weeks. At the end of that time, an extra "boost" of radiation is sometimes given to the place where the tumor was removed. The boost may be either external or internal (using an implant). Patients stay in the hospital for a short time for implant radiation.

Radiation therapy, alone or with chemotherapy or hormone therapy, is sometimes used before surgery to destroy cancer cells and shrink tumors. This approach is most often used in cases in which the breast tumor is large or not easily removed by surgery.

Before having radiation therapy, a patient may want to ask her doctor these questions:

• Why do I need this treatment?
• What are the risks and side effects of this treatment?
• When will the treatments begin? When will they end?
• How will I feel during therapy?
• What can I do to take care of myself during therapy?
• Can I continue my normal activities?
• How will my breast look afterward?
• What are the chances of the tumor coming back in my breast?

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given by mouth or by injection. Either way, chemotherapy is a systemic therapy because the drugs enter the bloodstream and travel throughout the body.

Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment, and so on. Most patients have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Depending on which drugs are given and the woman's general health, however, she may need to stay in the hospital during her treatment.

Hormonal therapy is used to keep cancer cells from getting the hormones they need to grow. This treatment may include the use of drugs that change the way hormones work or surgery to remove the ovaries, which make female hormones. Like chemotherapy, hormonal therapy is a systemic treatment; it can affect cancer cells throughout the body.

Patients may want to ask these questions about chemotherapy or hormonal therapy:

• Why do I need this treatment?
• What drugs will I be taking? What will they do?
• Will I have side effects? What can I do about them?
• If I need hormonal treatment, which would be better for me, drugs or an operation?
• How long will I be on this treatment?

Treatment Choices

Treatment decisions are complex. They are often affected by the judgment of the doctor and by the desires of the patient.

A patient's treatment options depend on a number of factors. These factors include her age and menopausal status; her general health; the size, location, and stage of the tumor; whether the doctor can feel lymph nodes under her arm; and the size of her breast. Certain features of the tumor cells (such as whether they depend on hormones to grow) are also considered. The most important factor is the stage of the disease. The stage is based on the size of the tumor and whether the cancer has spread. The following section contains brief descriptions of the stages of breast cancer and the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

• Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ. Lobular carcinoma in situ, or LCIS, refers to abnormal cells in the lining of a lobule. These abnormal cells seldom become invasive cancer. However, their presence is a sign that a woman has an increased risk of developing breast cancer. This risk of cancer is increased for both breasts. Some women with LCIS may choose to take a medication called tamoxifen to try to prevent breast cancer, or they may take part in studies of other promising new preventive treatments. Others may not receive any treatment, but return to the doctor regularly for checkups. Still others may have surgery to remove both breasts to try to prevent cancer from developing. (In most cases, removal of underarm lymph nodes is not necessary.)  Ductal carcinoma in situ, also called intraductal carcinoma or DCIS, refers to cancer cells in an area of abnormal tissue in the lining of a duct that have not invaded the surrounding breast tissue. If DCIS lesions are left untreated, over time cancer cells may break through the duct and spread to nearby tissue, becoming an invasive breast cancer. Patients with DCIS may have a mastectomy or may have breast-sparing surgery followed by radiation therapy. Underarm lymph nodes are not usually removed. Women with DCIS may want to talk with their doctors about the possible usefulness of treatment with tamoxifen.
• Stage I and stage II are early stages of breast cancer, but the cancer has invaded nearby tissue. Stage I means that cancer cells have not spread beyond the breast and the tumor is no more than about an inch across. Stage II means one of the following: the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm; the tumor is between 1 and 2 inches with or without spread to the lymph nodes under the arm; or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm. Women with early stage breast cancer may have breast-sparing surgery followed by radiation therapy as their primary local treatment, or they may have a mastectomy, with or without breast reconstruction (plastic surgery) to rebuild the breast. Sometimes radiation therapy is also given to the chest wall after mastectomy. These approaches are equally effective in treating early stage breast cancer. The choice of breast-sparing surgery or mastectomy depends mostly on the size and location of the tumor, the size of the woman's breast, certain features of the cancer, and how the woman feels about preserving her breast. With either approach, lymph nodes under the arm usually are removed. Many women with stage I and most with stage II breast cancer have chemotherapy and/or hormonal therapy in addition to surgery or surgery and radiation therapy. This added treatment is called adjuvant therapy. It is given to try to destroy any remaining cancer cells and prevent the cancer from recurring, or coming back.
• Stage III is also called locally advanced cancer. The tumor in the breast is large (more than 2 inches across), the cancer is extensive in the underarm lymph nodes, or it has spread to other lymph nodes or tissues near the breast. Inflammatory breast cancer is a type of locally advanced breast cancer. Patients with stage III breast cancer usually have both local treatment to remove or destroy the cancer in the breast and systemic treatment to stop the disease from spreading. The local treatment may be surgery and/or radiation therapy to the breast and underarm. The systemic treatment may be chemotherapy, hormonal therapy, or both; it may be given before or after the local treatment.
• Stage IV is metastatic cancer. The cancer has spread from the breast to other parts of the body. Women who have stage IV breast cancer receive chemotherapy and/or hormonal therapy to destroy cancer cells and control the disease. They may have surgery or radiation therapy to control the cancer in the breast. Radiation may also be useful to control tumors in other parts of the body.
• Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained in the area after treatment or because the disease had already spread before treatment. Most recurrences appear within the first 2 or 3 years after treatment, but breast cancer can recur many years later. Cancer that returns only in the area of the surgery is called a local recurrence. If the disease returns in another part of the body, it is called metastatic breast cancer. The patient may have one type of treatment or a combination of treatments.

