Background
Detection and Diagnosis
Staging
Treatment and Care
Support for Women with Breast Cancer
Background
Breast cancer
is the most common type of cancer among women in this country (other than skin cancer). The number
of new cases of
breast cancer in women was estimated to be about 212,600 in 2003.
This National Cancer Institute (NCI) booklet (NIH Publication Number is 03-1556) has important
information about breast cancer. It discusses possible
causes, screening, symptoms,
diagnosis, treatment, and recovery. It also has information to help women with breast cancer cope
with the disease.
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Breast Cancer in Men
Each year, about 1,300 men in this country learn they have breast cancer. Much of the information
in this booklet applies to men with breast cancer.
More information about breast cancer in men is available on NCI's Web site at
http://cancer.gov and from NCI's Cancer Information Service at 1-800-4-CANCER.
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Research continues to teach us about breast cancer. Scientists are learning more about causes and
new ways to prevent,
find, and treat this disease. Because of research, people with breast cancer can look forward to a
better
quality of life and less chance of dying from this disease. The NCI provides the most up-to-date
information over the telephone and on the Internet:
- Telephone: Information specialists at the NCI's Cancer Information Service at 1-800-4-CANCER can answer questions about cancer and can send materials published by NCI.
- Internet: People can ask questions online and get immediate help through
LiveHelp
Words that may be new to readers appear in italics. The "Dictionary" section explains these
terms. Some words in the "Dictionary" have a "sounds-like" spelling to show how to pronounce them.
The
breasts are
glands that can make milk.
Each breast sits on chest muscles that cover the ribs.
Each breast is divided into 15 to 20 sections called
lobes. Lobes contain many smaller
lobules. Lobules contain groups
of tiny glands that can produce milk. Milk flows from the lobules through thin tubes called
ducts
to the nipple.
The nipple is in the center of a dark area of skin called the areola. Fat fills the spaces between the lobules and ducts.
The breasts also contain
lymph vessels, which carry a clear
fluid called
lymph.
The lymph vessels lead to small, round
organs
called
lymph nodes.
Groups of lymph nodes are found near the breast in the axilla (underarm), above the collarbone, in the chest behind the breastbone, and in many other parts of the body. The lymph nodes trap bacteria, cancer
cells, or other harmful substances that may be in the lymphatic system.
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| These pictures show the parts of the breast and the lymph nodes and lymph vessels near the breast. |
Cancer begins in cells, the building blocks that make up
tissues. Tissues make up the organs of the body. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.
Sometimes this orderly process goes wrong. New cells form when the body does not need them,
and old cells do not die when they should. These extra cells can form a mass of
tissue called a growth or tumor.
Not all tumors are cancer. Tumors can be benign or malignant:
- Benign tumors are not cancer:
- Benign tumors are rarely life-threatening.
- Usually, benign tumors can be removed, and they seldom grow back.
- Cells from benign tumors do not spread to tissues around them or to other parts of the body.
- Malignant tumors are cancer:
- Malignant tumors generally are more serious than benign tumors. They may be life-threatening.
- Malignant tumors often can be removed, but they can grow back.
- Cells from malignant 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 cancer cells spread from the original cancer (primary tumor) to form new tumors in other organs. The spread of cancer is called metastasis.
When breast cancer cells enter the lymphatic system, they may be found in lymph nodes near the breast.
The cancer cells also may travel to other organs through the lymphatic system or bloodstream. When cancer spreads
(metastasizes), the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if breast cancer spreads to the bone, the cancer cells in the bone are breast cancer cells. The disease is metastatic breast cancer, not bone cancer. It is treated as breast cancer, not as bone cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.
No one knows the exact causes of breast cancer. Doctors can seldom explain why one woman gets breast cancer and another does not.
Doctors do know that bumping, bruising, or touching the breast does not cause breast cancer. And breast cancer is not contagious. No one can "catch" this disease from another person.
However, research has shown that women with certain
risk factors
are more likely than others to develop breast cancer. A
risk factor is anything that increases a person's chance of developing a disease. Studies have found
the following risk factors for breast cancer:
- Age: The chance of getting breast cancer goes up as a woman gets older. A woman over age 60 is at greatest risk. This disease is very uncommon before menopause.
- Personal history of breast cancer: A woman who has had breast cancer in one breast has an increased risk of getting this disease in her other breast.
- Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer, especially at a young age (before age 40). Having other relatives with breast cancer on either her mother's or her father's side of the 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 or
lobular carcinoma in situ [LCIS]) increases the risk of breast cancer.
- Genetic alterations: Changes in certain
genes
(BRCA1, BRCA2, and others) increase the risk of breast cancer. In families in which many women have had the disease, genetic testing can sometimes show the presence of specific genetic changes. Health care providers may suggest ways to try to reduce the risk of breast cancer, or to improve the detection of this disease in women who have these changes in their genes. The Cancer Information Service can provide printed material about genetic 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 began menstruation (had their first menstrual period) at an early age (before age 12), went through menopause late (after age 55), or never had children also are at an increased risk.
- Women who take
menopausal hormone therapy (either estrogen alone or estrogen plus progestin) for 5 or more years after menopause also appear to have an increased chance of developing breast cancer.
- Much research has been done to learn whether having an abortion or a miscarriage affects a woman's chance of developing breast cancer later on. Large, well-designed studies have consistently shown no link between abortion or miscarriage and the development of breast cancer.
