Breast cancer, the second-leading cause of cancer deaths in American women, is the disease women fear most.
Experts predict 178,000 women will develop breast cancer in the United States in 2007. Breast cancer can also
occur in men, but it's far less common. For 2007, the predicted number of new breast cancers in men is 2,000.
Yet there's more reason for optimism than ever before. In the last 30 years, doctors have made great strides in
early diagnosis and treatment of the disease and in reducing breast cancer deaths. In 1975, a diagnosis of breast
cancer usually meant radical mastectomy — removal of the entire breast along with underarm lymph nodes and
muscles underneath the breast. Today, radical mastectomy is rarely performed. Instead, there are more and
better treatment options, and many women are candidates for breast-sparing operations.
Signs and symptoms
Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered
early, you have more treatment options and a better chance for a cure.
Most breast lumps aren't cancerous. Yet the most common sign of breast cancer for both men and women is a
lump or thickening in the breast. Often, the lump is painless. Other potential signs of breast cancer include:
A spontaneous clear or bloody discharge from your nipple, often associated with a breast lump
Retraction or indentation of your nipple
A change in the size or contours of your breast
Any flattening or indentation of the skin over your breast
Redness or pitting of the skin over your breast, like the skin of an orange
A number of conditions other than breast cancer can cause your breasts to change in size or feel. Breast tissue
changes naturally during pregnancy and your menstrual cycle. Other possible causes of noncancerous (benign)
breast changes include fibrocystic changes, cysts, fibroadenomas, infection or injury.
If you find a lump or other change in your breast — even if a recent mammogram was normal — see your
doctor for evaluation. If you haven't yet gone through menopause, you may want to wait through one menstrual
cycle before seeing your doctor. If the change hasn't gone away after a month, have it evaluated promptly.
In breast cancer, some of the cells in your breast begin growing abnormally. These cells divide more rapidly
than healthy cells do and may spread (metastasize) through your breast, to your lymph nodes or to other parts of
your body. The most common type of breast cancer begins in the milk-producing ducts, but cancer may also
begin in the lobules or in other breast tissue.
In most cases, it isn't clear what causes normal breast cells to become cancerous. Doctors do know that only 5
percent to 10 percent of breast cancers are inherited. Families that do have genetic defects in one of two genes,
breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2), have a much greater risk of developing both
breast and ovarian cancer. Other inherited mutations — including the ataxia-telangiectasia mutation gene, the
cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene — also make it more likely
that you'll develop breast cancer. If one of these genes is present in your family, you have a 50 percent chance
of having the gene.
Yet most genetic mutations related to breast cancer aren't inherited. These acquired mutations may result from
radiation exposure — women treated with chest radiation therapy for lymphoma in childhood or during
adolescence when breasts are developing have a significantly higher incidence of breast cancer than do women
not exposed to radiation. Mutations may also develop as a result of exposure to cancer-causing chemicals, such
as the polycyclic aromatic hydrocarbons found in tobacco and charred red meats.
Researchers are now trying to discover whether a relationship exists between a person's genetic makeup and
environmental factors that may increase the risk of breast cancer. Breast cancer eventually may prove to have a
number of causes.
Each of your breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes
are further divided into smaller lobules that produce milk during pregnancy and breast-feeding. Small ducts
conduct the milk to a reservoir that lies just beneath your nipple. Supporting this network is a deeper layer of
connective tissue called stroma.
A risk factor is anything that makes it more likely you'll get a particular disease. Some risk factors, such as your
age, sex and family history, can't be changed, whereas others, including weight, smoking and a poor diet, are
under your control.
But having one or even several risk factors doesn't necessarily mean you'll develop cancer — most women with
breast cancer have no known risk factors other than simply being women. In fact, being female is the single
greatest risk factor for breast cancer. Although men can develop the disease, it's far more common in women.
Other factors that may make you more susceptible to breast cancer include:
Age. Your chances of developing breast cancer increase with age. Close to 80 percent of breast cancers
occur in women older than age 50. In your 30s, you have a one in 233 chance of developing breast cancer.
By age 85, your chance is one in eight.
A personal history of breast cancer. If you've had breast cancer in one breast, you have an increased risk
of developing cancer in the other breast.
Family history. If you have a mother, sister or daughter with breast or ovarian cancer or both, or a male
relative with breast cancer, you have a greater chance of also developing breast cancer. In general, the
more relatives you have who were diagnosed with breast cancer before reaching menopause, the higher
your own risk. If you have one first-degree relative — a mother, sister or daughter — who was diagnosed
with the disease before age 50, your risk is doubled. If you have two or more relatives, your risk increases
even more. Just because you have a family history of breast cancer doesn't mean it's hereditary, though.