Side Effects of Treatment

It is hard to limit the effects of cancer treatment so that only cancer cells are removed or destroyed. Because healthy cells and tissues may also be damaged, treatment often causes unwanted side effects.

The side effects of cancer treatment are different for each person, and they may even be different from one treatment to the next. Doctors try to plan treatment to keep problems to a minimum. They also watch patients carefully so that they can help with any problems that occur. The National Cancer Institute booklets Radiation Therapy and You, Chemotherapy and You, and Understanding Breast Cancer Treatment: A Guide for Patients have helpful information about these cancer treatments and coping with their side effects.

Surgery

Surgery causes short-term pain and tenderness in the area of the operation, so women may need to talk with their doctor about which method of pain control would be appropriate. Any kind of surgery also carries a risk of infection, poor wound healing, bleeding, or a reaction to the anesthesia used in surgery. Women who experience any of these problems should tell their doctor or nurse right away.

Removal of a breast can cause a woman's weight to shift and be out of balance--especially if she has large breasts. This imbalance can cause discomfort in a woman's neck and back. Also, the skin in the breast area may be tight, and the muscles of the arm and shoulder may feel stiff. After a mastectomy, some women have some permanent loss of strength in these muscles, but for most women, reduced strength and limited movement are temporary. The doctor, nurse, or physical therapist can recommend exercises to help a woman regain movement and strength in her arm and shoulder.

Because nerves may be injured or cut during surgery, a woman may have numbness and tingling in the chest, underarm, shoulder, and arm. These feelings usually go away within a few weeks or months, but some women may have permanent numbness.

Removing the lymph nodes under the arm slows the flow of lymph. In some women, this fluid builds up in the arm and hand and causes swelling (lymphedema). Women need to protect the arm and hand on the treated side from injury, even long after surgery. They should ask the doctor how to handle any cuts, scratches, insect bites, or other injuries that may occur. Also, they should contact the doctor if an infection develops in the arm or hand.

Radiation Therapy

The radiation oncologist will explain the possible side effects of radiation therapy for breast cancer--including uncommon side effects that may involve the heart, lungs, and ribs. One of the common side effects is fatigue, especially in the later weeks of treatment and for sometime afterward. Resting is important, but doctors usually advise their patients to try to stay reasonably active, matching their activities to their energy level. It is also common for the skin in the treated area to become red, dry, tender, and itchy. Toward the end of treatment, the skin may become moist and "weepy." Exposing this area to air as much as possible will help the skin heal. Because bras and some types of clothing may rub the skin and cause irritation, patients may want to wear loose-fitting cotton clothes. Good skin care is important at this time, and patients should check with their doctor before using any deodorants, lotions, or creams on the treated area. These effects of radiation therapy on the skin are temporary, and the area gradually heals once treatment is over. However, there may be a permanent change in the color of the skin.

For most women, the breast will look and feel about the same after radiation therapy. Occasionally, the treated breast may be firmer. Also, it may be larger (due to fluid buildup) or smaller (because of tissue changes) than it was before. For some women, the breast skin is more sensitive after radiation treatment; for others, it is less sensitive.

Chemotherapy

The side effects of chemotherapy depend mainly on the drugs the patient receives. As with other types of treatment, side effects vary from person to person. In general, anticancer drugs affect rapidly dividing cells. These include blood cells, which fight infection, cause the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, patients are more likely to get infections, bruise or bleed easily, and may have less energy during treatment and for some time afterward. Cells in hair follicles and cells that line the digestive tract also divide rapidly. As a result of chemotherapy, patients may lose their hair and may have other side effects, such as loss of appetite, nausea, vomiting, diarrhea, or mouth sores. Many of these side effects can now be controlled, thanks to improvements in antiemetics (drugs that reduce or prevent vomiting) and other medications. Side effects generally are short-term problems. They gradually go away during the recovery part of the chemotherapy cycle or after the treatment is over.