- Race: Breast cancer occurs more often in white women than Latina, Asian, or African American women.
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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: Older women who have mostly dense (not fatty) tissue on a
mammogram (x-ray of the breast) are at increased risk of breast cancer.
- Taking DES (diethylstilbestrol): DES is a synthetic form of estrogen that was given to some pregnant women in the United States between about 1940 and 1971. (DES is no longer given to pregnant women.) Women who took DES during pregnancy have a slightly increased risk of breast cancer. This does not yet appear to be the case for their daughters who were exposed to DES before birth. However, as these daughters grow older, more studies of their breast cancer risk are needed.
- Being
obese
after menopause: After menopause, women who are obese have an increased risk of developing breast cancer. Being obese
means that the woman has an abnormally high proportion of body fat. Because the body makes some of its estrogen
(a
hormone) in fatty tissue, obese women are more likely than thin women to have higher levels of estrogen in
their bodies. High levels of estrogen may be the reason that obese women have an increased risk of breast cancer.
Also, some studies show that gaining weight after menopause increases the risk of breast cancer.
- Physical inactivity: Women who are physically inactive throughout life appear to have an increased risk of breast cancer. Being physically active may help to reduce risk by preventing weight gain and obesity.
- Alcoholic beverages: Some studies suggest that the more alcoholic beverages 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 be avoided. It is helpful to be aware of risk factors. But it is also important to keep in mind that most women who have these risk factors do not get breast cancer.
Also, most women who develop breast cancer have no history of the disease in their family. In fact, except for growing older, most women with breast cancer have no strong risk factors.
Still, a woman who thinks she may be at risk of breast cancer should discuss this concern with her health care provider. The health care provider may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.
The NCI's Breast Cancer Risk Assessment Tool is at http://bcra.nci.nih.gov/brc/ on the Internet. This tool allows a health care provider to estimate a woman's risk of developing invasive cancer of the breast.
Detection and Diagnosis
A woman should talk with her health care provider about her personal risk of getting breast cancer. She should ask questions about when to start and how often to be checked for the disease. These decisions, like many other medical decisions, should fit each woman's needs.
Screening
for cancer before there are
symptoms
can be important. It can help doctors find and treat cancer early. Treatment is more likely to be effective when cancer is found early.
The health care provider may suggest screening tests to check for breast cancer before any symptoms develop:
Screening Mammogram
To find breast cancer early, the NCI recommends that:
- Women in their 40s and older should have mammograms (pictures of the breast made with x-rays) every one to two years.
- Women who are at higher than average risk of breast cancer should talk with their health care providers about whether to have mammograms before age 40 and how often to have them.
Screening mammograms can often show a breast lump before it can be felt. They also can show a cluster of very tiny specks of calcium. These specks are called
microcalcifications. Lumps or specks can be signs of cancer.
If the doctor sees an abnormal area on the mammogram, the woman may need more pictures taken. Also, the woman may need to have a biopsy. A biopsy is the only way to tell for sure if cancer is present.
The radiologist will study the mammogram for breast changes that do not look normal and for differences between your breasts.
When possible, he or she will compare your most recent mammogram with past mammograms to check for changes. Mammography is a good tool
to find breast changes in most women who have no signs of breast cancer. However, it does not detect all breast cancers, and many changes
it finds are not cancer. See your health care provider if you have a lump that was not seen on a mammogram or notice any other breast changes.
What a Mamagram can show:
Mammograms are the best tool doctors have to find breast cancer early. However, it is good for a woman to keep in mind that:
- A mammogram may miss some cancers that are present. (This is called a "false negative.")
- A mammogram may show things that turn out not to be cancer. (This is called a "false positive.")
- Some fast-growing tumors may already have spread to other parts of the body before a mammogram detects them.
Mammograms (as well as dental x-rays, and other routine x-rays) use very small doses of radiation. Although the benefits nearly always outweigh the risks, repeated exposure to x-rays could be harmful. It is a good idea for a woman to talk with her health care providers about the need for each x-ray and to ask about the use of shields during the
x-ray to protect other parts of the body.
Clinical Breast Exam
During a clinical breast exam, the health care provider feels the breasts while the woman is standing or sitting up and lying down. The woman may be asked to raise her arms over her head, let them hang by her sides, or press her hands against her hips.
The health care provider looks for differences between the breasts, including unusual differences in size or shape. The skin of each breast is checked for a rash, dimpling, or other abnormal signs. The nipples may be squeezed to see if fluid is present.
Using the pads of the fingers to feel for lumps, the health care provider checks the entire breast, the underarm, and the collarbone area, first on one side, then on the other. A lump is generally the size of a pea before anyone can feel it. The lymph nodes near the breast may be checked to see if they are swollen.
A thorough clinical breast exam may take 10 minutes.
Breast Self-Exam
Some women perform monthly breast self-exams to check for any changes in their breasts. When a woman does this exam, it is important for her to remember that each woman's breasts are different, and that changes can occur because of aging, the menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for the breasts to feel a little lumpy and uneven. Also, it is common for a woman's breasts to be swollen and tender right before or during her menstrual period.
Women who notice anything unusual during a breast self-exam or at any other time should contact their health care provider.