Most people with a family history of breast cancer (familial breast cancer risk) haven't inherited a defective
gene, such as BRCA1 or BRCA2. Rather, cancer becomes so common in women who live into their 80s
and beyond that random, noninherited breast tumors may appear in more than one member of a single
Genetic predisposition. Between 5 percent and 10 percent of breast cancers are inherited. Defects in one
of several genes, especially BRCA1 or BRCA2, put you at greater risk of developing breast, ovarian and
colon cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing
abnormally. But if they have a mutation, the genes aren't as effective at protecting you from cancer.
Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you're
more likely to develop breast cancer later in life. Your risk is greatest if you received radiation as an
adolescent during breast development.
Excess weight. The relationship between excess weight and breast cancer is complex. In general, weighing
more than is healthy increases your risk, particularly if you gained the weight as an adolescent. But risk is
even greater if you put the weight on after menopause. Your risk also is greater if you have more body fat
in the upper part of your body.
Early onset of menstrual cycles. If you got your period at a young age, especially before age 12, you may
have a greater likelihood of developing breast cancer. Experts attribute this risk to the early exposure of the
breast tissue to estrogen.
Late menopause. If you enter menopause after age 55, you're more likely to develop breast cancer.
Experts attribute this to the prolonged exposure of the breast tissue to estrogen.
First pregnancy at older age. If your first full-term pregnancy occurs after age 30, or you never become
pregnant, you have a greater chance of developing breast cancer. Although it's not entirely clear why, an
early first pregnancy may protect breast tissue from developing genetic mutations that result from estrogen
Race. White women are more likely to develop breast cancer than black, Hispanic or Asian women are,
but black women are more likely to die of the disease because their cancers are found at a more advanced
stage. Although some studies show that black women may have more aggressive tumors, it's also likely
that the disparity is at least partially due to socioeconomic factors. Women of all races with incomes below
the poverty level are more often diagnosed with late-stage breast cancer and more likely to die of the
disease than are women with higher incomes. Low-income women often don't receive the routine medical
care that would allow breast cancer to be discovered earlier.
Hormone therapy. Treating menopausal symptoms with the hormone combination of estrogen and
progesterone for four or more years increases your risk of breast cancer. In addition, therapy with estrogen
and progesterone can make malignant tumors harder to detect on mammograms, leading to cancers that are
diagnosed at more advanced stages and that are harder to treat. Using estrogen alone hasn't been shown to
increase breast cancer risk in postmenopausal women.
Birth control pills. Use of birth control pills is associated with an increased risk of breast cancer in
premenopausal women. The risk seems to be greater for women who use birth control pills for four or
more years before their first full-term pregnancy, but since delayed first pregnancy is also a risk factor, part
of the risk could be attributed to that. Overall, risk of breast cancer for users of birth control pills is small
and appears to be confined to the short term. Risk levels return to normal within five to 10 years after
discontinuing use. Using birth control pills also doesn't appear to further increase breast cancer risk in
women with a family history of breast cancer or with a personal history of benign breast disease. Because
this is an area of ongoing study, talk with your doctor about the latest information on the pill and breast
Smoking. Evidence is mixed on the relationship between smoking and breast cancer risk. Some studies
show no link between cigarette smoking and exposure to secondhand smoke and breast cancer. Others
suggest that smoking increases breast cancer risk. Exposure to secondhand smoke and breast cancer risk
remains an area of active research. Despite the controversy surrounding this issue, there are clear health
benefits — other than minimizing breast cancer risk — to quitting smoking and limiting your exposure to
Excessive use of alcohol. According to the American Cancer Society, women who drink more than one
alcoholic beverage a day have about a 20 percent greater risk of breast cancer than do women who don't
drink. To reduce your breast cancer risk, limit alcohol to no more than one drink daily.
Precancerous breast changes (atypical hyperplasia, lobular carcinoma in situ). These changes are
discovered only after you have a breast biopsy, most commonly done for another reason. If these changes
are present, your risk of breast cancer is higher than it is for women who don't have one of these so-called
"markers." If you have carcinoma in situ, discuss treatment and monitoring options with your doctor.
Mammographic breast density. Breasts described as "dense" have a high ratio of connective and
glandular tissue to fat. On X-ray images, dense breast tissue looks solid and white, so it can mask tumors
and make mammograms difficult to interpret. Increasingly, though, breast density is also being recognized
as a breast cancer risk factor in itself. The mechanism behind this increased risk is unknown.
Your age and menopausal status affect your breast density. Younger women tend to have denser breasts.
Hormones also have an effect — higher hormone levels generally mean denser breasts. Still, the actual
increase in risk due to mammographic density is very small. If you're at high risk of breast cancer and your
mammograms are difficult to interpret because of breast density, your doctor may recommend additional
When to seek medical advice
Although most breast changes aren't cancerous, it's important to have them evaluated promptly. See your doctor
if you discover a lump or any of the other warning signs of breast cancer, especially if the changes persist after
one menstrual cycle or they change the appearance of your breast. If you've been treated for breast cancer,
report any new signs or symptoms immediately. Possible warning signs include a new lump in your breast or a
bone ache or pain that doesn't go away after three weeks. In addition, talk to your doctor about developing a
breast-screening program, which may vary, depending on your family history and other significant risk factors.
