Breast cancer

Definition
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.

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.
Causes
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.

Risk factors
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 family.
 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 exposure.
 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 cancer.
 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 secondhand
smoke.
 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 screening tests.

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.
Tests 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 other tests.

Breast self-examination
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 questions.

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 armpit (axilla).

Mammogram
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 women.

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.

Other tests

 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 detection rate.
 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 their 40s.
 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 unknown.

 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.

Experimental procedures

 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 —
mammography.

Diagnostic procedures
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
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.
Biopsy
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
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.

Genetic tests
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).

Treatments and drugs

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.

Surgery
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.

Reconstructive surgery
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 later date.

 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
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
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.

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 months.

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
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 aromatase inhibitors.

 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 women.

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.

Biological therapy
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 disease.
 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 cells.
  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 breast cancers.

Clinical trials
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.

Prevention
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
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 modulators (SERMs):

 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 cancer.

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.
Preventive surgery
Although it's a radical step, preventive surgery also reduces breast cancer risk in high-
risk women. Options include:

 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.

Lifestyle factors
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 whole grains.
 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.
 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.

Coping and support

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.

Telling others
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 co-workers.

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.