Also, it is important to remember that breast self-exams cannot replace regular screening mammograms and clinical breast exams. Although breast self-exams lead to more breast biopsies, studies so far have not shown that breast self-exams reduce the number of deaths from breast cancer.
Breast cancer can cause changes that women should watch for:
- 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
- The nipple is 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)
Although early breast cancer usually does not cause pain, a woman should see her health care provider about breast
pain or any other symptom that does not go away. Most often, these symptoms are not cancer, but it is important to check with the health care provider so that any problems can be diagnosed and treated as early as possible.
If a woman has a breast change, her doctor must determine whether it is due to breast cancer or some other cause.
The woman has a physical exam. The doctor asks about her personal and family medical history. She may have a mammogram or other
imaging procedure that makes pictures of tissues inside the breast. After the tests, the doctor may decide that no further tests are needed and no treatment is necessary. Or the woman may need a biopsy to examine the suspicious area for cancer cells.
Clinical Breast Exam
The health care provider feels each breast for lumps and looks for other problems. If a woman has a breast lump, the health care provider can tell a lot about it by feeling it and the tissue around it. Benign lumps often feel different from cancerous ones. The health care provider can check the size, shape, and texture of the lump and feel whether it moves easily. 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 Mammography
Diagnostic mammograms
involve x-ray pictures of the breast to get clearer, more detailed pictures of any area that looks abnormal on a screening mammogram. They also are used to help the doctor learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.
Ultrasonography
Using high-frequency sound waves,
ultrasonography
(ultrasound) can often show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). The doctor can view these pictures on a monitor. After the test, the pictures can be stored on video and printed out. This exam may be used along with a mammogram.
Magnetic Resonance Imaging
For
magnetic resonance imaging
(MRI), a powerful magnet linked to a computer is sometimes used to make detailed pictures of tissue inside the breast. The doctor can view these pictures on a monitor and can print them on film. MRI may be used along with a mammogram.
Biopsy
Often, fluid or tissue must be removed from the breast to help the doctor learn whether cancer is present. This is called a biopsy. For the biopsy, the doctor may refer the woman to a surgeon or breast disease specialist.
Sometimes a suspicious area that can be seen on a mammogram cannot be felt during a clinical breast exam. The doctor can use imaging devices to help see the area to then obtain tissue. Such procedures include
ultrasound-guided,
needle-localized, or
stereotactic biopsy.
Doctors can remove tissue from the breast in different ways:
- Fine-needle aspiration: The doctor uses a thin needle to remove fluid and/or cells from a breast lump. If the fluid appears to contain cells, it goes to a lab where a pathologist uses a microscope to check for cancer cells. If the fluid is clear, it may not need to be checked by a lab.
- Core biopsy: The doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
- Surgical biopsy: In an incisional biopsy, the surgeon removes a sample of a lump or abnormal area. In an excisional biopsy, the surgeon removes the entire lump or abnormal area. A pathologist examines the tissue for cancer cells.
If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts. Another type, called
lobular carcinoma, begins in the lobules.
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A woman who needs a biopsy may want to ask her doctor the following questions:
- What kind of biopsy will I have? Why?
- How long will it take? Will I be awake? Will it hurt? Will I have anesthesia? What kind?
- How soon will I know the results?
- Are there any risks? What are the chances of infection or bleeding after the biopsy?
- If I do have cancer, who will talk with me about treatment? When?
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If the diagnosis is cancer, the doctor may order special lab tests on the tissue that was removed. The results of these tests help the doctor learn more about the cancer and plan appropriate treatment.
Many women with breast cancer will have the
hormone receptor test.
It shows whether the cancer needs hormones
(estrogen or progesterone) to grow. The result helps the doctor plan treatment.
Sometimes a sample of breast tissue is checked for the human
epidermal growth factor receptor-2
(HER2)
or the
HER2/neu gene.
The presence of the HER2 receptor or gene may increase the chance that the breast cancer will come back.
Staging
To plan a woman's treatment, the doctor needs to know the extent (stage) of the disease. The stage is based on the size of the tumor and whether the cancer has spread. Staging may involve x-rays and lab tests to learn whether the cancer has spread and, if so, to what parts of the body. When breast cancer spreads, cancer cells are often found in lymph nodes under the arm
(axillary lymph nodes). The extent of the cancer often is not known until after surgery to remove the tumor in the breast and the lymph nodes under the arm.
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A woman may want to ask her doctor these questions after staging:
- What kind of breast cancer do I have?
- What did the hormone receptor test show? What other lab tests were done on the tumor tissue, and what did they show?
- What is the stage of the disease? Has the cancer spread?
- How will this information help in deciding what type of treatment or further tests I will need?
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Doctors describe breast cancer by the following stages:
- Stage 0 is called
carcinoma in situ.
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Lobular carcinoma in situ (LCIS)
refers to abnormal cells in the lining of
a lobule. These abnormal cells are a
marker of increased risk. That means a woman with LCIS has an increased risk of developing invasive cancer in either
breast sometime in the future. (Both breasts are at risk.)
- Ductal carcinoma in situ
(DCIS) is a precancerous condition in the lining of a
duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread outside the duct to invade the surrounding breast tissue. However, if not treated, DCIS sometimes becomes invasive cancer.