Screening and diagnosis
Screening — looking for evidence of disease before signs or symptoms appear — is the key to finding breast
cancer in its early, treatable stages. Depending on your age and risk factors, screening may include breast self-
examination, examination by your nurse or doctor (clinical breast exam), mammograms (mammography) or
Breast self-examination is an option beginning at age 20. By becoming proficient at breast self-examination and
familiar with the usual appearance and feel of your breasts, you may be able to detect early signs of cancer.
Learn how your breasts typically look and feel and watch for changes. If you detect a change, promptly bring it
to your doctor's attention. Have your doctor review your examination technique if you'd like input or you have
Clinical breast exam
Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer
Society recommends having clinical breast exams once every three years until age 40. After that, the American
Cancer Society recommends having a yearly clinical exam.
During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel
lumps you miss when you examine your own breasts and will also check for enlarged lymph nodes in your
A mammogram, which uses a series of X-ray images of your breast tissue, is currently the best imaging
technique for detecting tumors before you or your doctor can feel them. For that reason, the American Cancer
Society has long recommended screening mammography for all women over 40.
Two types of mammograms include:
Screening mammograms. Screening mammograms are performed on a regular basis — about once a year
— to check your breast tissue for any changes since your last mammogram.
Diagnostic mammograms. Your doctor may recommend a diagnostic mammogram to evaluate a breast
change detected by you or your doctor. During a diagnostic mammogram, the radiologist performing the
exam can take additional views to evaluate the area of concern more closely.
Yet mammograms aren't perfect. A certain percentage of breast cancers — sometimes even lumps you can feel
— don't show up on X-rays (false-negative result). The rate is higher for women in their 40s. That's because
women of this age and younger tend to have denser breasts, making it more difficult to distinguish abnormal
from normal tissue.
At other times, mammograms may indicate a problem when none exists (false-positive result). This can lead to
unnecessary biopsies, to fear and anxiety, and to increased health care costs. The skill and experience of the
radiologist reading the mammogram also have a significant effect on the accuracy of the test results. In spite of
these drawbacks, however, most experts agree mammography is the most reliable screening test for most
During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes
the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat
uncomfortable. If you have too much discomfort, inform the technician. If you have tender breasts, schedule
your mammogram for a time after your menstrual period. Avoiding caffeine for two days before the test may
help reduce breast tenderness.
Also available at some mammography centers is a soft, single-use, foam pad that can be placed on the surface
of the compression plates of the mammography machine, making the test less uncomfortable. The pad doesn't
interfere with the image quality of the mammogram.
If possible, try to schedule your mammogram around the same time as your annual clinical exam. That way the
radiologist can specifically look at any changes your doctor may discover.
Most important, don't let a lack of health insurance keep you from having regular mammograms. Many state
health departments and Planned Parenthood clinics offer low-cost or free screenings.
Computer-aided detection (CAD). In traditional mammography, your X-rays are reviewed by a
radiologist, whose skill and experience play a large part in determining the accuracy of the test results. In
CAD, a computer scans your mammogram after a radiologist has reviewed it. CAD identifies highly
suspicious areas on the mammogram, allowing the radiologist to focus on specific spots, but many of these
areas may later prove to be normal. Still, using mammography and CAD together may increase the cancer
Digital mammography. In this procedure, an electronic process is used to collect and display X-ray
images on a computer screen. This allows your radiologist to alter contrast and darkness, making it easier
to identify subtle differences in tissue. In addition, digital images can be transmitted electronically, so
women who live in remote areas can have their mammograms read by an expert who is based elsewhere.
Digital mammography has been found to be most helpful in evaluating dense breast tissue in women in
Magnetic resonance imaging (MRI). This technique uses a magnet and radio waves to take pictures of
the interior of your breast. Although not used for routine screening, MRI can reveal tumors that are too
small to detect through physical exams or are difficult to see on conventional mammograms. MRI doesn't
take the place of mammograms, but rather is performed as an additional (adjunct) study of the breast.
MRI isn't recommended for routine screening on women at average risk because it has a high rate of false-
positive results, leading to unnecessary anxiety and biopsies. It's also expensive, not readily available and
requires interpretation by an experienced radiologist. However, the American Cancer Society now
recommends annual screening MRI for women with a lifetime breast cancer risk of 20 percent or higher,
women who received chest radiation between ages 10 and 30, and women with a strong family history of
breast and ovarian cancers.
Recent recommendations propose that women with newly diagnosed breast cancer in one breast have a
one-time MRI done. MRI can detect breast tumors in the opposite (contralateral) breast missed by
mammograms. The test can also detect additional lesions in the affected breast. However, whether finding
early tumors in this situation improves treatment outcomes — and deaths from breast cancer — is still
Breast ultrasound (ultrasonography). Your doctor may use this technique to evaluate an abnormality
seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to produce images
of structures deep within the body. Because it doesn't use X-rays, ultrasound is a safe diagnostic tool that
can help determine whether an area of concern is a cyst or solid tissue. But breast ultrasound isn't used for
routine screening because it has a high rate of false-positive results — finding problems where none exist.