With modern chemotherapy, long-term side effects are quite rare, but there have been cases in which the heart is weakened, and second cancers such as leukemia (cancer of the blood cells) have occurred. Also, some anticancer drugs can damage the ovaries. If the ovaries fail to produce hormones, the woman may have symptoms of menopause, such as hot flashes and vaginal dryness. Her periods may become irregular or may stop, and she may not be able to become pregnant. However, some women may still be able to get pregnant during treatment. Because the effects of chemotherapy on an unborn child are not known, it is important for a woman to talk to her doctor about birth control before treatment begins. After treatment, some women regain their ability to become pregnant, but in women over the age of 35 or 40, infertility is likely to be permanent.

Hormonal Therapy

Hormonal therapy can cause a number of side effects. They depend largely on the specific drug or type of treatment, and they vary from patient to patient. Tamoxifen is the most common hormonal treatment. This drug blocks the body's use of estrogen but does not stop estrogen production. Tamoxifen may cause hot flashes, vaginal discharge or irritation, and irregular periods. Any unusual bleeding should be reported to the doctor. Younger women taking tamoxifen may become pregnant more easily and should discuss birth control methods with their doctor.

Serious side effects of tamoxifen are rare, but this drug can cause blood clots in the veins, especially in the legs. In a very small number of women, tamoxifen has caused cancer of the lining of the uterus. The doctor may do a pelvic exam, as well as biopsies or other tests of the lining of the uterus, to monitor for this condition. (This does not apply to women who have had a hysterectomy, surgery to remove the uterus.)

Young women whose ovaries are removed to deprive the cancer cells of estrogen experience menopause immediately. The side effects they have are likely to be more severe than the effects of natural menopause.

Nutrition for Cancer Patients

Loss of appetite can be a problem for cancer patients. People may not feel hungry when they are uncomfortable or tired. Also, some of the common side effects of cancer treatment, such as nausea, vomiting, and mouth sores, can make it hard to eat. The doctor can prescribe medicine to help with these problems. Good nutrition is important. Patients who eat well often feel better and have more energy. Eating well means getting enough calories and protein to help prevent weight loss, regain strength, and rebuild normal tissues.

Doctors, nurses, and dietitians can explain the side effects of treatment and can suggest ways to deal with them. Patients and their families also may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful suggestions.

Breast econstruction

After a mastectomy, some women decide to wear a breast form (prosthesis). Others prefer to have breast reconstruction, either at the same time as the mastectomy or later on. Each option has its pros and cons, and what is right for one woman may not be right for another. What is important is that nearly every woman treated for breast cancer has choices. It is best to consult with a plastic surgeon before the mastectomy, even if reconstruction will be considered later on.

Various procedures are used to reconstruct the breast. Some use implants (either saline or silicone); others use tissue moved from another part of the woman's body. Concerns about the safety of silicone breast implants have restricted their use to clinical trials approved by the Food and Drug Administration. Women interested in having silicone implants should talk with their doctor about enrolling in one of these trials. A woman's age, body type, and the type of cancer treatment she had help determine which type of reconstruction is best. The women should ask the plastic surgeon to explain the risks and benefits of each type of reconstruction. The National Cancer Institute booklet Understanding Breast Cancer Treatment: A Guide for Patients contains more information about breast reconstruction. The Cancer Information Service can suggest other sources of information about breast reconstruction and can tell callers how to contact breast cancer support groups. Members of such groups are often willing to share their personal experiences with breast reconstruction.

Rehabilitation

Rehabilitation is a very important part of breast cancer treatment. The health care team makes every effort to help women return to their normal activities as soon as possible. Recovery will be different for each woman, depending on the extent of the disease, the type of treatment, and other factors.

Exercising after surgery can help a woman regain motion and strength in her arm and shoulder. It can also reduce pain and stiffness in her neck and back. Carefully planned exercises should be started as soon as the doctor says the woman is ready, often within a day or so after surgery. Exercising begins slowly and gently and can even be done in bed. Gradually, exercising can be more active, and regular exercise becomes part of a woman's normal routine. (Women who have a mastectomy and immediate breast reconstruction need special exercises, which the doctor or nurse will explain.)