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| This picture shows ductal carcinoma in situ. |
- Stage I is an early stage of invasive breast cancer. Stage I means that the tumor is no more than 2 centimeters (less than three-quarters of an inch) across, and cancer cells have not spread beyond the breast.
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| This picture shows cancer that has spread outside the duct and has invaded nearby breast tissue. |
- Stage II is one of the following:
- The tumor in the breast is no more than 2 centimeters (less than three-quarters of an inch)
across, and the cancer has spread to the lymph nodes under the arm; or
- The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2 inches), and the
cancer may have spread to the lymph nodes under the arm; or
- The tumor is larger than 5 centimeters (2 inches) but 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 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 treatment. It may
recur locally (in the breast or chest wall) or in any other part of the body (such as bone, liver, or
lungs).
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Treatment and Care
Many women with breast cancer want to learn all they can about their disease and their treatment choices. They want to take an active part in making decisions about their medical care. Learning more about the disease helps many women cope. But how much information to seek and how to deal with it are personal choices. Each woman can make her own decision about how much she wants to know.
The shock and stress after a diagnosis of cancer can make it hard to think of everything to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, a woman can take notes or ask whether she may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen.
The doctor may refer a woman with breast cancer to a specialist, or the woman may ask for a referral.
Specialists who treat breast cancer include
surgeons,
medical oncologists,
radiation oncologists, and
plastic surgeons. A woman may have a different specialist for each type of treatment.
Treatment generally begins within a few weeks after the diagnosis. Usually, there is time for a woman to talk with her doctor about treatment options, get a second opinion, and learn more about breast cancer before making a treatment decision.
Getting a Second Opinion
Before starting treatment, a woman with breast cancer may want to get a second opinion about her diagnosis and treatment options. Some insurance companies require a second opinion; others may cover a second opinion if the woman or doctor requests it. It may take time and effort to gather medical records (mammogram films, biopsy slides,
pathology report, and proposed treatment plan) and arrange to see another doctor. In general, taking several weeks to get a second opinion does not make treatment less effective.
There are a number of ways to find a doctor for a second opinion:
- The woman's doctor may refer her to one or more specialists. At cancer centers, several specialists often work together as a team.
- The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.
- A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.
- The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The
Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at
http://www.abms.org. (Click on "Who's Certified.")
Treatment Methods
Women with breast cancer have many treatment options. These include
surgery,
chemotherapy,
radiation therapy,
hormonal therapy, and
biological therapy. These options are described
below.
In most cases, the most important factor in treatment choices is the stage of the disease.
See the section called Treatment Choices by Stage.
Many women receive more than one type of treatment. In addition, at any stage of disease, women
with breast cancer may have treatment to control pain and other symptoms of the cancer, to relieve the
side effects of treatment, and to ease emotional problems. This kind of treatment is called supportive care, symptom management, or palliative care. Information about supportive care is available on NCI's Web site at
http://cancer.gov and from NCI's Cancer Information Service at 1-800-4-CANCER.
Treatment for cancer is either local therapy or systemic therapy:
- Local therapy: Surgery and radiation therapy are local treatments. They remove or
destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy
may be used to control the disease in those specific areas but not elsewhere.
- Systemic therapy: Chemotherapy, hormonal therapy, and biological therapy are systemic
treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women
with breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have
systemic therapy after surgery and/or radiation to prevent the cancer from coming back. Systemic
treatments also are used for cancer that has spread.
Most women want to know how treatment may change their normal activities. They want to know how
they will look during and after treatment. The doctor is the best person to describe treatment
choices, side effects, and the expected results of treatment. Each woman can work with her doctor
to develop a treatment plan that meets her needs and personal values.
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A woman may want to ask her doctor these questions before treatment begins:
- What are my treatment choices? Which do you recommend for me? Why?
- What are the expected benefits of each kind of treatment?
- What are the risks and possible side effects of each treatment?
- What is the treatment likely to cost? Is this treatment covered by my insurance plan?
- How will treatment affect my normal activities?
- Would a clinical trial (research study) be appropriate for me?
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Women do not need to ask all of their questions at once. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.
Surgery
Surgery is the most common treatment for breast cancer. There are several types of surgery.
(See the pictures below.) The doctor can explain each type, discuss and compare the benefits and risks, and describe how each will affect the woman's appearance:
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Breast-sparing surgery: An operation to remove the cancer but not the breast is called breast-sparing surgery, breast-conserving surgery, lumpectomy, segmental mastectomy, or partial mastectomy.
Through a separate incision, the surgeon often removes the underarm lymph nodes to learn whether cancer cells have entered the lymphatic system. The procedure to remove the underarm lymph nodes is called an
axillary lymph node dissection.
After breast-sparing surgery, most women receive radiation therapy to the breast to destroy cancer cells that may remain in the breast.
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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. After surgery, the woman may receive radiation therapy.
Studies have found equal survival rates for breast-sparing surgery (with radiation therapy) and mastectomy for Stage I and
Stage II breast cancer.
A new method of checking for cancer cells in the lymph nodes is called sentinel lymph node biopsy. In this operation, a specially trained surgeon removes only one or a few lymph nodes (the sentinel nodes) instead of removing a much larger number of underarm lymph nodes.
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| In breast-sparing surgery, the surgeon removes the tumor in the breast and some tissue around it.