Ductal lavage. In this procedure, your doctor inserts a tiny, flexible tube (catheter) into the lining of a duct
in your breast — the site where most cancers originate — and withdraws a sample of cells. The cells are
then examined for precancerous changes that might eventually lead to disease. These changes may show
up long before tumors can be detected on a mammogram. But because ductal lavage is a new and invasive
procedure, many unknowns remain, including the rate of false-negative results, the exact location in the
breast of abnormal cells and whether those cells will necessarily lead to cancer. Clinical trials are being
conducted to help find the answers to these questions. In the meantime, ductal lavage isn't recommended as
a screening tool.
Molecular breast imaging (MBI). This experimental technique tracks the movement of a radioactive
isotope injected into the bloodstream and taken up by breast tissue, particularly tumors. In preliminary
studies, MBI found small tumors that both mammography and ultrasound missed. It's not yet clear how
any abnormal findings from MBI could be biopsied, but this is an area of study. Besides requiring some
radiation, this imaging method also involves slight compression of the breast. This imaging technique is
being studied in women with dense breast tissue and women at high risk of breast cancer. Depending on
study results, MBI would most likely become an adjunct to — but not a replacement for —
Unlike screening tests, diagnostic procedures help to further characterize breast abnormalities found by some
other means, such as by feeling a breast lump or seeing a spot on a mammogram or MRI. These tests help your
doctor determine the need for a biopsy and also may be used to help guide a biopsy.
Ultrasound uses sound waves to create an image of your breast on a computer screen. By analyzing this image,
your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually
aren't cancerous, although your doctor may recommend draining the cyst. If the cyst appears very typical and
disappears completely with removal of the fluid, then observation is the only follow-up necessary. If the cyst
appears complex, doesn't disappear completely when the fluid is drained or contains bloody fluid, a biopsy is
necessary to determine whether cancer is present.
A biopsy — a small sample of tissue removed for analysis in the laboratory — is the only test that can tell if
cancer is present. Biopsies can provide important information about an unusual breast change and help
determine whether surgery is needed and if so, the type of surgery required. Types of biopsies include:
Fine-needle aspiration biopsy. Your doctor uses a thin, hollow needle to withdraw tissue from the lump.
He or she then sends the tissue to a lab for microscopic analysis. The procedure takes about 30 minutes and
is similar to drawing blood. A similar procedure — fine-needle aspiration — is typically performed to
remove the fluid from a painful cyst, but it can also help distinguish a cyst from a solid mass.
Core needle biopsy. A radiologist or surgeon uses a hollow needle to remove tissue samples from a breast
lump. As many as 15 samples, each about the size of a grain of rice, may be taken then sent to a
pathologist to be analyzed for malignant cells. The advantage of a core needle biopsy is that it removes
more tissue for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the
placement of the needle.
Stereotactic biopsy. This technique is used to sample and evaluate an area of concern, such as
microcalcification, that can be seen on a mammogram but that cannot be felt or seen on an ultrasound.
During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide.
Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.
Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a
mammogram but can't be felt or evaluated with a stereotactic biopsy. Using your mammogram as a guide,
a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed
right before a surgical biopsy and is a way to guide the surgeon to the area to be removed and tested.
Surgical biopsy. This remains one of the most accurate methods for determining whether a breast change
is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small
lump will be completely removed (excisional biopsy). If the lump is large, only a sample will be taken
(incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.
Estrogen and progesterone receptor tests
Malignant cells removed in a biopsy can be tested for the presence of hormone receptors. If the cancer cells
have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as
tamoxifen, which prevents estrogen from binding to these sites.
Staging tests determine the size and location of your cancer and whether it has spread. They also help with
treatment planning. Cancer is staged using the numbers 0 through IV.
Stage 0 cancers are also called noninvasive, or in situ (in one place), cancers. Although they don't have the
ability to invade normal breast tissue or spread to other parts of your body, it's important to have them removed
because they eventually can become invasive cancers.
Stage I to IV cancers are invasive tumors that have the ability to invade normal breast tissue or spread to other
areas. A stage I cancer is small and well localized and has a high cure rate. But the higher the stage number, the
lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your
bones, lungs or liver. Although it's not possible to cure cancer at this stage, it may still respond well to various
treatments, which could effectively shrink and control the cancer for an extended period of time.
If you have a strong family history of breast cancer or other cancers, blood tests may help identify defective
BRCA or other genes that are being passed through the family. These tests are often inconclusive and should
only be done in select cases after a thorough evaluation with a genetic counselor. Unless you are at high risk of
hereditary breast or ovarian cancers, genetic testing usually isn't recommended.