Often, lymphedema after surgery can be prevented or reduced with certain exercises and by resting with the arm propped up on a pillow. If lymphedema occurs, the doctor may suggest exercises and other ways to deal with this problem. For example, some women with lymphedema wear an elastic sleeve or use an elastic cuff to improve lymph circulation. The doctor also may suggest other approaches, such as medication, manual lymph drainage (massage), or use of a machine that compresses the arm. The woman may be referred to a physical therapist or another specialist.

Followup Care

Regular followup exams are important after breast cancer treatment. The doctor will continue to check the woman closely to be sure that the cancer has not returned. Regular checkups usually include examinations of the breasts, chest, underarm, and neck. From time to time, the woman has a complete physical exam and a mammogram. Some women may also have additional tests.

A woman who has had cancer in one breast has an increased risk of developing cancer in her other breast. She should report any changes in the treated area or in the other breast to her doctor right away.

Also, a woman who has had breast cancer should tell her doctor about other physical problems if they come up, such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or blurred vision. She should also report dizziness, coughing or hoarseness, headaches, backaches, or digestive problems that seem unusual or that don't go away. These symptoms may be a sign that the cancer has returned, but they can also be signs of various other problems. It's important to share your concerns with a doctor.

Living With Cancer

The diagnosis of breast cancer can change a woman's life and the lives of those close to her. These changes can be hard to handle. It is common for the woman and her family and friends to have many different and sometimes confusing emotions.

At times, patients and their loved ones may be frightened, angry, or depressed. These are normal reactions when people face a serious health problem. Many people find it helps to share their thoughts and feelings with loved ones. Sharing can help everyone feel more at ease. It can open the way for others to show their concern and offer their support.

Sometimes women who have had breast cancer are afraid that changes to their body will affect not only how they look but how other people feel about them. They may be concerned that breast cancer and its treatment will affect their sexual relationships. Many couples find that talking about these concerns helps them find ways to express their love during and after treatment. Some seek counseling or a couples' support group.

Cancer patients may worry about holding a job, caring for their families, or starting new relationships. Worries about tests, treatments, hospital stays, and medical bills are also common. Doctors, nurses, or other members of the health care team can help calm fears and ease confusion about treatment, working, or daily activities. Also, meeting with a nurse, social worker, counselor, volunteer, or member of the clergy can be helpful to patients who want to talk about their feelings or discuss their concerns about the future or about personal relationships.

Support for Breast Cancer Patients

Finding the strength to deal with the changes brought about by breast cancer can be easier for patients and those who love them when they have appropriate support services.

Many patients find it helpful to talk with others who are facing problems like theirs. Cancer patients often get together in self-help and support groups, where they can share what they have learned about cancer and its treatment and about coping with the disease. Often a social worker or nurse meets with the group.

Several organizations offer special programs for breast cancer patients. Trained volunteers, who have had breast cancer themselves, may talk with or visit patients, provide information, and lend emotional support before and after treatment. They often share their experiences with breast cancer treatment, rehabilitation, and breast reconstruction.

Friends and relatives, especially those who have had cancer themselves, can also be very supportive. It is important to keep in mind, however, that each patient is different. Treatment and ways of dealing with cancer that work for one person may not be right for another, even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

Often, the doctor's staff or a social worker at the hospital or clinic can suggest local and national groups that can help with emotional support, rehabilitation, financial aid, transportation, or home care. Information about finding support groups and other programs and services for breast cancer patients and their families is also available through the Cancer Information Service.

What the Future Holds

Researchers continue to look for better ways to detect and treat breast cancer, and the chances of survival keep improving. Still, it is natural for patients to be concerned about their future.

Sometimes patients use statistics they have heard to try to figure out their own chances of being cured. It is important to remember, however, that statistics reflect the experience of large groups of patients, not individuals. Statistics can't be used to predict what will happen to a particular woman because no two patients are alike. The doctor who takes care of the patient and knows her medical history is in the best position to talk with her about the probable outcome or course of her disease (prognosis). Women should feel free to ask the doctor about their prognosis, but they should keep in mind that not even the doctor knows exactly what will happen. Doctors often talk about surviving cancer, or they may use the term remission. Doctors use these terms because, although many breast cancer patients are cured, the disease can recur, even many years later.

The Promise of Cancer Research

Cancer research gives hope. Doctors and researchers at hospitals and medical centers all across the country are learning more about what causes breast cancer and are exploring ways to prevent it. They are also finding better ways to detect, diagnose, and treat this disease.

Causes and Prevention

Doctors can seldom explain why one person gets breast cancer and another doesn't. It is clear, however, that breast cancer is not caused by bumping, bruising, or touching the breast. And this disease is not contagious; no one can "catch" breast cancer from another person.