(Sometimes an excisional biopsy--which removes all of the tumor--serves as a lumpectomy. Biopsy is described in the
Occasionally, some of the lining over the chest muscles below the tumor is removed as well. Some lymph nodes under the arm may also be removed.
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| In modified radical mastectomy, the surgeon removes the whole breast, most or all of the lymph nodes under the arm, and, often, the lining over the chest muscles. The smaller of the two chest muscles also may be taken out to make it easier to remove the lymph nodes. |
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A woman may want to ask her doctor these questions before having surgery:
- What kinds of surgery can I consider? Is breast-sparing surgery an option for me? Which operation do you recommend for me? What are the risks of surgery?
- Will my lymph nodes be removed? How many? Why?
- How will I feel after the operation? How long will I be in the hospital?
- Will I need to learn how to take care of myself or my incision when I get home?
- Where will the scars be? What will they look like?
- If I decide to have plastic surgery to rebuild my breast, how and when can that be done? Can you suggest a
plastic surgeon for me to contact?
- Will I have to do special exercises to help regain motion and strength in my arm and shoulder? Will a physical therapist or
nurse show me how to do the exercises?
- When can I get back to my normal activities? What activities should I avoid?
- Is there someone I can talk with who has had the same surgery I'll be having?
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Women may choose to have breast reconstruction
(plastic surgery to rebuild the shape of the breast). It may be done at the same time as a mastectomy or later. Women considering reconstruction may wish to talk about it with a plastic surgeon before having a mastectomy.
Radiation therapy
Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. It generally follows breast-sparing surgery. Sometimes, depending on the size of the tumor and other factors, radiation therapy also is used after mastectomy. The radiation destroys breast cancer cells that may remain in the area.
Some women have radiation therapy (alone or with chemotherapy or hormonal therapy) before surgery to destroy cancer cells and shrink tumors. This approach is most often used when the breast tumor is large or cannot easily be removed by surgery.
Doctors use two types of radiation therapy to treat breast cancer:
- External radiation: The radiation comes from a machine. For external radiation therapy, a woman with breast cancer goes to the hospital or clinic. Generally, treatments are scheduled 5 days a week for several weeks.
- Internal radiation (implant radiation): The radiation comes from radioactive material placed in thin plastic tubes put directly in the breast. For implant radiation, the woman stays in the hospital. The implants remain in place for several days. They are removed before the woman goes home.
Some women with breast cancer have both kinds of radiation therapy.
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A woman may want to ask her doctor these questions before having radiation therapy:
- Why do I need this treatment?
- What are the benefits, risks, and side effects of this treatment? Will it affect my skin?
- Are there any long-term effects?
- When will treatment begin? How will we know the treatment is working? When will treatment end?
- How will I feel during therapy? Will I be able to drive myself to and from therapy?
- What can I do to take care of myself before, during, and after radiation therapy?
- Can I continue my normal activities?
- How will my chest look afterward?
- What is the chance that the tumor will come back in my breast?
- How often will I need checkups?
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Chemotherapy
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 as a pill or by injection into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body.
Most women with breast cancer have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. But some women may need to stay in the hospital during chemotherapy.
Hormonal therapy
Hormonal therapy keeps cancer cells from getting the natural hormones (estrogen and progesterone) they need to grow. If lab tests show that the breast tumor has hormone receptors, the woman may have hormonal therapy. Like chemotherapy, hormonal therapy can affect cells throughout the body.
This treatment may be a medicine or surgery:
- Medicine: The doctor may suggest a drug that can block the natural hormone. One example is tamoxifen, which blocks estrogen. Another type (aromatase inhibitor) prevents the body from making the female hormone estradiol, a form of estrogen.
- Surgery: If a woman has not gone through menopause, she may have surgery to remove her
ovaries. The ovaries are the main source of the body's estrogen. (After menopause, hormone production by the ovaries naturally declines so surgery would not be needed.)
Biological therapy
Biological therapy uses the body's natural ability (immune system) to fight cancer. Some women with metastatic breast cancer receive a biological therapy called Herceptin®
(trastuzumab). It is a monoclonal antibody, a substance made in the laboratory that can bind to cancer cells.
Herceptin is given to women whose lab tests show that a breast tumor has too much of a specific protein known as HER2. By blocking HER2, Herceptin can slow or stop the growth of the cancer cells.
Herceptin is injected into a vein. It may be given by itself or along with chemotherapy. Like chemotherapy and hormonal therapy, it can affect cancer cells throughout the body.
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A woman may want to ask her doctor these questions before having systemic therapy (chemotherapy, hormonal therapy, or biological therapy):
- Why do I need this treatment?
- What drugs will I be taking? What will they do?
- If I need hormonal treatment, would surgery to remove the ovaries or drugs be better for me?
- When will treatment start? When will it end?
- What are the expected benefits of the treatment? How will we know the treatment is working?
- What are the risks and possible side effects of treatment? What can I do about them? Which side effects should I tell you about? Will there be long-term side effects?
- Where will I go for treatment? Will I be able to drive home afterward? Will I need to stay in the hospital?
- How will treatment affect my normal activities?
- Would a clinical trial be appropriate for me?
- What kind of follow-up care will I need?