In general, testing is beneficial only if the results will help you make a decision about how you might best
reduce your breast or other cancer risk. Options range from lifestyle changes and closer screening and therapy
with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy
and removal of your ovaries (oophorectomy).
To perform a breast self-exam, use a circling, massaging motion and follow a clock pattern or a wedge pattern.
Alternatively, you can use a sweeping motion to examine breast tissue — sweeping your fingers from the outer
part of your breast in toward your nipple.
A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a
potentially life-threatening illness, you must make complex decisions about treatment.
Talk with your health care team to learn as much as you can about your treatment options. Consider a second
opinion from a breast specialist in a breast center or clinic. Talking to other women who have faced the same
decision also may help.
Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional
(adjuvant) therapy such as radiation, chemotherapy or hormone therapy. Experimental treatments are also
available at cancer treatment centers.
Today, radical mastectomy is rarely performed. Instead, the majority of women are candidates for simple
mastectomy or lumpectomy. If you decide on mastectomy, you may opt for breast reconstruction.
Breast cancer operations include the following:
Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a
surrounding area of normal tissue. Many women can have lumpectomy — often followed by radiation
therapy — instead of mastectomy, and in most cases survival rates for both operations are similar. But
lumpectomy may not be an option if a tumor is very large, deep within your breast, or if you have already
had radiation therapy, have two or more widely separated areas of cancer in the same breast, have a
connective tissue disease that makes you sensitive to radiation, or if you have inflammatory breast cancer.
If you have a large tumor but still want to consider the possibility of lumpectomy, chemotherapy before
surgery may be an option to shrink the tumor and make you eligible for the procedure.
In general, lumpectomy is almost always followed by radiation therapy to destroy any remaining cancer
cells. But when very small, noninvasive cancers are involved, some studies question the role and benefits
of radiation therapy — especially for older women. These studies haven't shown that lumpectomy plus
radiation prolongs a woman's life any better than does lumpectomy alone.
Partial or segmental mastectomy. Another breast-sparing operation, partial mastectomy involves
removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest
muscles that lie beneath it. In almost all cases, you'll have a course of radiation therapy following your
operation, similar to if you had a lumpectomy.
Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue — the
lobules, ducts, fatty tissue and skin, including the nipple and areola. Depending on the results of the
operation and follow-up tests, you may also need further treatment with radiation to the chest wall,
chemotherapy or hormone therapy.
Modified radical mastectomy. In this procedure, a surgeon removes your entire breast, including the
overlying skin, and some underarm lymph nodes (axillary lymph node dissection), but leaves your chest
muscles intact. This makes breast reconstruction less complicated.
Sentinel lymph node biopsy
Because breast cancer first spreads to the lymph nodes under the arm, all women with invasive cancer need to
have these nodes examined. Rather than remove as many lymph nodes as possible, surgeons now focus on
finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first
place cancer cells will travel. If a sentinel node is removed, examined and found to be normal, the chance of
finding cancer in any of the remaining nodes is small and no other nodes need to be removed. This spares many
women the need for a more extensive operation and greatly decreases the risk of complications.
Axillary lymph node dissection
If the sentinel lymph node does show the presence of cancer, then your surgeon removes additional lymph
nodes in your armpit (axilla). The removal of these lymph nodes does increase the risk of serious arm swelling
(lymphedema), but newer surgical techniques make this complication much less likely. Knowing if cancer has
spread to the lymph nodes is important in determining the best course of treatment, including whether you'll
need chemotherapy or radiation therapy.
If you want to have breast reconstruction done, discuss this with your surgeon before you have any surgery
done. Not all women are candidates for reconstruction. A plastic surgeon can describe the various procedures,
show you photos of women who have had different types of reconstruction, and discuss which type of
reconstruction might be best in your case. Your options include reconstruction with a synthetic breast implant or
reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a
Reconstruction with implants. This technique uses artificial material — silicone gel or saline, in an
implantable, leak-proof shell — to replace surgically removed breast tissue. If you don't have enough
muscle and skin to cover an implant, your doctor may use a tissue expander, which is an empty implant
shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills
it with fluid — usually over a period of several months. When your muscle and skin have stretched
enough, the expander is removed and replaced with a permanent implant.
Reconstruction with a tissue flap. Known as a transverse rectus abdominal muscle (TRAM) flap, this
surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen, although
surgeons sometimes may use tissue from your back or buttocks instead. Because the procedure is fairly
complicated, recovery may take six to eight weeks. Complications include the risk of infection and tissue
death. If you have a low percentage of body fat, this type of reconstruction may not be an option for you.
Deep inferior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your
abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact,
you're less likely to experience complications than you are with traditional TRAM flap breast
reconstruction. You may also have less pain, and your healing time may be reduced.
Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant,
you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your
surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the
nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it
around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.
Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a
radiation oncologist at a radiation center. In general, radiation is the standard of care following a lumpectomy
for both invasive and noninvasive breast cancers. Oncologists are also likely to recommend radiation following
a mastectomy for a large tumor, for inflammatory breast cancer, for cancer that has invaded the chest wall or for
cancer that has spread to more than four lymph nodes in your armpit.
If you won't be receiving chemotherapy, radiation is usually started three to four weeks after surgery. If your
doctors recommend chemotherapy, it's usually administered before you undergo radiation therapy. You'll
typically receive radiation treatment five days a week for five to six consecutive weeks. The treatments are
painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however,
and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender,
as if it had been sunburned.
In a small percentage of women, more serious problems may occur, including arm swelling, damage to the
lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy also
makes it somewhat more likely that you'll develop another tumor. For these reasons, it's important to learn about
the risks and benefits of radiation therapy when deciding between lumpectomy and mastectomy. You may also
want to talk to a radiation oncologist about clinical trials investigating shorter courses of radiation or focal
application of radiation.
Chemotherapy uses drugs to destroy cancer cells. The size of the tumor, characteristics of the cancer cells, and
extent of spread of the cancer help determine your need for chemotherapy. If your cancer has a high chance of
returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to
decrease the chance that the cancer will recur. This is known as adjuvant chemotherapy. If your cancer has
already spread to other parts of your body, chemotherapy may be recommended to try to control the cancer and
decrease any symptoms the cancer is causing.
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Treatment often involves receiving two or more drugs in different combinations. These may be administered
intravenously, in pill form or both. You may have between four and eight treatments spread over three to six
Because chemotherapy affects healthy cells as well as cancerous ones, side effects are common. Your digestive
tract, hair and bone marrow — all composed of fast-growing cells — tend to take the brunt of this toxicity,
leading to hair loss, nausea, vomiting and fatigue. Not everyone has all of these side effects, however, and
methods to control chemotherapy side effects have improved greatly in the past few decades. Notably, more
effective drugs are now available to help prevent or reduce nausea and vomiting.
Depending on the chemotherapy drugs your doctor recommends, other side effects may occur, including
possible damage to the heart, nerves, kidneys and other organs. Chemotherapy may also temporarily affect your
white blood cells — cells that fight off infection.
Another recently described side effect is "chemobrain," the common term for memory and concentration
problems that happen to some people during and after chemotherapy. Chemobrain is associated with difficulties
involving specific thought processes, including word finding, memory and multitasking.
Premature menopause and infertility also are potential side effects of chemotherapy. The older you are when
you begin treatment, the greater the likelihood that your reproductive cycle will be affected. In rare cases,
certain chemotherapy medications may lead to cancer of the white blood cells (acute myeloid leukemia) —
often years after treatment ends.
Hormone therapy — perhaps more properly termed hormone blocking therapy — is often used to treat women
whose cancers are sensitive to hormones — estrogen and progesterone receptor positive cancers. Similar to
chemotherapy, this form of therapy can be used to decrease the chance of your cancer returning. If the cancer
has already spread, hormone therapy may shrink and control it.
Two classes of medications are used in hormone therapy: selective estrogen receptor modulators (SERMs) and
Selective estrogen receptor modulators (SERMs). SERMs act by blocking any estrogen present in the
body from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing
tumor cells. SERMs can be used in both pre- and postmenopausal women.
The most common SERM prescribed for hormone therapy is tamoxifen (Nolvadex). Tamoxifen is used as
a treatment for women with hormone-sensitive metastatic breast cancer, as an adjuvant therapy for women
with early-stage estrogen receptor positive breast cancer, and as a preventive agent in some high-risk
women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of
breast cancer and is less toxic than most anti-cancer drugs.
But tamoxifen isn't trouble-free. Women taking tamoxifen may experience menopausal symptoms such as
night sweats, hot flashes, and vaginal itching, discharge or dryness. More serious side effects, including
blood clots and endometrial cancer, occur infrequently. Older women, especially those with other medical
conditions, may be at greater risk of more serious side effects than are younger women.
Aromatase inhibitors. This class of drugs, which includes anastrozole (Arimidex), letrozole (Femara) and
exemestane (Aromasin), blocks the conversion of a hormonal substance (androstenedione) into estrogen.
This effectively stops estrogen production in cells other than the ovaries. Fat cells, the adrenal gland and
other normal cells all make small amounts of estrogen. These drugs are only effective in postmenopausal
In several randomized, controlled trials, women receiving aromatase inhibitors have fared slightly better
than have those receiving tamoxifen. Women treated with aromatase inhibitors also had a lower incidence
of blood clots and endometrial cancer. To date, the primary drawback of aromatase inhibitors is an
increased risk of osteoporosis. The main question about aromatase inhibitors seems to be whether women
should take tamoxifen first and then switch to an aromatase inhibitor or simply take an aromatase inhibitor
from the start.