Scientists are trying to learn more about factors that increase the risk of developing this disease. For example, research is in progress to determine whether the risk of breast cancer is affected by environmental factors. Pesticides, magnetic fields, engine exhausts, and contaminants in water and food are some of the environmental factors under study.

Some aspects of a woman's lifestyle may affect her chances of developing breast cancer. For example, some studies point to a slightly higher risk of breast cancer among women who drink alcohol. The risk appears to go up with the amount of alcohol consumed.

Scientists are trying to learn whether having an abortion or a miscarriage increases the risk of breast cancer. Thus far, studies have produced conflicting results, and this question is still unresolved.

Some evidence suggests a link between diet and breast cancer. Studies show that breast cancer is more common in populations that consume a high-fat diet than in populations that consume a low-fat diet. However, it is not yet known whether a diet low in fat will actually prevent breast cancer. Also, recent studies suggest that regular exercise may decrease the risk of breast cancer in younger women.

Research has led to the identification of certain alterations in genes that place women at a greater risk for developing breast cancer. Women with a strong family history of breast cancer may choose to have a blood test to see if they have inherited an alteration in the BRCA1 or BRCA2 gene. Certain alterations in either of these genes increase a woman's chances of developing breast cancer. Special counseling before and after testing helps women understand and deal with the possible outcomes--both benefits and risks--of having a genetic test. For example, a potential benefit of genetic testing is that it gives women the ability to make informed medical and lifestyle decisions. However, information about having a genetic alteration could affect a woman's employment or her health, life, and disability insurance. Women who are concerned about an inherited risk for breast cancer should talk to their doctor. The doctor may suggest seeing a health professional trained in genetics.

Ongoing studies are looking at ways to prevent breast cancer through changes in diet. Other studies are looking for drugs that may prevent the development of this disease. In one study, the drug tamoxifen reduced the number of new cases of breast cancer among women at an increased risk for the disease.

Detection and Diagnosis

At present, mammograms are the most effective tool we have to detect breast cancer. Researchers are looking for ways to make mammography more accurate. They are also exploring other techniques, such as digital mammography (using computers to read mammograms), magnetic resonance imaging (MRI), breast ultrasonography, and breast-specific positron emission tomography (PET), to produce detailed pictures of the tissues in the breast.

In addition, researchers are studying tumor markers, substances that may be present in abnormal amounts in the blood, urine, or nipple aspirates of a woman who has breast cancer. Some of these markers are used to follow women who have already been diagnosed with breast cancer. At this time, however, no blood or urine test is reliable enough to be used routinely to detect breast cancer.

Clinical Trials

Research has led to significant advances in the treatment of breast cancer, and researchers continue to search for more effective ways to treat this disease. They are also exploring ways to reduce the side effects of treatment and improve the quality of patients' lives. When laboratory research shows that a new treatment method has promise, cancer patients receive the treatment in studies called clinical trials. These studies are designed to answer important questions and to find out whether the new approach is both safe and effective. Often, clinical trials compare a new treatment with a standard approach. Through research, doctors try to find new, more effective ways to treat cancer. Patients who take part in clinical trials may have the first chance to benefit from improved treatment methods, and they make an important contribution to medical science.

Studies of new approaches for patients with all stages of breast cancer are under way. A new procedure, sentinel lymph node biopsy, may eventually reduce the number of lymph nodes that need to be removed for biopsy and possibly prevent or lessen the severity of lymphedema. Researchers are also testing new chemotherapy doses and treatment schedules; the effectiveness of using chemotherapy before surgery (called neoadjuvant chemotherapy); and new ways of combining treatments, such as adding hormonal therapy or radiation therapy to chemotherapy. They are working with various anticancer drugs and drug combinations, as well as with several types of hormonal therapy. Some studies include biological therapy, treatment with substances that boost the immune system's response to cancer or help the body recover from the side effects of treatment.

In a number of studies, doctors are trying to learn whether very high doses of anticancer drugs are more effective than the usual doses in destroying breast cancer cells. Because these higher doses seriously damage the patient's bone marrow, where blood cells are formed, researchers are testing ways to replace the bone marrow or to help it recover.

Cancer patients may want to read a National Cancer Institute booklet called Taking Part in Clinical Trials: What Cancer Patients Need To Know, which explains some of the possible benefits and risks of clinical trials. Those who are interested in taking part in a clinical trial should discuss this option with their doctor.

Women can learn about ongoing clinical trials through PDQ. This NCI cancer information database also contains current information on cancer prevention, screening, treatment, and supportive care. Information from PDQ is available from the Cancer Information Service.

Source: National Cancer Institute, National Institutes of Health