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Treatment Choices by Stage
A woman's treatment options depend on the stage of her disease and the following factors:
- The size of the tumor in relation to the size of her breast
- The results of lab tests (such as whether the breast cancer cells depend on hormones to grow)
- Whether she has gone through menopause
- Her general health
The following are brief descriptions of treatments commonly used for each stage. (Other treatments may be appropriate for some women.) Clinical trials can be an option at all stages of breast cancer.
Stage 0
Stage 0 breast cancer refers to lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS):
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LCIS: Most women with LCIS do not have treatment. Instead, the doctor may recommend regular checkups to look for signs of breast cancer.
Some women take tamoxifen to reduce the risk of developing breast cancer.
Others may take part in studies of promising new preventive treatments.
Having LCIS in one breast increases the risk of cancer for both breasts. For that reason, a very small number of women with LCIS decide to have surgery to remove both breasts (bilateral prophylactic mastectomy) to try to prevent cancer from developing. The surgeon usually does not remove the underarm lymph nodes.
- DCIS: Most women with DCIS have breast-sparing surgery followed by radiation therapy. Some choose to have a
total mastectomy. Underarm lymph nodes are not usually removed. Women with DCIS may receive tamoxifen to reduce the risk of developing invasive breast cancer.
Stages I, II, and IIIA
Women with Stage I, II, or IIIA breast cancer may have a combination of treatments. Some (especially those with Stage I or II breast cancer) choose breast-sparing surgery followed by radiation therapy to the breast. Others decide to have a mastectomy. With either approach, women (especially those with Stage II or IIIA breast cancer) often have lymph nodes under the arm removed. The doctor may suggest radiation therapy after mastectomy if cancer cells are found in more than three underarm lymph nodes, or if the tumor in the breast is large.
The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors:
- The size, location, and stage of the tumor
- The size of the woman's breast
- Certain features of the cancer
- How the woman feels about saving her breast
- How the woman feels about radiation therapy
- The woman's ability to travel to a radiation treatment center
Some women (especially those with large Stage II or IIIA breast tumors) have chemotherapy before surgery. This treatment is called neoadjuvant therapy. Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible.
After surgery, many women receive adjuvant therapy (chemotherapy, hormonal therapy, or both). Adjuvant therapy is used to destroy any remaining cancer cells and prevent the cancer from coming back in the breast or elsewhere.
Stages IIIB and IIIC
Women with stage IIIB (including those with inflammatory breast cancer) or stage IIIC breast cancer usually have chemotherapy.
If the chemotherapy shrinks the tumor, the doctor then may recommend additional treatment:
- Mastectomy: The surgeon removes the breast and usually the lymph nodes under the arm. After surgery, the woman may receive radiation therapy to the chest and underarm area.
- Breast-sparing surgery: The surgeon removes the cancer but not the breast. Usually, lymph nodes under the arm are removed. After surgery, the woman may receive radiation therapy to the breast and underarm area.
- Radiation therapy instead of surgery: Some women have radiation therapy but no surgery.
The doctor also may recommend additional chemotherapy, hormonal therapy, or both. Systemic therapy may help prevent the disease from coming back in the breast or elsewhere.
Stage IV
In most cases, women with
stage IV breast cancer have hormonal therapy, chemotherapy, or both. Some also may have biological therapy. Radiation may be used to control tumors in certain parts of the body. These treatments are not likely to
cure the disease, but they may help a woman live longer.
Many women have palliative (supportive) care along with anticancer treatments intended to slow the progress of the disease. Some may receive only palliative care to manage their symptoms. Palliative care can help the woman feel better--physically and emotionally. The goal of this type of treatment is to control a woman's pain and other symptoms and to relieve the side effects of treatment (such as nausea), rather than to extend her life.
Recurrent Breast Cancer
Recurrent cancer is cancer that has come back after treatment. Treatment for the recurrent disease depends mainly on the location and extent of the cancer and on the type of treatment the woman had before.
If breast cancer comes back in the breast (and not anywhere else) after breast-sparing surgery, the woman may have a mastectomy. Chances are good that the disease will not come back again elsewhere.
If breast cancer recurs in other parts of the body, the treatment may involve chemotherapy, hormonal therapy, or biological therapy. Radiation therapy may help control cancer that recurs in the chest muscles or in certain other areas of the body.
As with Stage IV breast cancer, treatment can seldom cure cancer that recurs outside the breast. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they have anticancer treatments to slow the progress of the disease. Some receive only palliative care to improve their
quality of life by easing pain, nausea, and other symptoms.
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Clinical Trials
Women with breast cancer may want to talk with their doctor about taking part in a clinical trial, a
research study of new ways to treat cancer and prevent
recurrence. Clinical trials are an important option for many women. Trials are available for all stages of breast cancer.
Patients who join trials have the first chance to benefit from new treatments that have shown promise in earlier research.
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Because cancer treatment is likely to damage healthy cells and tissues, unwanted side effects are common. Specific side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, or even for women having the same treatments. And a woman's side effects may change from one treatment session to the next. The health care provider will explain the possible side effects of treatment and how to manage them.
Surgery
Surgery causes short-term pain and tenderness in the area of the operation. Before surgery, women may want to talk with their health care provider about pain management. Any kind of surgery also carries a risk of infection, bleeding, or other problems. Women who develop any problems should tell their health care provider right away.