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As scientists learn more about the differences between normal cells and cancer cells, treatments aimed at these
differences — called biological therapy — are being developed. Three biological therapies are now available
for breast cancer. They include:
Trastuzumab (Herceptin). This FDA-approved biological therapy uses monoclonal antibody technology
to attack a protein — called HER2-neu — that's overproduced in about one out of every three breast
cancers. By attacking this protein, Herceptin kills cancer cells on its own and in conjunction with
chemotherapy or hormone therapy. Herceptin can be used as an adjuvant therapy or to treat advanced
Bevacizumab (Avastin). Now approved for treating metastatic breast cancer, Avastin also uses
monoclonal antibody technology to target new blood vessels and stop them from growing. Cancer cells
need to grow new blood vessels in order to survive. This therapy halts that process and kills the cancer
Lapatinib (Tykerb). Like Herceptin, Tykerb zeros in on and blocks the effects of the HER2 protein. But
while Herceptin blocks HER2's action from the outside of the cell, Tykerb is a smaller molecule that works
on the inside of the cell. Tykerb works for some women for whom Herceptin is no longer effective. This
drug is only approved for use in conjunction with chemotherapy and in women with advanced, metastatic
Clinical trials are used to test new and promising agents in the treatment of cancer. Clinical trials represent the
cutting edge of technology, but they're often unproven treatments that may or may not be superior to currently
available therapies. Talk with your doctor about clinical trials to see if one is right for you.
Clinical trials involve more than just new medications. For example, breast surgeons and radiologists are
developing nonsurgical methods of destroying cancerous breast tissue. One of these techniques, radiofrequency
ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into
the tumor. Inside the tumor, the probe creates heat that destroys cancer cells. Although early tests of
radiofrequency ablation have been promising, not all women would be candidates for the procedure if it
eventually were approved for widespread use.
Nothing guarantees that you won't develop breast cancer. But there are some things you may be able to do to
reduce your risk of the disease.
Chemoprevention is the use of certain medications to decrease breast cancer risk. Two drugs used for breast
cancer prevention in high-risk women come from the class of drugs known as selective estrogen receptor
Tamoxifen (Nolvadex). Tamoxifen is approved for use as a preventive agent in women age 35 and older
who have an elevated risk of developing breast cancer within the next five years. Data from several clinical
prevention trials found that tamoxifen use in women at higher than average risk results in a relative risk
reduction of about one-third for noninvasive breast cancer and about one-half for invasive breast cancer.
Raloxifene (Evista). Raloxifene is approved for prevention of invasive breast cancer in postmenopausal
women at high risk of the disease, as well as in women with postmenopausal osteoporosis. In the second
group, the drug is approved for both breast cancer prevention and osteoporosis treatment. Large clinical
trials have also suggested that raloxifene is as effective as tamoxifen in preventing estrogen receptor
positive breast cancer in high-risk postmenopausal women who don't have a personal history of breast
The Gail model computerized risk assessment is a simple and helpful tool to estimate a woman's risk of
developing invasive breast cancer. A five-year Gail model score higher than 1.66 percent is considered
high risk. This tool is available online at the National Cancer Institute.
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Although it's a radical step, preventive surgery also reduces breast cancer risk in high-risk women. Options
Prophylactic mastectomy. This preventive surgery involves removing one or both of your breasts to
prevent or reduce your risk of breast cancer. You might consider this option if you're at high risk of breast
cancer, you've already had cancer in one breast, you have a family history of breast cancer, you received
positive results from genetic testing, or your doctors have identified early signs of cancer in your breast.
Prophylactic oophorectomy. This preventive option involves surgically removing your ovaries. Although
the procedure is usually performed to reduce ovarian cancer risk, having an oophorectomy before you
reach menopause also reduces your risk of breast cancer.
Some lifestyle strategies may help reduce breast cancer risk:
Ask your doctor about aspirin. Taking an aspirin just once a week may help protect against breast
cancer, but be sure to talk to your doctor before you start. When used for long periods of time, aspirin can
cause stomach irritation, bleeding and ulcers. More serious aspirin side effects include bleeding in the
intestinal and urinary tracts and hemorrhagic stroke. In general, you're not a candidate for aspirin therapy if
you have a history of ulcers, liver or kidney disease, bleeding disorders, or gastrointestinal bleeding.
Limit alcohol. Drinking alcohol is strongly linked to breast cancer. The type of alcohol consumed —
wine, beer or mixed drinks — seems to make no difference. To help protect against breast cancer, limit the
amount of alcohol you drink to less than one drink a day or avoid alcohol completely.
Maintain a healthy weight. There's a clear link between obesity — weighing more than is appropriate for
your age and height — and breast cancer. The association is stronger if you gain the weight later in life,
particularly after menopause.
Avoid long-term hormone therapy. The link between postmenopausal hormone therapy and breast
cancer has been a subject of debate for years, partly because research results have been mixed. Estrogen
exposure clearly contributes to breast cancer risk, but for most women, the size of the contribution over a
lifetime is small — particularly in the absence of other risk factors, such as family history of the disease. If
you're approaching menopause and having frequent symptoms, it's probably safe to take hormones for as
long as four to five years. Any longer does increase your breast cancer risk, without conferring any clear
benefits. The same is true of hormone therapy after age 60.