Removal of one or both breasts can cause a woman to feel off balance--especially if she has large breasts. This imbalance can cause discomfort in her neck and back. Also, the skin in the area where the breast was removed may feel tight. The muscles of the arm and shoulder may feel stiff and weak, but these problems usually 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 her chest, underarm, shoulder, and upper arm. These feelings usually go away within a few weeks or months, but for some women, numbness does not go away.
Lymphedema
Removing the lymph nodes under the arm slows the flow of lymph fluid. The fluid may build up in the arm and hand and cause swelling (lymphedema).
This problem can develop right after surgery or months to years later.
A woman needs to protect her arm and hand on the treated side for the rest
of her life. She will need to:
- Avoid wearing tight clothing or jewelry on her affected arm
- Carry her purse or luggage with the other arm
- Use an electric razor to avoid cuts when shaving her underarm
- Have shots, blood tests, and blood pressure measurements on the other arm
- Wear gloves to protect her hands when gardening and when using strong detergents
- Have careful manicures and avoid cutting her cuticles
- Avoid burns or sunburns to her affected arm and hand
A woman should ask her doctor how to handle any cuts, insect bites, sunburn, or other injuries to the arm or hand. Also, she should contact the doctor if that arm or hand is injured, swells, or becomes red and warm.
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 to improve lymph circulation. The doctor also may suggest other approaches, such as medication, manual lymph drainage (massage), or use of a machine that gently compresses the arm. The woman may be referred to a physical therapist or another specialist.
More information about lymphedema is available on NCI's Web site at
cancer.org and from NCI's Cancer Information Service at 1-800-4-CANCER.
Radiation Therapy
During radiation therapy, women with breast cancer may become tired, especially toward the end of treatment. This feeling may continue for a while after treatment is over. Resting is important, but doctors usually advise patients to try to stay as active as they can.
It is also common for the skin in the treated area to become red, dry, tender, and itchy. The breast may feel heavy and tight. These problems will go away over time. Toward the end of treatment, the skin may become moist and "weepy." Exposing this area to air as much as possible can help the skin heal.
Because bras and some other types of clothing may rub the skin and cause irritation, women may want to wear loose-fitting cotton clothes during this time. Gentle skin care also is important, and women 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 lasting change in the color of the skin.
Chemotherapy
As with radiation, chemotherapy affects normal cells as well as cancer cells. The side effects of chemotherapy depend mainly on the specific drugs and the
dose. In general, anticancer drugs affect cells that divide rapidly, especially:
- Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.
- Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair 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. Many of these side effects can be controlled with drugs.
Some anticancer drugs can damage the ovaries. If the damaged ovaries stop making hormones, the
woman may have symptoms of menopause, such as hot flashes and vaginal dryness. Her menstrual periods may become irregular or may stop, and she may become infertile (unable to become pregnant). For women over the age of 35, infertility is likely to be permanent.
On the other hand, if a woman remains fertile during chemotherapy, she may be able to become pregnant. Because the effects of chemotherapy on an unborn child are not known, a woman may wish to talk with her doctor about birth control before treatment begins.
Although long-term side effects are quite rare, there have been cases in which the heart becomes weakened. Also,
second cancers, such as leukemia (cancer of the blood cells), have occurred in people who have had chemotherapy.
Hormonal Therapy
The side effects of hormonal therapy depend largely on the specific drug or type of treatment.
Tamoxifen is the most common hormonal treatment. It blocks the effects of estrogen on cells.
Not all women who take tamoxifen have side effects. In general, the side effects of tamoxifen are
similar to some of the symptoms of menopause. The most common side effects are hot flashes and vaginal
discharge. Some women experience irregular menstrual periods, headaches,
fatigue, nausea and/or vomiting, vaginal dryness or itching, irritation of the skin around the
vagina, and skin rash.
Women who are still menstruating may become pregnant when taking tamoxifen. Tamoxifen may harm
the unborn baby. Women should discuss birth control methods with their doctor before taking
tamoxifen.
Serious side effects of tamoxifen are rare. However, it can cause blood clots in the veins,
especially in the legs and in the lungs. In a small number of women, tamoxifen can slightly
increase the risk of stroke. Also, it can cause cancer that arises in the lining or the muscular
wall of the
uterus. Any unusual vaginal bleeding should be reported to the doctor. The doctor may do a pelvic
exam, as well as a biopsy of the lining of the uterus, or other tests.
If the hormonal therapy is surgery to remove the ovaries, a woman will go through menopause
immediately. The side effects are likely to be more severe than problems associated with natural
menopause. The health care provider can suggest ways to cope with these side effects.
Biological Therapy
Herceptin is the biological therapy used to treat some women with breast cancer that has spread.
Side effects that most commonly occur during the first treatment with Herceptin are fever and chills.
Other possible side effects include pain, weakness, nausea, vomiting, diarrhea, headaches,
difficulty breathing, and rashes. These side effects generally become less severe after the
first treatment.
Herceptin also may cause heart damage, which may lead to heart failure. It can also affect the
lungs, causing breathing problems that require immediate medical attention. Before a woman receives
Herceptin, the health care provider checks the woman for heart and
lung problems. During treatment, the health care provider watches for signs of heart and lung
problems.
Some women with breast cancer use
complementary and alternative medicine healing approaches to reduce stress or to reduce side effects and symptoms:
- An approach is generally called complementary medicine when it is used in addition to treatments prescribed by a doctor.