Stay physically active. No matter what your age, aim for at least 30 minutes of exercise on most days. Try
to include weight-bearing exercises such as walking, jogging or dancing. These have the added benefit of
keeping your bones strong.
Eat foods high in fiber. Try to increase the amount of fiber you eat to between 20 and 30 grams daily —
about twice that in an average American diet. Among its many health benefits, fiber may help reduce the
amount of circulating estrogen in your body. Foods high in fiber include fresh fruits and vegetables and
Emphasize olive oil. Oleic acid, the main component of olive oil, appears both to suppress the action of
the most important oncogene in breast cancer and to increase the effectiveness of the drug Herceptin.
Avoid exposure to pesticides. The molecular structure of some pesticides closely resembles that of
estrogen. This means they may attach to receptor sites in your body. Although studies have not found a
definite link between most pesticides and breast cancer, it is known that women with elevated levels of
pesticides in their breast tissue have a greater breast cancer risk.
New directions in research
Scientists are investigating a number of potential preventive therapies for breast cancer, including:
Retinoids. Natural or synthetic forms of vitamin A (retinoids) may have the ability to destroy or inhibit the
growth of cancer cells. Unlike other experimental therapies, retinoids may be effective in premenopausal
women and in those whose tumors aren't estrogen positive. Research is ongoing.
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Flaxseed. Flaxseed is high in lignan, a naturally occurring compound that lowers circulating estrogens in
your body. Flaxseed appears to decrease estrogen production — acting much like tamoxifen does — which
may inhibit the growth of breast cancer tumors. Lignans are also antioxidants with weak estrogen-like
characteristics. These characteristics may be the mechanism by which flaxseed works to decrease hot
flashes. Further research should clarify the connection.
A diagnosis of breast cancer can be overwhelming. It may take some time to sort through all your emotions. But
you can still be in charge of your life. You'll have many decisions to make in the weeks and months ahead. The
more you know, the better prepared you'll be to make the best choices. As soon as you find out you have breast
cancer, start educating yourself about its treatment.
In addition to talking to your medical team — your breast specialist, surgeon, medical oncologist (a specialist in
chemotherapy and hormone therapy) and radiation oncologist (a specialist in radiation therapy) — you may also
want to talk to a counselor or medical social worker. Or you may find it helpful and encouraging to talk to other
women with breast cancer.
There are also excellent books on breast cancer and many reputable resources on the Internet. Be sure to look
for the most current information because breast cancer treatments change rapidly.
One of your first decisions will likely be how and when to tell those closest to you. If you have children, telling
them — no matter what their ages — can be difficult, but honesty is the best approach. You don't have to give
all the details. How much and what you say will depend on each child's age and ability to understand. But trying
to hide your illness isn't a good idea. Instead, tell your children you're doing everything possible to get well.
The decision to tell friends and co-workers isn't an easy one. Especially in the beginning, you may not want
anyone outside your family to know. But over time, you may find it helpful to confide in a few close friends or
Keep in mind that people may not always react as you expect. Some may have many of the same feelings you
do — anger, fear, grief. Others may be incredibly supportive. And some may not say much at all or may even
avoid you. That's not because they don't care, but because they may not know what to say. Let them know that
there are no right words and that their concern is enough.
Maintaining a strong support system
More and more studies show that strong relationships are crucial in dealing with life-threatening illnesses. In
fact, friends and family are often an integral part of your treatment. Sometimes, though, you may want or need
different kinds of support. If so, you may find the concern and understanding of other women with breast cancer
especially comforting. Breast cancer survivors have developed a tremendous support network. Your doctor or a
medical social worker may be able to put you in touch with a group near you. Or you can contact a cancer
organization, such as the American Cancer Society, to find out what's available in your area.
Dealing with intimacy
Western culture places a great emphasis on women's breasts. They're associated with attractiveness, femininity
and sexuality. Because of these attitudes, breast cancer may affect your self-image and erode your confidence in
intimate relationships. Although it can be difficult, you need to talk to your partner about your concerns —
preferably before your surgery.
Taking care of yourself
During your treatment, you'll need to plan your schedule carefully. Allow yourself time to rest. And don't be
afraid to ask for help. Your friends and family want to help, but they may not always know what to do. Be
specific about your needs. For example, you might ask a friend to pick up your children from school, shop for
groceries or prepare meals. If you need to, be prepared to relinquish your role as caretaker for a while. This
doesn't mean you're helpless or weak. Far from it. It means you're using all your energy to get well.
At the same time, you'll likely want to stay as independent as possible. Sometimes in their desire to help, other
people may try to take over your life. Or they may act as if you're terribly fragile. Both can be detrimental to
your recovery. Don't hesitate to tell friends and loved ones how you want to be treated.