- An approach is called
alternative medicine
when it is used instead of a standard treatment.
Some common types of complementary and alternative medicine are acupressure, acupuncture, massage therapy, herbal products, vitamins or special diets, visualization, meditation, and spiritual healing. Many women report that such approaches help them feel better.
However, some types of complementary and alternative medicine may interfere with or may be harmful
when used with treatments prescribed by a doctor. Before trying any of these therapies, a woman
should discuss their possible benefits and risks with her doctor.
Some types of complementary and alternative medicine may be expensive. Health insurance may not
cover the cost.
Some women who need a mastectomy decide to have breast reconstruction, either at the same time as
the mastectomy or later on. Other women prefer to wear a breast form
(prosthesis).
Still others decide to do nothing. All of these options have 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. A woman considering breast reconstruction should consult with a plastic surgeon
before the mastectomy, even if the reconstruction would be done later on.
Various procedures are used to reconstruct the breast. Some women choose to have implants
(either saline or silicone).
The safety of silicone breast implants has been under review by the Food and Drug Administration
(FDA) for several years. Women interested in having silicone implants should talk with their doctor
about the FDA's findings and the availability of silicone implants.
A woman also may have breast reconstruction with tissue that is moved from another part of her
body. Skin, muscle, and fat can be moved to the chest from the lower
abdomen, back, or buttocks. The plastic surgeon uses this tissue to create a breast shape.
Which type of reconstruction is best depends on a woman's age, body type, and the type of surgery
she had. The plastic surgeon can explain the risks and benefits of each type of reconstruction.
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A woman may want to ask her doctor these questions 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 breast reconstruction begin?
- How many surgeries will I need?
- What are the risks at the time of surgery? Later?
- Will there be scars? Where? What will they look like?
- If skin, muscle, and fat from another part of my body is used, will there be any permanent changes where 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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The Cancer Information Service at 1-800-4-CANCER can suggest other sources of information
about breast reconstruction.
Health care providers make every effort to help women with breast cancer return to their normal
activities as soon as possible. Recovery is different for each woman, depending on the type of
treatment, whether the disease has spread, and other factors.
Exercising the arm and shoulder after surgery can help a woman regain motion and strength in these
areas. It can also reduce pain and stiffness in her neck and back. Special exercises can begin 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. It is often done under the direction of a physical
therapist. Over time, exercising can be more active. Regular exercise can then become part of a
woman's normal routine. (Women who have a mastectomy and immediate breast reconstruction need
special exercises, which the health care provider will explain.)
Often, performing certain exercises and resting with the arm propped up on a pillow can
prevent or reduce lymphedema after surgery.
Regular checkups are important after breast cancer treatment. Even when the cancer seems to
have been completely removed or destroyed, the disease sometimes returns because undetected cancer
cells remained somewhere in the body after treatment. The health care provider monitors recovery
and checks for recurrence of cancer. Checkups help ensure that any changes in health are noted.
A woman who has had cancer in one breast should report any changes in the treated area or in the
other breast to her doctor right away. A woman should also report if she has any physical problems,
such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or
blurred vision. She should also report headaches, dizziness, shortness of breath, coughing or
hoarseness, backaches, or digestive problems that seem unusual or that don't go away. Some problems
may arise months or years after treatment. They may suggest that the cancer has returned, but they
can also be symptoms of many other health problems. It is important to share these concerns with a
health care provider so problems can be diagnosed and treated as soon as possible.
Follow-up usually includes examination of the breasts, chest, neck, and underarm areas. Because a
woman who has had breast cancer is at risk of getting cancer again, she should have mammograms of the
preserved breast and/or opposite breast. However, a woman usually does not need a mammogram of the
reconstructed breast. Sometimes the doctor may order other imaging procedures or lab tests.
The NCI has prepared a booklet for people who have completed their treatment to help answer questions
about follow-up care and other concerns.
Support for Women with Breast
Cancer
A 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. Many women find that having good information and support
services can make it easier to cope.
People living with cancer may worry about caring for their families, keeping their jobs, or
continuing daily activities. Concerns about tests, treatments, hospital stays, and medical bills
are also common. The health care provider can answer questions about treatment, working, or other
activities. Meeting with a
social worker, counselor, or member of the clergy can be helpful to those who want to talk about
their feelings or discuss their concerns. Often, a social worker can suggest resources for help
with recovery, emotional support, financial aid, transportation, or home care.
Friends and relatives can be very supportive. Also, many women find it helps to discuss their
concerns with others who have cancer. Women with breast cancer often get together in support
groups, where they can share what they have learned about coping with their disease and the effects
of their treatment. It is important to keep in mind, however, that each woman is different. Ways
that one woman deals with cancer may not be right for another. A woman may want to ask her health
care provider about advice she receives from other breast cancer survivors.
Several organizations offer special programs for women with breast cancer. Trained volunteers,
who have had breast cancer themselves, may talk with or visit women with breast cancer, provide
information, and lend emotional support. They often share their experiences with breast cancer
treatment, rehabilitation, and breast reconstruction.
Sometimes women who have had breast cancer are afraid that changes to their body will affect not
only how they look but also how other people feel about them. They may be concerned that breast
cancer and its treatment will affect their sexual relationships. Many couples find it helps to
talk about their concerns. Some find that counseling or a couples'
support group
can be helpful.
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